Analysis of different prognoses in two hepatocellular carcinoma patients with pathological complete response after conversion therapy: a case report.

BACKGROUND: Hepatocellular carcinoma is a common lethal malignancy, with most patients diagnosed at an advanced stage, precluding surgical resection. Conversion therapy combining locoregional and systemic treatments has emerged as an effective approach to downstage tumors and facilitate curative-intent surgery. However, the prognosis after conversion therapy varies significantly among patients. Case reports can reveal differences in clinical outcomes following conversion therapy and their underlying causes. CASE PRESENTATION: Here, we report two patients of advanced hepatocellular carcinoma with vascular invasion who underwent conversion therapy consisting of hepatic artery infusion chemotherapy, transarterial chemoembolization, targeted therapy (lenvatinib), and immunotherapy (programmed cell death protein 1 inhibitors). Both patients experienced significant tumor shrinkage, allowing successful surgical resection, and postoperative pathology confirmed pathological complete response. However, their long-term prognoses differed markedly: one patient, a 38-year-old male patient of Asian descent, remained recurrence-free for over 4 years, while the other patient, a 47-year-old male patient of Asian descent, experienced recurrence within 11 months after surgery. These differences might be associated with adverse baseline features and imaging findings, including preoperative portal vein tumor thrombus, markedly elevated alpha-fetoprotein, insufficient tumor shrinkage despite radiological complete response, and the coexistence of intrahepatic/extrahepatic bile duct stones, all of which may have predisposed the second patient to early recurrence. CONCLUSION: Although conversion therapy can significantly downstage advanced hepatocellular carcinoma and allow curative-intent resection, the variability in long-term outcomes highlights the critical importance of preoperative tumor characteristics and treatment response assessment. Optimizing patient selection and enhancing postoperative surveillance and intervention strategies may improve long-term outcomes for these patients.