Hepatectomy After Conversion Therapy for Initially Unresectable HCC: What is the Difference?

Abstract

Conversion therapy gives some patients with initially unresectable hepatocellular carcinoma (HCC) access to surgery. The purpose of this study was to evaluate the safety and efficacy of hepatectomy after conversion therapy and how it differed from those who undergoing direct hepatectomy. Patients and Methods: From January 2018 to April 2022, 745 patients underwent hepatectomy for HCC were enrolled. Among them, 41 patients of unresectable HCC underwent hepatectomy after conversion therapy. A demographically and clinically comparable cohort was created from the remaining patients in a 1:1 ratio using propensity score matching. Results:The median duration of conversion therapy was 108 (42-298) days, 8 patients achieved complete response (CR) and 33 achieved partial response (PR). Conversion therapy resulted in some degree of myelosuppression, but liver function index remained good. Compared with the direct hepatectomy group, the conversion group had more blood loss (600 mL vs 400 mL, p=0.015), longer operative time (270 min vs 240 min, p=0.02), higher blood transfusion rates, and longer hospital stay (8 days vs 11 days, p<0.001). Patients in the conversion group had significantly more complications of any grade (82.9% vs 51.2%, p=0.002) and grade 3/4 (26.8% vs 4.9%, p=0.013), and 6 patients developed post-hepatectomy liver failure (PHLF). There were no deaths in either group. All patients achieved R0 resection, 6 (6/41, 14.6%) achieved pathological complete response (pCR), 14 achieved major pathologic responses (MPR). During a median follow-up of 12.8 months, 14 patients in the conversion group experienced recurrence or metastasis, no deaths. Conclusion: Hepatectomy after conversion therapy was more difficult than direct hepatectomy, but accurate preoperative assessment could ensure the safety of the surgery. The damage of liver function after conversion therapy was more severe than expected, PHLF should be prevented and treated. Hepatectomy was effective and necessary, postoperative pathological examination could provide guidance for adjuvant therapy.

Conversion therapy of a giant HCC with portal vein thrombus and inferior vena cava tumor thrombus

“…However, evidence-based data on the timing of surgery, surgical procedures, postoperative complications, postoperative recurrence time, and long-term prognosis in these patients are lacking. Although liver resection after conversion therapy is considered more di cult and more complicated than normal liver resection, CS can be performed safer with accurate preoperative evaluation (especially whether R0 can be achieved or not), precise intraoperative technique, and careful control of bleeding Further follow-up is needed for recurrence and long-term survival after CS [27] Controlling adverse events through systemic therapy is also an extremely important factor in achieving conversion surgery. We should be pay attention to the use of ICIs in patients with autoimmune diseases, interstitial pneumonias, or a history of organ transplantation.…”

Conversion therapy for initially unresectable hepatocellular carcinoma: Current status and prospects

“…Some studies have suggested that surgery should be performed after successful downstaging through continued treatment with TKIs and/ or anti-PD-1 antibodies to stabilize lesions, an interval that is typically 1-2 months. In instances of less difficult resection, LR is recommended after downstaging to meet surgical resectability criteria to minimize complications (91). In instances of more difficult resection and poor tumor behavior, surgery is recommended only after achieving maximum remission depth and maintaining stability for 3-4 months to improve the partial response rate (91).…”

“…In instances of less difficult resection, LR is recommended after downstaging to meet surgical resectability criteria to minimize complications (91). In instances of more difficult resection and poor tumor behavior, surgery is recommended only after achieving maximum remission depth and maintaining stability for 3-4 months to improve the partial response rate (91).…”

“…LR after conversion therapy can be challenging due to the adverse reactions it causes, such as bone marrow suppression, decreased platelet function and count, increased fragility of blood vessels and liver tissue, localized adhesions, and hepatic edema. Compared to patients who underwent direct surgery, those in the triple conversion therapy group (HAIC/TACE+anti-PD-1 antibody+TKI) for LR conversion lost more blood during surgery (600 mL vs. 400 mL, p = 0.015), had a longer operating time (270 min vs. 240 min, p = 0.02), a higher transfusion rate, and a longer duration of hospitalization (11 days vs. 8 days, p < 0.001) (91).…”

Watch-and-wait strategy vs. resection in patients with radiologic complete response after conversion therapy for initially unresectable hepatocellular carcinoma: a propensity score-matching comparative study

“…Partial hepatectomy remains an effective treatment option for early-stage HCC, boasting a 5-year survival rate of 70–80% 2 . However, amounts of HCC patients lost the opportunity for hepatectomy initially due to factors such as intermediate or advanced tumor stage, liver dysfunction, insufficient residual liver volume, or surgical technique, leading to resection rates below 40% 3 . Conversion therapy has the potential to transform unresectable or borderline HCC tumors into resectable ones, thereby improving survival outcomes for patients with initially unresectable HCC (uHCC) 4 .…”