When Resectability Emerges After Systemic Therapy in Hepatocellular Carcinoma: A Proposed Response-Guided...

Immune checkpoint inhibitor-based combination therapies have increased the likelihood that a subset of patients with initially unresectable hepatocellular carcinoma (HCC) may achieve sufficient tumor regression to become technically resectable However, when resectability emerges systemic therapy, the optimal next step remains uncertain. Surgical resection may eradicate residual macroscopic disease, whereas continued systemic therapy may help maintain control of occult micrometastatic disease. In this review, we summarize the available evidence on surgical consolidation after conversion and propose a conceptual response-guided consolidation framework to support post-conversion decision-making. The current evidence base remains dominated by retrospective comparative studies, although early randomized data have recently emerged in selected populations. Overall, surgical consolidation appears feasible and may improve progression-related outcomes in carefully selected responders, but definitive survival benefit across all response categories remains unproven. Within the proposed framework, partial response appears to represent the most consistent clinical scenario supporting surgery, stable disease should be interpreted as a heterogeneous category requiring further biological and radiographic discrimination, and complete response remains the most uncertain setting in which surgery may not always be necessary. Beyond radiographic response alone, pathological response and biomarker-based predictive enrichment may help refine future selection strategies. We therefore suggest that post-conversion resectability should be viewed not simply as a technical surgical endpoint, but as a therapeutic decision point requiring multidisciplinary assessment of anatomical feasibility, response depth and durability, hepatic reserve, and biological risk. This proposed framework is intended as a practical interim model rather than an established clinical standard and requires prospective validation.