Hepatocellular carcinoma—neoadjuvant systemic and local treatment concepts to improve resectability rates and oncological outcome

Hepatocellular carcinoma (HCC) is one of the most common cancers with an increasing incidence and high mortality rate worldwide. Surgical resection is still an essential curative-intent treatment for improving the prognosis of patients with HCC. Due to the concomitance of HCC with cirrhosis, chronic liver disease, alcohol consumption and its complications, clinical treatment is challenging. Despite the rational approaches to prevention that have been developed, many patients are diagnosed at an advanced stage and are not eligible for surgical treatment, for example, because of poor underlying liver function or extrahepatic disease spread. The recurrence rates after curative resection still remain high. The implementation of neoadjuvant therapy in HCC management plays an important role in preventing tumor progression, but also shows promising results in downstaging HCC to enable surgical resection. The absence of randomized controlled trials leaves uncertainty in improving outcome, and consensus guidelines are lacking. In this review article, we summarize the clinical efficacy of evolving neoadjuvant treatments for patients with intermediate or advanced stage HCC.