Liver Resection After 'T+A' Induction Improves Survival Over Maintenance Therapy

A phase 3 clinical trial found that liver resection significantly prolonged the time to treatment failure compared with maintenance therapy in patients with locally advanced hepatocellular carcinoma who received induction therapy with the combination of atezolizumab and bevacizumab (hereafter, 'T+A').

A research team led by Fan Jia of Fudan University published the findings in the medical journal The Lancet on Aug. 22, 2026. The study is the first phase 3 trial to demonstrate that liver resection is superior to maintenance therapy after 'T+A' induction therapy.

The researchers enrolled 489 treatment-naive patients with hepatocellular carcinoma, macrovascular invasion and no extrahepatic metastases during the induction phase at 24 hospitals in China. Of these, 201 were randomly assigned to a surgery group (101 patients) or a maintenance therapy group (100 patients).

In the analysis, the median time to treatment failure was 20.4 months in the surgery group, 8.6 months longer than the 11.8 months in the maintenance therapy group. The hazard ratio (HR) was 0.60. The R0 resection rate in the surgery group was 93%, and the pathologic complete response rate was 28%.

In terms of safety, the incidence of grade 3 or higher adverse events was higher in the surgery group, at 39% (32 of 83 patients), compared with 21% (21 of 100 patients) in the maintenance therapy group. Common adverse events included elevated alanine aminotransferase (ALT) levels (8% vs. 1%), thrombocytopenia (8% vs. 3%) and proteinuria (4% vs. 7%). Two treatment-related deaths due to liver dysfunction and liver failure were reported in the surgery group.

Hepatocellular carcinoma is a major pathologic type of liver cancer, the sixth most common cancer worldwide and the third-leading cause of cancer death. Systemic therapy is the standard treatment for patients with advanced hepatocellular carcinoma, but complete responses are rare, and treatment generally results only in temporary tumor control.

Accordingly, conversion therapy involving curative resection in some patients whose tumors have shrunk with immunotherapy has attracted attention in guidelines from the European Association for the Study of the Liver (EASL), the Barcelona Clinic Liver Cancer (BCLC) system and the China Liver Cancer (CNLC) guidelines. However, high-quality evidence supporting the approach has been lacking.

The research team said the trial provides level 1 evidence for a conversion resection strategy and could change the treatment paradigm for locally advanced hepatocellular carcinoma.