Perioperative strategies for the treatment of HCC

Curative-intent treatments for hepatocellular carcinoma (HCC), including liver resection and transplantation, are limited by high recurrence rates and strict patient selection criteria. The success of immune checkpoint inhibitors (ICIs) in advanced disease has driven their integration into the perioperative setting, with the aim of improving long-term outcomes and expanding access to curative strategies. Neoadjuvant immunotherapy represents a biologically attractive approach, leveraging the intact tumour microenvironment to enhance systemic antitumour immunity and eradicate micrometastatic disease. Early-phase trials have demonstrated feasibility and promising efficacy outcomes, while recent phase 2/3 data suggest improved event-free survival with perioperative ICI-based combinations (CARES-009 trial), but no survival benefit with adjuvant ICI alone (IMbrave050 trial). In parallel, conversion strategies incorporating ICIs with tyrosine kinase inhibitors and locoregional therapies are increasing resectability rates in selected patients with initially unresectable disease. In the transplant setting, ICIs show potential as a bridging or downstaging strategy, although concerns regarding allograft rejection and optimal washout intervals remain. Emerging biomarkers, including pathological response and circulating tumour DNA, may refine patient selection and guide the design of adaptive clinical trials. Collectively, these advances support a shift toward biomarker-driven, perioperative immunotherapy strategies to optimise curative-intent management of HCC.