Surgical Outcomes and Recurrence Management in Borderline Resectable Hepatocellular Carcinoma: Implications for Multidisciplinary Strategies

ABSTRACT Background Oncological resectability classification for hepatocellular carcinoma (HCC) emphasizes the need to reassess treatment strategies for borderline resectable (BR) cases. This study evaluated surgical outcomes and prognostic factors in BR‐HCC and reconsidered multidisciplinary approaches for recurrence management. Methods The study comprised 433 patients who underwent primary hepatic resection for HCC between 2000 and 2023. Patients were classified as R, BR1, and BR2 according to the Expert Consensus Statement 2023. Multivariate Cox proportional hazard models were conducted to identify prognostic factors for disease‐free and overall survival in BR (BR1 + BR2) patients. Results Among 70 patients with BR‐HCC (BR1: n = 37, BR2: n = 33), 5‐year overall survival was 53% in BR1 versus 22% in BR2 patients ( p = 0.06). In multivariate analysis, up‐to‐7 out ( p < 0.001) and lymph node metastasis ( p < 0.001) were independent predictors of cancer recurrence, whereas anatomical resection was associated with improved disease‐free survival ( p = 0.02). Independent predictors of overall survival included older age ( p = 0.01), Child‐Pugh B ( p < 0.001), up‐to‐7 out ( p = 0.01), macrovascular invasion ( p = 0.01), and lymph node metastasis ( p < 0.001). Recurrence occurred in 89% of BR‐HCC patients, with BR2 showing more frequent early recurrence within 1 year ( p = 0.006) and recurrence beyond Milan criteria ( p = 0.02) compared to BR1. Patients receiving surgical resection or radiofrequency ablation for recurrence demonstrated better survival compared with other treatments ( p < 0.001). Conclusions BR1 and BR2‐HCC represent biologically aggressive subsets with high recurrence rates and poor prognosis, particularly in tumors with up‐to‐7 out status, lymph node metastasis, and macrovascular invasion. Active salvage treatment for recurrence may improve survival, highlighting the importance of multidisciplinary approaches in BR‐HCC management.