{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,15]],"date-time":"2026-10-15T09:47:05Z","timestamp":1792057625295,"version":"4.4.0"},"reference-count":31,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2026,7,28]],"date-time":"2026-07-28T00:00:00Z","timestamp":1785196800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2026,7,28]],"date-time":"2026-07-28T00:00:00Z","timestamp":1785196800000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"University of Medicine and Pharmacy of Timisoara"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Curr. Oncol.","Current Oncology"],"abstract":"<jats:p>Background and Objectives: Conversion therapy has expanded treatment options for patients with initially unresectable hepatocellular carcinoma (HCC), but the surgical literature remains focused more often on radiologic response than on the pathological, perioperative, and postoperative outcomes of patients who actually proceed to hepatectomy. This focused systematic review aimed to synthesize the available evidence on conversion hepatectomy after contemporary combination downstaging for initially unresectable HCC. Materials and Methods: A structured PubMed\/MEDLINE search with backward reference-list screening was performed and last updated on 3 February 2026. The full Boolean strategy, field tags, and eligibility framework are now reported explicitly. Because the literature was observational and clinically heterogeneous, findings were synthesized narratively and complemented by structured assessments of reporting completeness, potential cohort overlap, and study-level bias. Results: Fourteen studies were included, nearly all retrospective and predominantly from East Asia. Treatment platforms clustered into systemic doublets, systemic plus HAIC strategies, and broader locoregional\u2013systemic triplet or multimodal approaches. Across studies reporting pathological response, pathological complete response ranged from 28.0% to 50.0%, while R0 resection ranged from 85.7% to 100%, where stated. Postoperative morbidity ranged from 14.3% to 71.4%, and major complication rates from 9.5% to 16.9%; however, extent of resection, liver reserve, post-hepatectomy liver failure, transfusion, and perioperative mortality were not uniformly reported. Most studies carried moderate-to-high overall concerns for bias because of response-based surgical selection, heterogeneous denominators, incomplete perioperative reporting, and possible partial overlap among some cohorts. Conclusions: The available literature suggests that conversion hepatectomy can be feasible and oncologically meaningful in carefully selected patients treated in experienced centers, but current evidence remains hypothesis-generating rather than practice-standardizing because it is observational, heterogeneous, and incompletely reported.<\/jats:p>","DOI":"10.3390\/curroncol33080453","type":"journal-article","created":{"date-parts":[[2026,7,28]],"date-time":"2026-07-28T14:37:00Z","timestamp":1785249420000},"page":"453","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Pathological and Perioperative Outcomes of Conversion Hepatectomy After Contemporary Combination Downstaging for Initially Unresectable Hepatocellular Carcinoma: A Systematic Review"],"prefix":"10.3390","volume":"33","author":[{"given":"Codruta","family":"Craciun","sequence":"first","affiliation":[{"name":"Doctoral School, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Livia","family":"Stanga","sequence":"additional","affiliation":[{"name":"Discipline of Microbiology, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Danut","family":"Dejeu","sequence":"additional","affiliation":[{"name":"Surgical Oncology Department, Emergency County Hospital Oradea, 410169 Oradea, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-7547-0869","authenticated-orcid":false,"given":"Ana-Maria","family":"Davidoiu","sequence":"additional","affiliation":[{"name":"Doctoral School, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adrian Cosmin","family":"Ilie","sequence":"additional","affiliation":[{"name":"Department of Functional Sciences, Discipline of Public Health, Center for Translational Research and Systems Medicine, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Patricia Octavia","family":"Mazilu","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lavinia","family":"Craciun","sequence":"additional","affiliation":[{"name":"Department of Anatomy and Embryology, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6048-6909","authenticated-orcid":false,"given":"Stelian","family":"Pantea","sequence":"additional","affiliation":[{"name":"Department X, Surgical Emergencies Clinic, \u201cVictor Babes\u201d University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,7,28]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"250","DOI":"10.1016\/j.jhep.2019.08.025","article-title":"Epidemiology and surveillance for hepatocellular carcinoma: New trends","volume":"72","author":"Singal","year":"2020","journal-title":"J. Hepatol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1038\/s41572-020-00240-3","article-title":"Hepatocellular carcinoma","volume":"7","author":"Llovet","year":"2021","journal-title":"Nat. Rev. Dis. Prim."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"410","DOI":"10.1001\/jamasurg.2022.7989","article-title":"Management of hepatocellular carcinoma: A review","volume":"158","author":"Brown","year":"2023","journal-title":"JAMA Surg."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"723","DOI":"10.1002\/hep.29913","article-title":"Diagnosis, staging, and management of hepatocellular carcinoma: 2018 practice guidance by the American Association for the Study of Liver Diseases","volume":"68","author":"Marrero","year":"2018","journal-title":"Hepatology"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1922","DOI":"10.1097\/HEP.0000000000000466","article-title":"AASLD practice guidance on prevention, diagnosis, and treatment of hepatocellular carcinoma","volume":"78","author":"Singal","year":"2023","journal-title":"Hepatology"},{"key":"ref_6","unstructured":"European Association for the Study of the Liver (2018). EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma. J. Hepatol., 69, 182\u2013236."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1894","DOI":"10.1056\/NEJMoa1915745","article-title":"Atezolizumab plus bevacizumab in unresectable hepatocellular carcinoma","volume":"382","author":"Finn","year":"2020","journal-title":"N. Engl. J. Med."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1163","DOI":"10.1016\/S0140-6736(18)30207-1","article-title":"Lenvatinib versus sorafenib in first-line treatment of patients with unresectable hepatocellular carcinoma: A randomised phase 3 non-inferiority trial","volume":"391","author":"Kudo","year":"2018","journal-title":"Lancet"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"2960","DOI":"10.1200\/JCO.20.00808","article-title":"Phase Ib study of lenvatinib plus pembrolizumab in patients with unresectable hepatocellular carcinoma","volume":"38","author":"Finn","year":"2020","journal-title":"J. Clin. Oncol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"599","DOI":"10.1038\/s41571-018-0073-4","article-title":"Molecular therapies and precision medicine for hepatocellular carcinoma","volume":"15","author":"Llovet","year":"2018","journal-title":"Nat. Rev. Clin. Oncol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"227","DOI":"10.21037\/hbsn-21-328","article-title":"Chinese expert consensus on conversion therapy for hepatocellular carcinoma (2021 edition)","volume":"11","author":"Sun","year":"2022","journal-title":"Hepatobiliary Surg. Nutr."},{"key":"ref_12","first-page":"4711","article-title":"The past, present and future of conversion therapy for liver cancer","volume":"11","author":"Song","year":"2021","journal-title":"Am. J. Cancer Res."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"732","DOI":"10.1002\/jhbp.1135","article-title":"Conversion surgery after preoperative therapy for advanced hepatocellular carcinoma in the era of molecular targeted therapy and immune checkpoint inhibitors","volume":"29","author":"Arita","year":"2022","journal-title":"J. Hepatobiliary Pancreat. Sci."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1345","DOI":"10.1016\/S0140-6736(22)01200-4","article-title":"Hepatocellular carcinoma","volume":"400","author":"Vogel","year":"2022","journal-title":"Lancet"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"294","DOI":"10.1038\/s41571-024-00868-0","article-title":"Adjuvant and neoadjuvant immunotherapies in hepatocellular carcinoma","volume":"21","author":"Llovet","year":"2024","journal-title":"Nat. Rev. Clin. Oncol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"n71","DOI":"10.1136\/bmj.n71","article-title":"The PRISMA 2020 statement: An updated guideline for reporting systematic reviews","volume":"372","author":"Page","year":"2021","journal-title":"BMJ"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"l6890","DOI":"10.1136\/bmj.l6890","article-title":"Synthesis without meta-analysis (SWiM) in systematic reviews: Reporting guideline","volume":"368","author":"Campbell","year":"2020","journal-title":"BMJ"},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Zhang, J., Zhang, X., Mu, H., Yu, G., Xing, W., Wang, L., and Zhang, T. (2021). Surgical conversion for initially unresectable locally advanced hepatocellular carcinoma using a triple combination of angiogenesis inhibitors, anti-PD-1 antibodies, and hepatic arterial infusion chemotherapy: A retrospective study. Front. Oncol., 11.","DOI":"10.3389\/fonc.2021.729764"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"2782","DOI":"10.1245\/s10434-022-12530-z","article-title":"Hepatectomy after conversion therapy using tyrosine kinase inhibitors plus anti-PD-1 antibody therapy for patients with unresectable hepatocellular carcinoma","volume":"30","author":"Zhu","year":"2023","journal-title":"Ann. Surg. Oncol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"e007366","DOI":"10.1136\/jitc-2023-007366","article-title":"Lenvatinib plus anti-PD-1 antibodies as conversion therapy for patients with unresectable intermediate-advanced hepatocellular carcinoma: A single-arm, phase II trial","volume":"11","author":"Zhang","year":"2023","journal-title":"J. Immunother. Cancer"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1477","DOI":"10.1007\/s12072-023-10561-6","article-title":"Perioperative safety, oncologic outcome, and risk factors of salvage liver resection for initially unresectable hepatocellular carcinoma converted by transarterial chemoembolization plus tyrosine kinase inhibitor and anti-PD-1 antibody: A retrospective multicenter study of 83 patients","volume":"17","author":"Lin","year":"2023","journal-title":"Hepatol. Int."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1709","DOI":"10.2147\/JHC.S432062","article-title":"Hepatectomy after conversion therapy with hepatic arterial infusion chemotherapy, tyrosine kinase inhibitors and anti-PD-1 antibodies for initially unresectable hepatocellular carcinoma","volume":"10","author":"Yu","year":"2023","journal-title":"J. Hepatocell. Carcinoma"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1078","DOI":"10.1016\/j.dld.2023.11.027","article-title":"Conversion surgery for initially unresectable hepatocellular carcinoma using lenvatinib combined with TACE plus PD-1 inhibitor: A real-world observational study","volume":"56","author":"Li","year":"2024","journal-title":"Dig. Liver Dis."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"3073","DOI":"10.1245\/s10434-024-14944-3","article-title":"Outcomes of salvage surgery versus non-salvage surgery for initially unresectable hepatocellular carcinoma after conversion therapy with transcatheter arterial chemoembolization combined with lenvatinib plus anti-PD-1 antibody: A multicenter retrospective study","volume":"31","author":"Wu","year":"2024","journal-title":"Ann. Surg. Oncol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"e1041","DOI":"10.1093\/oncolo\/oyae032","article-title":"Salvage surgery for initially unresectable HCC with PVTT converted by locoregional treatment plus tyrosine kinase inhibitor and anti-PD-1 antibody","volume":"29","author":"Wang","year":"2024","journal-title":"Oncologist"},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Jia, J., Ding, C., Mao, M., Gao, F., Shao, Z., Zhang, M., and Zheng, S. (2024). Pathological complete response after conversion therapy in unresectable hepatocellular carcinoma: A retrospective study. BMC Gastroenterol., 24.","DOI":"10.1186\/s12876-024-03298-5"},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Chang, Z., Li, M., Sun, Z., Liu, Z., Yang, Y., Xu, L., Li, L., Zhang, C., Sun, P., and Zhong, J. (2024). Clinical study on conversion therapy of hepatocellular carcinoma: Summary and comparison of clinical data from a single center of consecutive four years. BMC Gastroenterol., 24.","DOI":"10.1186\/s12876-024-03457-8"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"109375","DOI":"10.1016\/j.ejso.2024.109375","article-title":"Prognosis predictors of hepatocellular carcinoma after hepatectomy following conversion therapy","volume":"51","author":"Liu","year":"2025","journal-title":"Eur. J. Surg. Oncol."},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Zhang, H., Yang, T., Huang, L., Li, B., Xu, H., and Wei, Y. (2025). Tumor regression grade predicts recurrence-free survival in intermediate-advanced hepatocellular carcinoma after conversion therapy. Front. Immunol., 16.","DOI":"10.3389\/fimmu.2025.1704239"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"107255","DOI":"10.5306\/wjco.v16.i6.107255","article-title":"Efficacy of salvage surgery for hepatocellular carcinoma following conversion therapy","volume":"16","author":"Zhang","year":"2025","journal-title":"World J. Clin. Oncol."},{"key":"ref_31","doi-asserted-by":"crossref","unstructured":"Lin, S., Song, Z., Chen, P., Yu, X., Xie, W., Hua, Y., Li, S., Shen, S., and Kuang, M. (2025). Conversion Therapy Based on TACE\/HAIC-Based Treatment to Improve the Therapeutic Effect of Initially Unresectable Hepatocellular Carcinoma. Liver Cancer.","DOI":"10.1159\/000547725"}],"container-title":["Current Oncology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1718-7729\/33\/8\/453\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,15]],"date-time":"2026-10-15T09:09:44Z","timestamp":1792055384000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1718-7729\/33\/8\/453"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,28]]},"references-count":31,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2026,8]]}},"alternative-id":["curroncol33080453"],"URL":"https:\/\/doi.org\/10.3390\/curroncol33080453","relation":{},"ISSN":["1718-7729"],"issn-type":[{"value":"1718-7729","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,28]]}}}