Development and validation of a nomogram to predict surgical resection after conversion therapy in unresectable hepatocellular carcinoma.

[OBJECTIVE] This study aimed to explore factors associated with the likelihood of surgical resection after triple-combination conversion therapy in patients with initially unresectable hepatocellular carcinoma (uHCC) and to develop an exploratory predictive model.

[METHODS] A retrospective analysis was conducted using clinical data from 210 patients with uHCC who underwent triple-combination conversion therapy at Sichuan Cancer Hospital between January 2022 and January 2025. Patients were randomly assigned to a training cohort (n = 147) and a validation cohort (n = 63) in a 7:3 ratio. Least absolute shrinkage and selection operator (LASSO) regression was applied to screen candidate predictors, followed by multivariate logistic regression to identify factors associated with surgical conversion. A nomogram was constructed based on these variables, and its discriminative ability, calibration, and potential clinical utility were internally assessed using receiver operating characteristic (ROC) analysis, calibration plots, the Hosmer-Lemeshow test, and decision curve analysis (DCA).

[RESULTS] Among the 210 patients, 47 (22.4%) successfully underwent conversion and radical resection. Multivariate logistic regression analysis suggested that lower tumor burden score (TBS; OR = 0.663), lower neutrophil-to-lymphocyte ratio (NLR; OR = 0.572), lower C-reactive protein-to-albumin ratio (CAR; OR = 0.057), and absence of cirrhosis (OR = 0.289) were associated with a higher likelihood of successful surgical conversion (P < 0.05). The nomogram showed moderate to good discriminative performance, with areas under the ROC curve (AUCs) of 0.850 (95% CI: 0.784-0.915) in the training cohort and 0.871 (95% CI: 0.783-0.962) in the validation cohort. Calibration plots and decision curve analysis provided descriptive information regarding model performance within the study cohort.

[CONCLUSION] The proposed nomogram, incorporating TBS, NLR, CAR, and cirrhosis status, represents an exploratory tool for estimating the probability of surgical conversion following triple-combination therapy in patients with uHCC. While the model may provide supplementary information to support clinical assessment and patient stratification, further multicenter and prospective studies are required to externally validate and refine its performance before broader clinical application.