Long-term outcome of hepatectomy following conversion therapy for initially unresectable hepatocellular carcinoma versus direct hepatectomy for early-stage hepatocellular carcinoma

Background: Although emerging evidence has reported the efficacy and safety of sequential surgery following targeted and immunotherapy conversion treatment for patients with initially unresectable hepatocellular carcinoma (HCC), these studies have been limited by small sample sizes and short follow-up periods. Moreover, whether such patients can achieve comparable survival outcomes to those undergoing upfront surgery for early-stage resectable HCC remains unreported. This study aims to compare long-term survival between patients with initially unresectable HCC who underwent sequential surgery after conversion therapy and those with early-stage HCC who received direct surgery. Methods: The retrospective cohort study was conducted from December 2018 through December 2023, with follow-up ending in June 2024. Ninety-nine patients with initially unresectable HCC underwent conversion therapy based on immune checkpoint inhibitors and anti-angiogenic targeted drugs, with a median duration of five cycles, followed by radical hepatectomy. One hundred and eleven patients with Barcelona Clinical Liver Cancer (BCLC) stage A HCC only underwent direct hepatectomy. Clinical characters, surgical features and survival outcomes of the two groups were compared. Results: 78.1%, respectively). Conclusions: For patients with initially unresectable HCC, radical hepatectomy after effective conversion therapy (defined as achieving either PR or CR by mRECIST) brings a satisfying long-term outcome that is comparable to BCLC-A HCC patients undergoing direct surgery.