Conversion Resection or Direct Resection for Patients with Intermediate-Stage Hepatocellular Carcinoma: A Multicentre Study

Introduction: The majority of patients with hepatocellular carcinoma (HCC) are diagnosed at an intermediate stage, and current treatment options are associated with unfavourable overall prognosis. This study aimed to evaluate the efficacy of conversion therapy before resection compared with direct resection or comprehensive therapy alone in patients with intermediate-stage HCC, with a focus on pathological responses and long-term outcomes. Methods: In this multicentre study, 248 patients diagnosed with intermediate-stage HCC between January 2020 and December 2023 were enrolled. Of these, 56 patients received preoperative conversion therapy followed by resection (conversion resection group), 162 underwent direct resection (direct resection group), and 30 received comprehensive therapy alone and did not undergo surgical resection (comprehensive therapy group). Propensity score matching was performed to balance the baseline characteristics, and pathological responses were systematically evaluated. Results: Among conversion resection group, 13 patients (23.2%) achieved a pathological complete response, and 29 (51.8%) achieved a major pathological response. The conversion resection group exhibited significantly lower microvascular invasion rates (17.9% vs. 58.6%, p < 0.001) and higher tumour differentiation grades (p < 0.001). The median recurrence-free survival (RFS) was markedly improved in the conversion resection group (not reached vs. 12.3 months, p < 0.001), with 3-year overall survival (OS) rates of 94.7% vs. 77.6% vs. 43.9% being observed in the conversion resection group, direct resection group and comprehensive therapy group, respectively (p < 0.001). Multivariate analysis identified conversion therapy as an independent prognostic factor for both RFS (HR: 0.241, p < 0.001) and OS (HR: 0.179, p = 0.006). Conclusions: Preoperative conversion therapy could significantly improve pathological responses and long-term survival outcomes in intermediate-stage HCC patients.