## 7 TACE Strategy According to the Number and Size of HCC  
BCLC-B HCC includes various tumor conditions and the goal of TACE treatment is not only to control the tumors but also to maintain the liver function [92]. Therefore, it is essential to change the technique and magnitude of TACE in individual cases, although there is no consensus on how to change the TACE techniques according to the tumor spread.  
In a report by [PERSON] et al. [96], a patient subgroup with Child-Pugh A class and tumors \(\leq\)7 cm and \(\leq\)4 lesions showed significantly favorable outcomes among BCLC-B HCC patients. The Child-Pugh score was also a significant prognostic factor, and the prognosis of Child-Pugh score 9 patients treated with cTACE was worse than that of the BSC group in the previous RCT [3; 97]. [PERSON] et al. [98] also reported that cTACE techniques has an impact on patient survival. In those with HCC \(\leq\)7 cm and \(\leq\)5 lesions, the prognosis of patients who underwent selective/superselective cTACE was significantly better than that of patients treated with non-selective cTACE (\(p\) = 0.033). These studies suggest that superselective cTACE is recommended for patients with Child-Pugh scores of 5-8 and HCC \(\leq\)7 cm and \(\leq\)5 lesions.  
Now, we perform cTACE for almost all HCC patients with Child-Pugh scores \(\leq\)8 because it has a stronger therapeutic effect compared with other techniques. For tumors \(\leq\)7 cm and \(\leq\)3 lesions, superselective cTACE, mainly ultraselective cTACE, is performed. For tumors \(>\)7 cm but \(\leq\)3 lesions, stepwise superselective cTACE is also performed with curative intent [81; 82]. Bland embolization, DEB-TACE, or systemic therapy is another option, especially for elderly patients. Bland embolization followed by cTACE is also another option to safely embolize the huge tumor [83]. For bilobar multiple lesions \(\geq\)4, superselective cTACE is not always indicated but the embolized area should be minimized to reduce liver toxicity. In this subgroup, DEB-TACE or systemic therapy is also an alternative option. For far advanced (large and bilobar) tumors, palliative cTACE, DEB-TACE, or bland embolization is indicated to aim at mass reduction or prevention of tumor rupture; however, systemic therapy is recommended first when the patient has a preserved hepatic function, although there is a risk of tumor bleeding in antiangiogenic therapy (Figure 5) [99]. In HCC patients with Child-Pugh score 9, DEB-TACE or bland embolization is recommended.  
Figure 5: Our TACE strategy according to the patient and tumor conditions. Abbreviation: C-P, Child-Pugh; \(n\), number; RFA, radiofrequency ablation.  
According to APPLE Consensus Statements, tumors \(\leq\)6 cm and \(\leq\)6 lesions are classified into the good response to cTACE subgroup, tumors \(>\)6 cm and \(\leq\)6 lesion and tumors \(\geq\)7 lesions are classified into the poor response to cTACE subgroup. DEB-TACE and systemic therapy is another option for these tumor conditions (Figure 6) [92]. In particular, antiangiogenic therapy is recommended for TACE-unsuitable tumors. In addition, the sequential therapy of an antiangiogenic and TACE is a novel option for antiangiogenic-refractory HCCs or even for down-staged HCCs by antiangiogenic therapy [92].