Can radiological response after downstaging of hepatocellular carcinoma serve as a basis for subsequent treatment selection?

Abstract

Background and aims: Downstaging of hepatocellular carcinoma (HCC) has prevailed as a key method to curative therapy for patients who present with unresectable HCC. However, evidence to support how to choose the subsequent treatment strategies after downstaging therapy is limited. This study aim to explore the prognostic significance of radiological response after downstaging in patients with HCC. Further elucidate the impact of liver resection (LR), liver transplantation (LT) and maintenance therapy on the prognosis of patients with partial radiological response>90% (rPR>90%) and complete radiological response (rCR) following downstaging therapy. Method: In this study, 354 consecutive patients diagnosed with HCC and treated with downstaging between January 2018 and December 2021 were included. Subsequently, they underwent LR, LT and maintenance therapy. Radiological response was assessed by determining the average percentage of tumor areas exhibiting inactivation. Specifically, radiological response was assessed as 100% minus the percentage of the longest surviving tumor diameter to the total tumor diameter. The endpoint of our study was to compare recurrence-free survival (RFS), and overall survival (OS) among patients who underwent LT, LR or maintenance therapy after downstaging therapy. Results: Among all 354 patients included in the study, we found there were no significant differences between the rCR and rPR>90% groups in terms of three-year RFS (78.9% and 70.0% vs. 71.4% and 63.4% P=0.16) and three-year OS (97.8% and 93.3% vs. 96.9% and 93.8% P=0.90) after LR. For patients who undergo LT treatment after downstaging therapy, the one-year and three-year RFS (100.0% and 88.9% vs. 92.7% and 85.4% P=0.71) and OS (100.0% and 88.9% vs. 97.6% and 95.1% P=0.49) in pCR group and pPR>90% group are comparable. For patients with rPR>90% and rCR after downstaging, both the LT (96.2% and 92.5% vs. 88.0% and 80.0% P=0.03)and LR groups (98.4% and 93.6% vs. 88.0% and 80.0% P<0.01) exhibited better one-year and three-year OS compared with the maintenance treatment group. Additionally, LT patients demonstrated higher one-year and three-year RFS compared with LR patients(94.3% and 84.9% vs. 74.1% and 65.7% P<0.01), although there was no significant difference between the two groups in terms of one-year and three-year OS(96.2% and 92.5% vs. 98.4% and 93.6% P=0.72). Conclusion: Surgical treatments following rPR>90% after downstaging is necessary.Besides, patients achieving rPR>90% or higher after downstaging followed by either LR or LT can both achieve satisfactory survival expectations.