Transarterial chemoembolization and transarterial radioembolization are both established locoregional options for hepatocellular carcinoma, yet direct comparative evidence is complicated by variation in disease stage, patient selection, procedural technique, and research design. Individual randomized and observational publications can therefore produce estimates that are difficult to interpret in isolation. Bringing randomized clinical trial and real-world evidence together offers a way to assess whether the overall comparative assessment is consistent across a broader clinical evidence base.

The systematic review identified 25 comparative publications for meta-analysis, comprising 8,146 patients. Fourteen publications contributed overall-survival data, with a pooled hazard ratio of 0.99 and a 95% confidence interval of 0.70 to 1.39. Thirteen publications contributed objective-response data, with a pooled risk ratio of 0.94 and a 95% confidence interval of 0.84 to 1.05. Four publications with meta-analyzable progression-free-survival data numerically favored transarterial radioembolization, but the pooled estimate did not reach statistical significance. Any-grade and grade 3 or higher adverse-event rates were also comparable in the pooled analyses, and prespecified subgroup findings were generally consistent with the overall results.

The secondary value of this analysis is the integration of randomized clinical trials and real-world comparative evidence within the same quantitative framework. Across a heterogeneous literature, the pooled results did not identify a statistically significant advantage for either treatment modalities on the major evaluated outcomes. This should not be interpreted as proof that the procedures are equivalent for every patient or clinical setting. Rather, it shifts attention away from assumed universal superiority and toward the patient, tumor, liver-function, procedural, and treatment-intent factors that may determine the most appropriate locoregional approach.