Adjuvant systemic therapy versus active surveillance after resection following conversion therapy for hepatocellular carcinoma: a propensity score matched study

BACKGROUND: The role of adjuvant systemic therapy after resection following conversion therapy in patients with hepatocellular carcinoma (HCC) rendered resectable by transarterial therapy combined with systemic therapy remains unclear. This study aimed to evaluate the impact of adjuvant systemic therapy on survival outcomes in real-world practice. METHODS: We retrospectively analyzed patients with initially unresectable HCC who underwent curative-intent resection after successful first-line transarterial therapy combined with systemic therapy between January 2018 and December 2023. Postoperative management included either adjuvant systemic therapy or active surveillance. Propensity score matching (1:2) was applied to balance baseline characteristics. Overall survival (OS) and recurrence-free survival (RFS) were evaluated using Kaplan-Meier methods and compared by log-rank tests. Subgroup and recurrence pattern analyses were also performed. RESULTS: Among 496 eligible patients, 120 received adjuvant systemic therapy and 376 underwent active surveillance. After matching, 326 patients were included (116 vs. 210). Adjuvant systemic therapy was associated with significantly improved OS (HR 0.58, 95% CI 0.38-0.89; p = 0.01) and RFS (HR 0.64, 95% CI 0.48-0.84; p = 0.002). Survival benefit of adjuvant systemic therapy was observed in patients with BCLC stage C disease (OS: HR 0.53, 95% CI 0.31-0.90, p = 0.02; RFS: HR 0.61, 95% CI 0.43-0.87, p = 0.007) and in those with BCLC stage A or B disease exceeding the up-to-seven criteria (OS: HR 0.46, 95% CI 0.22-0.95, p = 0.03; RFS: HR 0.56, 95% CI 0.34-0.91, p = 0.02). Multivariable analysis identified adjuvant systemic therapy as an independent predictor of improved OS and RFS. CONCLUSIONS: In patients undergoing resection following conversion therapy for initially unresectable HCC, adjuvant systemic therapy was associated with improved survival, particularly among those with high-risk disease features.