Hepatocellular Carcinoma Bridging and Downstaging: Advances in Locoregional Therapy

Hepatocellular carcinoma (HCC) remains a major contributor to global cancer mortality, with many patients presenting beyond the bounds of upfront curative therapy (resection/transplant). Locoregional therapies, particularly transarterial chemoembolization (TACE), transarterial embolization (TAE), and transarterial radioembolization (TARE), therefore play an essential role in bridging and downstaging strategies designed to enable curative intent in otherwise ineligible patients. Bridging therapy aims to maintain transplant eligibility and reduce waitlist dropout, whereas downstaging seeks to reduce tumor burden to meet accepted criteria for resection or transplantation. This review synthesizes current evidence on TACE, TAE, and TARE for bridging to resection and transplantation, as well as for downstaging to surgical eligibility, drawing from systematic reviews and cohort studies in the recent literature. We examine modality-specific outcomes, contextualized by tumor biology, liver function, and treatment selection criteria. Comparative effectiveness and the need for standardized outcome measures will be highlighted, reflecting heterogeneity in study endpoints and patient populations. Finally, future directions in personalized locoregional therapy, integration with systemic therapies, and refined conversion strategies will be discussed, with emphasis on the need for consensus in defining treatment success. By integrating evolving clinical evidence with practical application, this review will help clarify the expanding role of locoregional therapies in enabling curative-intent strategies for HCC.