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Life sciences · Journal article
Frontiers in Oncology · October 14, 2026
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Objective The combination of targeted therapy, immunotherapy, and locoregional treatment has established conversion therapy as a viable strategy for China Liver Cancer Staging (CNLC) stage IIb/IIIa hepatocellular carcinoma (HCC). However, upon meeting the criteria for tumor resectability after successful conversion, it remains controversial whether surgical resection (SR) provides superior survival benefits compared to continued medical treatment (CMT), and the optimal timing for surgery is still undefined. Methods We retrospectively analyzed 363 CNLC stage IIb/IIIa HCC patients who met strict tumor resectability criteria after a conversion regimen of lenvatinib, anti-PD-1 antibodies, and transarterial chemoembolization (TACE). Patients were randomly assigned to a training cohort (n = 255) and an internal validation cohort (n = 108) at a 7:3 ratio. Propensity score matching (PSM) was utilized to balance the baseline characteristics. Survival outcomes were compared and prognostic nomograms were developed using Cox proportional hazards regression. Results After 1:3 PSM, the training cohort comprised 63 SR patients and 189 CMT patients. The SR group demonstrated significantly better median overall survival (mOS, 32.1 vs. 24.3 months; P < 0.0001) and median progression-free survival (mPFS, 15.3 vs. 10.6 months; P = 0.0041) than the CMT group. The prognostic nomograms developed for both groups exhibited excellent discrimination via bootstrap resampling and in the internal validation cohort. Restricted cubic spline (RCS) and Kaplan-Meier analyses revealed that an interval > 90 days from meeting resectability criteria to surgery, and a pre-operative AFP to baseline AFP (at the time resectability was met) ratio > 1, were significantly associated with worse OS. Conclusion For CNLC stage IIb/IIIa HCC patients achieving tumor resectability following conversion therapy, SR is significantly associated with improved survival outcomes compared to CMT. Based on our exploratory findings, surgery within 90 days of meeting resectability criteria may be considered a beneficial strategy, provided that the pre-operative AFP level does not exceed the level observed when resectability was initially achieved.