[Neoadjuvant radiotherapy for hepatocellular carcinoma: the path to synergy with surgery]

Neoadjuvant radiotherapy is an important strategy for patients with resectable hepatocellular carcinoma (HCC) with high-risk recurrence profiles. In China, HCC is primarily caused by hepatitis virus infection, making it sensitive to radiotherapy. Based on this characteristic, this paper systematically elaborates on the objectives of preoperative neoadjuvant radiotherapy, the applicable patient populations, the technical prerequisites for its combination with surgery, its clinical application advantages, future directions, and proposes a "surgery-oriented" radiotherapy concept. Traditional stereotactic body radiotherapy (SBRT), when used as preoperative therapy for large hepatocellular carcinoma, can easily lead to perhepatic adhesions which increases surgical difficulty and risks. To address this challenge, our team has proposed a patented method for generating a resection-mimicking dose distribution with high-dose radiotherapy for large HCC. This approach optimizes dose distribution and precisely protects the future liver remnant, significantly reducing postoperative recurrence without substantially increasing surgical difficulty. Neoadjuvant radiotherapy offers unique advantages, including high local control rates, durable response, reduced risk of microvascular invasion, low progression rates, and favorable safety profiles, while also providing a time window of liver function recovery for surgery. This paper also explores the strategy selection for combining neoadjuvant radiotherapy with systemic therapy, the timing of surgery, and points out that promoting this technology requires collaborative innovation between hepatobiliary surgeons and radiation oncologists to optimize radiotherapy design and its integration with surgery. Practical experience indicates that neoadjuvant radiotherapy has the potential to improve the prognosis of patients with high-risk resectable HCC, though more high-level clinical evidence is needed to support its use in the future.