Neoadjuvant and adjuvant systemic treatment for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a highly lethal malignancy, and few patients are candidates for curative-intended therapies. The mainstay of curative treatment in HCC is surgical resection, ablation, and transplantation. However, rates of recurrence are high, and there is no established approach to reduce the risk of recurrence and mortality. We discuss the available data and current landscape of (neo)adjuvant therapies aimed at decreasing recurrence risk and improving overall survival, including liver-directed therapies, tyrosine kinase inhibitors, and immunotherapy. Neoadjuvant strategies aimed at downstaging advanced HCC to enable local treatment and minimize the risk of recurrence using novel agents are also a topic of interest in current research. The improvements achieved in the advanced stages with immune-checkpoint inhibitors are priming ongoing trials that address potential future directions for both adjuvant and neoadjuvant strategies that may change the treatment paradigm of HCC in the near future.