Revisiting the role of local treatments in the era of targeted therapy and immunotherapy for hepatocellular carcinoma.

The advent of targeted therapy and immunotherapy has revolutionised the management of hepatocellular carcinoma (HCC) patients with all stages, dramatically improving their survival outcomes. Currently, radical resection is still the preferred first-line treatment for early-stage HCC, nevertheless, the surgical outcomes remain unsatisfactory due to high recurrence rate of 70% within 5 years after surgery. Moreover, up to two thirds of diagnosed HCC patients are in the advanced stages of the disease, exhibiting intrahepatic or extrahepatic metastases and vascular invasion. In recent years, the combination of surgical and other local treatments with targeted therapy and immunotherapy has dramatically improved the overall survival for HCC patients and also increased the complexity of HCC management, demanding a dynamic adaptation of the available staging-based strategies and flexible therapeutic allocation. In this review, we mainly elaborate the fundamental principles and recent advancements in the surgical management of locally advanced HCC, such as neoadjuvant, adjuvant and conversion therapy, as well as the regulatory effects of local treatments on targeted therapy and immunotherapy. Finally, the value of splenectomy for unresectable HCC patients with hypersplenism is also discussed.