Neoadjuvant therapy improves recurrence-free survival in patients with hepatocellular carcinoma abutting major hepatic veins who underwent tumor-vessel detachment

Background Tumor-vessel detachment is widely used in the surgical management of hepatocellular carcinoma (HCC) adjacent to major hepatic veins (MHV). However, this technique is frequently associated with narrow or positive surgical margins and an elevated risk of local recurrence. This study aimed to evaluate whether neoadjuvant therapy could achieve wider resection margins and reduce tumor recurrence in this patient population. Methods This retrospective study included 99 HCC patients who underwent hepatectomy with tumor-MHV detachment. We compared surgical margin width and recurrence-free survival (RFS) between patients who received preoperative neoadjuvant therapy (transarterial chemoembolization combined with anti-angiogenic agents or immunotherapy) and those who underwent upfront surgery. Propensity score matching (PSM) was performed to mitigate potential confounding factors. Results Among the 99 patients, 42 who received preoperative neoadjuvant therapy were assigned to the neoadjuvant therapy followed by surgical resection (NASR) group, and 57 who underwent upfront surgery were assigned to the surgical resection (SR) group. Neoadjuvant therapy significantly reduced median alpha-fetoprotein (AFP) levels from 61.3 ng/mL (range: 3.5–1933.8) to 6.7 ng/mL (range: 3.2–84.9) ( P =0.016) and decreased tumor size from 5.6 ± 2.2 cm to 4.5 ± 2.1 cm ( P =0.019). Surgical resection was successfully completed in 38 patients (90.5%) in the NASR group. Compared with the SR group, the NASR group achieved wider surgical margins (0.30 cm vs. 0.10 cm, P =0.027), a lower local recurrence rate (2.4% vs. 17.5%, P =0.022), and significantly improved 1-, 3-, and 5-year RFS ( P =0.025). After PSM, 39 matched pairs were generated, and the NASR group continued to demonstrate superior RFS ( P =0.010). Multivariate analysis identified neoadjuvant therapy as an independent favorable prognostic factor for RFS, both before (HR=0.405, 95% CI: 0.210–0.784; P =0.007) and after matching (HR=0.438, 95% CI: 0.226–0.855; P =0.015). Conclusion For patients with HCC adjacent to MHV requiring hepatectomy, preoperative neoadjuvant therapy confers a significant oncologic benefit by enabling wider surgical margins after tumor-vessel detachment and prolonging RFS.