Immunotherapy Sensitizes the Efficacy of Arterial and Portal Vein Embolization before Major Hepatectomy in Patients with Hepatocellular Carcinoma

Abstract Objective The aim of this study was to evaluate the efficacy of immune checkpoint blockades (ICBs) in sequential transarterial chemoembolization (TACE) and portal vein embolization (PVE) prior to surgery in patients with hepatocellular carcinoma (HCC). Background Sequential TACE and PVE can promote hypertrophy of the future liver remnant (FLR) and improve resectability in patients with HCC. Effect of ICBs on sequential TACE and PVE remained scarce. Methods Between 2014 and 2024, 145 patients with HCC underwent sequential TACE and PVE were enrolled, including 49 patients who received ICBs prior to PVE (IM group), whereas 96 patients without ICBs (CON group). Clinicopathological characteristics, liver function, FLR growth kinetics, and surgical and oncological outcomes were compared between groups. Results Baseline characteristics and perioperative outcomes were comparable between groups. ICBs significantly enhanced liver regeneration, as reflected by a higher kinetic growth rate (3.6 vs. 2.8 mL/day, P = 0.046). The rate of subsequent hepatectomy was higher in the IM group (71.4% vs. 59.4%), although not statistically significant ( P = 0.154). ICBs significantly improved event-free survival in the IM group ( P = 0.037). Among patients undergoing hepatectomy, recurrence-free and overall survival were also significantly improved in the IM group compared with the CON group. Pathological evaluation demonstrated a markedly higher rate of complete tumor necrosis (33.3% vs 7.3%, P = 0.002) and increased infiltration of CD8⁺ T cells ( P = 0.048). Conclusions Immunotherapy of ICBs effectively increases the rate of FLR hypertrophy in patients with HCC who underwent sequential TACE and PVE. And immunotherapy significantly improves patients’ prognosis after sequential TACE and PVE.