Survival Outcomes, Recurrence Patterns and its Corresponding Therapeutic Management After Conversion Therapy followed by Curative Resection for Hepatocellular Carcinoma: A Real World Study

Introduction: There remained a scarcity of research focusing on long-term survival, the administration of adjuvant therapy and recurrence following conversion resection in patients suffering from initially unresectable hepatocellular carcinoma(uHCC). Our study aims to provide a comprehensive understanding of clinical outcomes and recurrence after conversion resection of initially uHCC patients. Methods: We retrospectively collected historically confirmed HCC patients who had undergone curative resection after conversion therapy between November 2014 to June 2023. The primary endpoints included overall survival(OS) and overall survival after recurrence(rOS). The second endpoints included recurrence free survival(RFS). BCLC staging system was applied to classify recurrence patterns (rBCLC). Results: A total of 419 initially uHCC patients were collected in Sun Yat-sen University Cancer Center. The median duration of follow-up was 44.3 months(95%CI,26.4-62.3). These patients exhibited a median OS not reached and a median RFS of 16.8 months(95%CI,11.5-22.1) after conversion resection. The achieving of CR according to mRECIST and pathological response ≥ 90% predicted better OS and RFS, while the decline of AFP or PIVKA-II ≥ 75% after conversion therapy predicted better RFS. Postoperative adjuvant therapy did not exhibit significantly improved OS or RFS compared to active surveillance before and after PSM or IPTW. Subgroup analyses failed to identify any population with clear benefit from adjuvant therapy, either. Recurrence occurred in 261(62.3%) patients at a median time of 7.2 months after resection. Median rOS for recurrent patients was 40.2 months(95% CI, 33.4–48.7). Patients with rBCLC stage 0/A exhibited significantly better rOS compared to those with rBCLC stage B/C. Across all rBCLC stages, curative treatment was identified as the optimal therapeutic strategy for achieving the best rOS. Furthermore, combination therapy did not demonstrate superior efficacy over TAT or systemic therapy alone at any recurrent disease stage. Conclusions: Patients with uHCC exhibited favorable prognosis after conversion resection. Tumor response of conversion therapy could predict clinical outcomes after conversion resection. Our data did not support the routine use of postoperative adjuvant therapy. When recurrence occurred, more intense and aggressive treatments were not supported by current evidence.