Reassessment of palliative surgery in conversion therapy of previously unresectable hepatocellular carcinoma: Two case reports and review of literature

Background: Most patients with hepatocellular carcinoma (HCC) have lost the opportunity for direct surgery at the time of diagnosis. Transarterial chemoembolization (TACE) combined with immune checkpoint inhibitors or tyrosine kinase inhibitors (TKI) can partially transform some unresectable HCC and improve the prognosis effectively. However, based on the promising prospects of combined targeted and immunotherapy for the effective treatment of HCC, the positive role of palliative surgery in the conversion treatment of advanced HCC urgently needs further intensive re-assessment.

Case summary: In this study, we describe two successful cases of "conversion therapy for unresectable HCC" achieved mainly by palliative surgery combined with TACE plus immunotherapy and TKIs. A 48-year-old patient with newly diagnosed HCC, presenting with a 6-cm mass in the segment VII/VIII of the right liver with multiple intrahepatic metastases, could not undergo one-stage radical surgical resection. He underwent palliative surgery with radiofrequency of metastatic lesions and the palliative resection of the primary mass, and received subsequent TACE treatments twice in the early postoperative period (2 weeks and 6 weeks), in addition to targeted and immune combination therapy with sintilimab injection and oral lenvatinib. No evidence of recurrence was observed during the 11-month follow-up period after surgery. The other patient was a 47-year-old patient with massive HCC (18 cm × 15 cm × 4.5 cm) in the left liver with severe cirrhosis. The left portal branch was occluded and a tumor thrombus formed, and the tumor partly involved the middle hepatic vein. The patient underwent palliative surgery of left hemihepatectomy (including resection of the middle hepatic vein) for HCC, followed by three TACE procedures and oral TKIs 2 weeks after surgery. Six months later, the re-examination via computed tomography revealed no tumour activity in the remaining right liver, while magnetic resonance imaging revealed slight local tumor enhancement in the caudate lobe of the liver considered, TACE was performed once again, and during the next follow-up of 10 months did not reveal new intrahepatic lesions or distant metastases.

Conclusion: These cases demonstrate that the addition of palliative surgery to conversion therapy in a selected population with a high tumor burden could benefit patients with initially unresectable HCC.