Abstract: Objective To evaluate the clinical efficacy and analyze of sequential surgical resection for initial unresectable hepatocellular carcinoma treated with interventional therapy combined with targeted immunotherapy. Methods The clinical data from 10 patients with initial unresectable hepatocellular carcinoma admitted to the 3201 hospital of Xi'an Jiaotong University Health Science Center from June 2021 to May 2023 were retrospectively collected and analysed. Results Of the 10 patients, 8 were male and 2 was female, with a median age of 55 years (33~72 years); there were 6 cases with Child Pugh grade A and 4 cases with grade B; 4 cases with CNLC stage IIb and 6 cases with IIIa; The PS scores of all patients were ≤1; there were 6 cases with cirrhosis and 4 cases without cirrhosis; 6 cases with portal vein cancer thrombus and 4 cases without portal vein cancer thrombus;the maximum tumor diameter before transformation therapy was 13 cm, with 7 cases having AFP>400 ng/mL and 3 cases having AFP<400 ng/mL before treatment; There were 7 cases with hepatitis B, 2 cases with hepatitis C and 1 case without viral hepatitis; The conversion treatment programmes included: 1) TACE combined with anti-angiogenic targeting drugs and immune checkpoint inhibitors in 5 cases, 2) HAIC combined with anti-angiogenic targeting drugs and immune checkpoint inhibitors in 5 cases. During the treatment, there were 4 cases with hypertension, 2 cases with fatigue, and 1 case with diarrhea; the median conversion time were 4 months. The maximum diameter of the tumor after conversion therapy before surgery was 8.8 cm, and the median AFP level after conversion therapy before surgery was 17.2 g/mL, In preoperative imaging assessment (mRECIST), there wereCR in 4 cases, PR in 3 cases, SD in 3 cases; preoperative PS score ≤1 point. After therapy, surgical resection was performed: 3 cases underwent partial hepatectomy, 7 cases underwent semi-hepatic resection; 7 cases underwent laparoscopic surgery, and 3 cases underwent open surgery; The median surgical time was 240 minutes. The median intraoperative blood loss was 400 mL.The median postoperative hospital stay was 8 days, and the median postoperative drainage tube removal time was 7 days. The postoperative pathological results shown that there were 3 cases of pCR, 7 cases of pPR, 8 cases of MVI grade M0, 2 cases of M1 , no case of positive resection margin. Postoperative ascites occurred in 1 case, bile leakage in 1 case, and there were no significant postoperative complications. The median follow-up time after surgery was 8 months, with 1 case experiencing recurrence and no patient died during follow-up. Conclusion Sequential surgical resection for initial unresectable hepatocellular carcinoma treated with interventional therapy combined with targeted immunotherapy is effective and safe.

Key words: Unresectable hepatocellular carcinoma, Conversion therapy, Targeted combined immunotherapy, Interventional therapy, Hepatectomy