Sequential surgery after conversion therapy for advanced hepatocellular carcinoma: Evidence, controversies, and perspectives
5 affiliations
- 1Faculty of Hepato-Pancreato-Biliary Surgery, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
- 2Department of Psychology, The Eighth Medical Center of Chinese PLA General Hospital, Beijing 100091, China
- 3The Second Clinical Medical College, Chongqing Medical University, Chongqing 400010, China
- 4Clinical School, Chengde Medical College, Chengde 067000, China
- 5The Norman Bethune-Third Clinical Medical College, Jilin University, Changchun, Jilin 130000, China
Abstract
Hepatocellular carcinoma (HCC) often has an insidious onset. Therefore, most patients with HCC are diagnosed at intermediate-to-advanced stages, and upfront radical resection cannot be performed. Systemic regimens that combine immune checkpoint inhibitors (ICIs) with antiangiogenic targeted drugs (AATDs) have established conversion therapy followed by sequential surgery as an important research direction for initially unresectable HCC. The aim of conversion therapy is not only to achieve radiographic response and technical resectability but also to reduce tumor viability, identify patients with favorable tumor biology, and gain durable oncologic benefit. Current evidence supports the combination of ICIs and AATDs as the backbone of conversion therapy, with locoregional therapies, including transarterial chemoembolization, hepatic arterial infusion chemotherapy, and stereotactic body radiotherapy, selectively integrated to address heavy intrahepatic tumor burden, control macrovascular thrombus, or treat residual viable lesions. The decision to proceed with sequential surgery should be made after a successful conversion is confirmed by a multidisciplinary evaluation incorporating tumor necrosis, hepatic functional reserve, future liver remnant volume, overall condition, perioperative drug-related risks, and patient preference. This review focuses on identifying the conversion-specific information required to guide surgical decision-making. Additionally, this study aimed to evaluate conversion rate, R0 resection, pathological response, and postoperative outcomes, explain why high objective response rates may not translate into improved postoperative survival, and provide a practical framework integrating tumor biology, hepatic reserve, perioperative risk, and patient preference.
Related
- Modified BRICS sequential regimen in advanced hepatocellular carcinoma patients with BCLC C stage: a real-world study
- Pathological Complete Response and Successful Conversion Hepatectomy in Initially Unresectable Giant Hepatocellular Carcinoma Following Triple Therapy With HAIC, Bevacizumab, and Tislelizumab: A Case Report
- Recent advances in conversion therapy for hepatocellular carcinoma with portal vein tumor thrombosis
- Resection rates after conversion therapy for initially unresectable hepatocellular carcinoma: a systematic review and meta-analysis
- Survival benefits and prognostic models of surgical resection versus continued medical treatment in CNLC stage IIb/IIIa hepatocellular carcinoma after meeting resectability criteria following conversion therapy
BibTeX
@article{huo2026sequential,
title = {{Sequential surgery after conversion therapy for advanced hepatocellular carcinoma: Evidence, controversies, and perspectives}},
author = {Yuhao Huo and Hongxiang Jiang and Yuanzhe Liu and Tong Jiang and Cong Ren and Xu Zhang and Boyu Wu and Haowen Tang},
journal = {ILIVER},
year = {2026},
month = sep,
doi = {10.1016/j.iliver.2026.100272},
url = {https://europepmc.org/article/PMC/PMC13717867},
note = {CC BY},
}
RIS
TY - JOUR
TI - Sequential surgery after conversion therapy for advanced hepatocellular carcinoma: Evidence, controversies, and perspectives
AU - Yuhao Huo
AU - Hongxiang Jiang
AU - Yuanzhe Liu
AU - Tong Jiang
AU - Cong Ren
AU - Xu Zhang
AU - Boyu Wu
AU - Haowen Tang
PY - 2026
DA - 2026/09/28
JO - ILIVER
DO - 10.1016/j.iliver.2026.100272
UR - https://europepmc.org/article/PMC/PMC13717867
AB - Hepatocellular carcinoma (HCC) often has an insidious onset. Therefore, most patients with HCC are diagnosed at intermediate-to-advanced stages, and upfront radical resection cannot be performed. Systemic regimens that combine immune checkpoint inhibitors (ICIs) with antiangiogenic targeted drugs (AATDs) have established conversion therapy followed by sequential surgery as an important research direction for initially unresectable HCC. The aim of conversion therapy is not only to achieve radiographic response and technical resectability but also to reduce tumor viability, identify patients with favorable tumor biology, and gain durable oncologic benefit. Current evidence supports the combination of ICIs and AATDs as the backbone of conversion therapy, with locoregional therapies, including transarterial chemoembolization, hepatic arterial infusion chemotherapy, and stereotactic body radiotherapy, selectively integrated to address heavy intrahepatic tumor burden, control macrovascular thrombus, or treat residual viable lesions. The decision to proceed with sequential surgery should be made after a successful conversion is confirmed by a multidisciplinary evaluation incorporating tumor necrosis, hepatic functional reserve, future liver remnant volume, overall condition, perioperative drug-related risks, and patient preference. This review focuses on identifying the conversion-specific information required to guide surgical decision-making. Additionally, this study aimed to evaluate conversion rate, R0 resection, pathological response, and postoperative outcomes, explain why high objective response rates may not translate into improved postoperative survival, and provide a practical framework integrating tumor biology, hepatic reserve, perioperative risk, and patient preference.
SN - 2772-9478
ER -