Options and survival benefits of conversion therapy for unresectable hepatocellular carcinoma

In the study by Wu et al,patients with unresectable hepatocellular carcinoma were subjected to transarterial chemoembolization(TACE)as a conversion therapy in order to render their tumors suitable for resection.A nomogram was devised and shown to be effective in predicting the survival of these patients.Generalization of the results,however,is questionable since the study subjects consisted of patients who had resection after TACE while excluding patients with the same disease but not suitable for TACE.Immunotherapy can be considered to be an option for conversion therapy.However,markers for determining responses to a conversion therapy and for guiding the decision between TACE and sequential immunotherapy have been lacking.The question of whether effective conversion therapy can truly enhance overall survival remains unanswered.

Conversion therapy in liver transplantation for hepatocellular carcinoma:What's new in the era of molecular and immune therapy?

Background:Hepatocellular carcinoma(HCC)is the sixth most common cancer globally,with limited therapies and unsatisfactory prognosis once in the advanced stages.With promising advances in locoregional and systematic treatments,fast development of targeted drugs,the success of immunotherapy,as well as the emergence of the therapeutic alliance,conversion therapy has recently become more well developed and an effective therapeutic strategy.This article aimed to review recent developments in conversion therapy in liver transplantation(LT)for HCC.Data sources:We searched for relevant publications on Pub Med before September 2022,using the terms“HCC”,“liver transplantation”,“downstaging”,“bridging treatment”and“conversion therapy.”Results:Conversion therapy was frequently represented as a combination of multiple treatment modalities to downstage HCC and make patients eligible for LT.Although combining various local and systematic treatments in conversion therapy is still controversial,growing evidence has suggested that multimodal combined treatment strategies downstage HCC in a shorter time,which ultimately increases the opportunities for LT.Moreover,the recent breakthrough of immunotherapy and targeted therapy for HCC also benefit patients with advanced-stage tumors.Conclusions:In the era of targeted therapy and immunotherapy,applying the thinking of transplant oncology to benefit HCC patients receiving LT is a new topic that has shed light on advanced-stage patients.With the expansion of conversion therapy concepts,further investigation and research is required to realize the full potential of conversion treatment strategies,including accurately selecting candidates,determining the timing of surgery,improving the conversion rate,and guaranteeing the safety and long-term efficacy of treatment.

Inflammation-related nomogram for predicting survival of patients with unresectable hepatocellular carcinoma received conversion therapy

BACKGROUND The efficacy of conversion therapy for patients with unresectable hepatocellular carcinoma(HCC)is a common clinical concern.AIM To analyse the prognostic factors of overall survival(OS)in patients with unresectable HCC who received conversion therapy.METHODS One hundred and fifty patients who met the inclusion criteria were enrolled and divided into a training cohort(n=120)and a validation cohort(n=30).Using the independent risk factors in the training cohort,a nomogram model was constructed to predict OS for patients treated with transarterial chemoembolization following hepatic resection.The nomogram was internally validated with the bootstrapping method.The predictive performance of nomogram was assessed by Harrell’s concordance index(C-index),calibration plot and timedependent receiver operating characteristic curves and compared with six other conventional HCC staging systems.RESULTS Multivariate Cox analysis identified that albumin,blood urea nitrogen,gamma-glutamyl transpeptidase to platelet ratio,platelet to lymphocyte ratio,macrovascular invasion and tumour number were the six independent prognostic factors correlated with OS in nomogram model.The C-index in the training cohort and validation cohort were 0.752 and 0.807 for predicting OS,which were higher than those of the six conventional HCC staging systems(0.563 to 0.715 for the training cohort and 0.458 to 0.571 for the validation cohort).The calibration plots showed good consistency between the nomogram prediction of OS and the actual observations of OS.Decision curve analyses indicated satisfactory clinical utility.With a total nomogram score of 196,patients were accurately classified into low-risk and high-risk groups.Furthermore,we have deployed the model into online calculators that can be accessed for free at https://ctmodelforunresectablehcc.shinyapps.io/DynNomapp/.CONCLUSION The nomogram achieved optimal individualized prognostication of OS in HCC patients who received conversion therapy,which could be a useful clinical tool to help guide postoperative personalized interventions and prognosis judgement.

Recent advances in conversion therapy schemes for stage Ⅳ gastric cancer

“Conversion therapy”is a treatment modality that involves the use of radiotherapy,chemotherapy,targeted therapy,immunotherapy,and other therapeutic methods to transform initially late-stage tumors that cannot be cured into treatments that can achieve an R0 curative effect.However,selecting an appropriate conversion therapy scheme remains a challenge,and there are currently few relevant studies on this topic.This article reviews successful cases of conversion therapy and clinical studies on treatment schemes,at domestic and international levels,over the past few years to offer a broad range of treatment options for patients.

Current status and perspectives of conversion therapy for advanced gastric cancer

The concept and strategy of advanced gastric cancer treatment have gradually undergone profound changes with the in-depth understanding of the biology and heterogeneous characteristics of gastric cancer.Moreover,the development and application of new anticancer drugs,including chemotherapy drugs,molecularly targeted drugs and immunotherapy drugs for advanced gastric cancer are reported.The connotation of conversion therapy refers to the unresectable or borderline resectable tumors for surgical technical and/or oncological reasons,after active and effective chemotherapy and other comprehensive treatment,the primary gastric lesions can be reduced to a lower stage,while the metastatic lesions can be effectively controlled,to achieve R0 resection and improve the long-term survival rate.Current promising research results of conversion therapy are mostly from single-arm phase II clinical studies with small samples or retrospective studies.Conversion therapy still faces many challenges,including limited diagnostic and assessment methods,insufficient evidence of highly effective treatment regimens,difficulty in clarifying surgical indications,etc.Therefore,the integrated conversion therapy for advanced gastric cancer needs to be carried out with the close cooperation of a multidisciplinary team.Prospective,multi-center randomized controlled trial studies should be conducted in the future,and precision medicine such as molecular biology should be combined to provide better anticancer drug regimens and higher-level clinical evidence for conversion therapy of advanced gastric cancer.

Successful totally laparoscopic right trihepatectomy following conversion therapy for hepatocellular carcinoma:A case report

BACKGROUND About 20%-30%of newly diagnosed hepatocellular carcinoma(HCC)patients are surgically feasible due to a variety of reasons.Active conversion therapy may provide opportunities of surgery for these patients.Nevertheless,the choice of surgical procedure is controversial after successful conversion therapy.We report a patient with HCC who underwent successful laparoscopic right trisectionectomy after conversion therapy with portal vein embolization and transarterial chemoembolization.CASE SUMMARY A 67-year-old male patient presented to our hospital with epigastric distention/discomfort and nausea/vomiting for more than 1 mo.Contrast-enhanced computed tomography scan of the abdomen demonstrated multiple tumors(the largest was≥10 cm in diameter)located in the right liver and left medial lobe,and the left lateral lobe was normal.The future remnant liver(FRL)of the left lateral lobe accounted for only 18%of total liver volume after virtual resection on the three-dimensional liver model.Conversion therapy was adopted after orally administered entecavir for antiviral treatment.First,the right portal vein was embolized.Then tumor embolization was performed via the variant hepatic arteries.After 3 wk,the FRL of the left lateral lobe accounted for nearly 30%of the total liver volume.Totally laparoscopic right trisectionectomy was performed under combined epidural and general anesthesia.The in situ resection was performed via an anterior approach.The operating time was 240 min.No clamping was required during the surgery,and the intraoperative blood loss was 300 mL.There were no postoperative complications such as bile leakage,and the incision healed well.The patient was discharged on the 8th postoperative day.During the 3-mo follow-up,there was no recurrence and obvious hyperplasia of residual liver was observed.Alpha-fetoprotein decreased significantly and tended to be normal.CONCLUSION Due to the different biological characteristics of the liver cancer and the pathophysiological features of the liver from other organs,the conversion treatment should take into account both the feasibility of tumor downstaging and the volume and function of the remnant liver.Our case provides a reference for clinicians in terms of both conversion therapy and laparoscopic right trisectionectomy.

Conversion therapy for advanced penile cancer with tislelizumab combined with chemotherapy:A case report and review of literature

BACKGROUND Locally advanced penile squamous cell carcinoma with unresectable inguinal lymph node metastasis has a poor prognosis,and surgical treatment alone offers limited benefits.Effective conversion therapy regimens are urgently needed.CASE SUMMARY We describe a locally advanced penile squamous cell carcinoma patient with bulky,fixed inguinal lymph node metastasis complicated with genital skin ulcers who underwent inguinal lymph node dissection and achieved a pathological complete response with conversion therapy comprising immunotherapy plus chemotherapy.CONCLUSION For unresectable locally advanced penile squamous cell carcinoma,neoadjuvant immunotherapy combined with chemotherapy is a potential treatment approach.Biomarkers of immunotherapy efficacy need to be explored,and clinical trials are needed to test these strategies.

Conversion therapy of hepatic artery ligation combined with transcatheter arterial chemoembolization for treating liver cancer:A case report

BACKGROUND Hepatocellular carcinoma is an aggressive tumor,and its latency and lack of clinical symptoms mean that most patients are already in the late stage when diagnosed.Large tumor volume and metastasis are the main reasons for not attempting surgery.Portal vein embolization and associated liver partition and portal vein ligation for staged hepatectomy are commonly used in clinical practice to increase the volume of remnant liver to allow surgical resection;however,research in this area is currently lacking.CASE SUMMARY A 48-year-old male patient with a history of viral hepatitis B for at least 30 years attended our center with a hepatic space-occupying lesion detected 3 d previously.Enhanced computed tomography scanning of the upper abdomen revealed a large mass in the right lobe of the liver,centered on the right posterior lobe,with the larger section measuring about 14 cm×10 cm×14 cm.He successfully underwent conversion therapy for a large right liver tumor after combined hepatic artery ligation and transcatheter arterial chemoembolization,and finally had an opportunity to undergo right hemi-hepatectomy and cholecystectomy.He remained asymptomatic with no obvious abnormalities on computed tomography scanning review at 2 mo after surgery.CONCLUSION This case highlights new ideas and provides a reference for conversion therapy of large liver tumors.

Successful conversion of advanced gastric cancer treated by immunotherapy combined with chemotherapy: A case report

Gastric cancer is one of the most common malignant tumors,for patients with advanced gastric cancer,the traditional treatment is mainly chemotherapy or combined targeted therapy;however,these have not achieved ideal efficacy.However,with the continuous deepening of research on molecular targeted drugs and immunosuppressants,the treatment of advanced gastric cancer patients has made new progress,and some new technologies have also been continuously emerged and applied,which brings hope for the treatment of advanced gastric cancer.Recently,several multicenter randomized controlled phase III studies on immunotherapy for advanced gastric cancer yielded encouraging results,demonstrating its superior efficacy in the treatment of advanced gastric cancer.However,prospective data to support the acceptance of surgery and the R0 removal rate following conversion therapy with immune checkpoint inhibitors are lacking.In this study,a 58-year-old woman with advanced gastric cancer and positive PD-L1 expression,negative HER-2 expression,and microsatellite stable status received immunochemotherapy combined with traditional Chinese medicine to achieve R0 resection and satisfactory efficacy.

Efficacy evaluation and survival analysis of the combination of oxaliplatin plus Teysuno (SOX) with immune checkpoint inhibitors in the conversion therapy of locally advanced gastric cancer

Background:The efficacy of combining immune checkpoint inhibitors(ICIs)with chemotherapy in neoadjuvant therapy for locally advanced gastric cancer has been explored.However,limited research exists on its effectiveness in conversion therapy,and its superiority over standalone chemotherapy remains to be elucidated.This study aims to investigate the efficacy and survival outcomes of patients treated with ICIs in combination with conversion therapy for locally advanced gastric cancer.Methods:Retrospective data from patients with locally advanced gastric cancer treated with either oxaliplatin+S-1(SOX)alone or in combination with ICIs in conversion therapywere collected.Clinical andpathological characteristics,disease-free survival,andefficacy assessments in nonoperable patients were compared between the 2 treatment groups.Efficacy was further evaluated through dynamic changes in serum markers,and patients’quality of life was assessed using the QLQ-STO22(Gastric Cancer–Specific Quality of Life Questionnaire)quality-of-life measurement scale.Results:A total of 140 patients underwent conversion therapy:80 in the SOX alone group and 60 in the SOX combined with the ICIs group.There were no significant differences in baseline characteristics between the 2 groups.Compared with the SOX alone group,the SOX combined with ICIs group exhibited a higher conversion rate(83.3%vs 75%,P=0.23),R0 resection rate(90.0%vs 83.3%,P=0.31),pathological complete response(pCR)rate(18%vs 5%,P=0.02),median disease-free survival(21.4 vs 16.9 months,P=0.007),the objective response rate in nonoperable patients(60%vs 40%,P=0.301),and median progression-free survival time(7.9 vs 5.7 months,P=0.009).The QLQ-STO22 quality-of-life assessment revealed statistically significant improvements in pain,swallowing difficulties,and dietary restrictions in the combination therapy group compared with those in the monotherapy group.The enhanced efficacy of immune combination with SOX is evident,as demonstrated by the significantly prolonged surgical duration in operated patients(206.6±26.6 min vs 197.8±19.8 min,P=0.35)and intraoperative blood loss(158.9±21.2 mL vs 148.9±25.1 mL,P=0.59).No significant differences were observed in postoperative complications.Conclusions:Compared with the SOX conversion therapy regimen,SOX combined with ICIs demonstrated higher conversion rates,R0 resection rates,pathological response rates,and disease-free survival without increasing surgical difficulty or complications.Nonoperable patients also experienced longer progression-free survival and objective response rates.

Development of conversion therapy for advanced hepatocellular carcinoma

Although the number of hepatocellular carcinoma(HCC)patients is decreasing due to the development of hepatic anti-virus therapy,it remains a leading cause of cancer-related death worldwide.The recent development of systemic or locoregional therapy for advanced or unresectable HCC has enabled advanced HCC to be downstaged,and reports of conversion therapy have increased;however,many clinical and scientific subjects rely on the therapeutic strategies of advanced HCC.There is a need to assess the evidence and develop clinical guidelines for conversion therapy for HCC;therefore,the Chinese Expert Consensus on Conversion Therapy for Hepatocellular Carcinoma(2021 Edition),consisting of 16 statements,has been developed for clinical practice(1).This consensus addresses treatment strategies for both technically and oncologically unresectable HCCs.We applaud Chinese establishment of this comprehensive and cutting-edge consensus on the treatment of advanced HCC.

Conversion therapy for advanced cholangiocarcinoma in the era of molecular targeted therapy and immune therapy

Cholangiocarcinoma(CCA)encompasses a range of neoplasms,namely intrahepatic CCA,perihilar CCA,and distal CCA,which are distinguished by their anatomical origin.In cases where radical resection of CCA is feasible and the patient’s physical condition permits surgical intervention,it is advisable to proceed with surgical treatment(1).However,the insidious onset of the disease restricts surgical candidacy to only 20-30%of patients(2,3).For those with unresectable CCAs,the recommended initial treatment is gemcitabine plus cisplatin(GemCis)chemotherapy(4).

Chinese expert consensus on conversion therapy for hepatocellular carcinoma(2021 edition)

Recent advances in systemic and locoregional treatments for patients with unresectable or advanced hepatocellular carcinoma(HCC)have resulted in improved response rates.This has provided an opportunity for selected patients with initially unresectable HCC to achieve adequate tumor downstaging to undergo surgical resection,a‘conversion therapy’strategy.However,conversion therapy is a new approach to the treatment of HCC and its practice and treatment protocols are still being developed.Review the evidence for conversion therapy in HCC and develop consensus statements to guide clinical practice.Evidence review:Many research centers in China have accumulated significant experience implementing HCC conversion therapy.Preliminary findings and data have shown that conversion therapy represents an important strategy to maximize the survival of selected patients with intermediate stage to advanced HCC;however,there are still many urgent clinical and scientific challenges for this therapeutic strategy and its related fields.In order to summarize and learn from past experience and review current challenges,the Chinese Expert Consensus on Conversion Therapy for Hepatocellular Carcinoma(2021 Edition)was developed based on a review of preliminary experience and clinical data from Chinese and non-Chinese studies in this field and combined with recommendations for clinical practice.Sixteen consensus statements on the implementation of conversion therapy for HCC were developed.The statements generated in this review are based on a review of clinical evidence and real clinical experience and will help guide future progress in conversion therapy for patients with HCC.

Systematic sequential therapy for ex vivo liver resection and autotransplantation: A case report and review of literature

BACKGROUND Perihilar cholangiocarcinoma(pCCA)is a highly malignant tumor arising from the biliary tree.Radical surgery is the only treatment offering a chance of long-term survival.However,limited by the tumor’s anatomic location and peri-vascular invasion,most patients lose the chance for curative treatment.Therefore,more methods to increase the resectability of tumors as well as to improve outcomes are needed.CASE SUMMARY A 68-year-old female patient had a hepatic hilar mass without obvious symptoms.Laboratory results showed hepatitis B positivity.Magnetic resonance imaging indicated that the mass(maximum diameter:41 mm)invaded the left and right branches of the main portal vein,as well as the middle,left and right hepatic veins;enlarged lymph nodes were also detected in the hilum.The patient was diagnosed with pCCA,and the clinical stage was determined to be T4N1M0(stage IIIC).Considering the tumor’s anatomic location and vascular invasion,systematic conversion therapy followed by ex vivo liver resection and autotrans-plantation(ELRA)was determined as personalized treatment for this patient.Our original systemic sequential therapeutic strategy(lenvatinib and tislelizumab in combination with gemcitabine and cisplatin)was successfully adopted as conversion therapy because she achieved partial response after three cycles of treatment,without severe toxicity.ELRA,anastomotic reconstruction of the middle hepatic vein,right hepatic vein,root of portal vein,inferior vena cava and right hepatic artery,and lymph node dissection were performed at one month after systemic therapy.Pathological and immunohistochemical examination confirmed the diagnosis of pCCA with lymph node metastasis.Although the middle hepatic vein was partially obstructed four months later,hepatic vein stent implantation successfully addressed this problem.The patient has survived for 22 mo after the diagnosis,with no evidence of recurrence or metastasis.CONCLUSION An effective therapeutic strategy for conversion therapy greatly increases the feasibility and efficiency of ELRA.

Chinese expert consensus on neoadjuvant and conversion therapies for hepatocellular carcinoma

The low resection and high recurrence rates in hepatocellular carcinoma(HCC)are the major challenges to improving prognosis.Neoadjuvant and conversion therapies are underlying strategies to overcome these challenges.To date,no guideline or consensus has been published on the neoadjuvant and conversion therapies in HCC.Recent studies showed that neoadjuvant therapy for resectable HCC and conversion therapy for unresectable HCC are safe,feasible,and effective.Neoadjuvant and conversion therapies have the following advantages in treating HCC:R0 resection with sufficient volume of future liver remnant,relatively simple operation,and wide applicability.Therefore,it was necessary to conduct a widely accepted consensus among the experts in China who have extensive expertise and experience in treating HCC using neoadjuvant and conversion therapies,which is important to standardize the application of neoadjuvant and conversion therapies for the management of HCC.The strategies of neoadjuvant therapy include the selection of the eligible patients,therapy regimen,cycles,effect evaluations,and multidisciplinary treatment.The management of patients with insufficient volume of future liver remnant and patients who cannot achieve R0 resection is the key to the strategies of conversion therapy.Here,we present the resultant evidence-and experience-based consensus to guide the application of neoadjuvant and conversion therapies in clinical practice.

Neoadjuvant chemotherapy for colorectal liver metastases:A contemporary review of the literature

Colorectal carcinoma(CRC)is one of the leading causes of cancer-related deaths worldwide,and up to 50%of patients with CRC develop colorectal liver metastases(CRLM).For these patients,surgical resection remains the only opportunity for cure and long-term survival.Over the past few decades,outcomes of patients with metastatic CRC have improved significantly due to advances in systemic therapy,as well as improvements in operative technique and perioperative care.Chemotherapy in the modern era of oxaliplatin-and irinotecancontaining regimens has been augmented by the introduction of targeted biologics and immunotherapeutic agents.The increasing efficacy of contemporary systemic therapies has led to an expansion in the proportion of patients eligible for curative-intent surgery.Consequently,the use of neoadjuvant strategies is becoming progressively more established.For patients with CRLM,the primary advantage of neoadjuvant chemotherapy(NCT)is the potential to down-stage metastatic disease in order to facilitate hepatic resection.On the other hand,the routine use of NCT for patients with resectable metastases remains controversial,especially given the potential risk of inducing chemotherapy-associated liver injury prior to hepatectomy.Current guidelines recommend upfront surgery in patients with initially resectable disease and low operative risk,reserving NCT for patients with borderline resectable or unresectable disease and high operative risk.Patients undergoing NCT require close monitoring for tumor response and conversion of CRLM to resectability.In light of the growing number of treatment options available to patients with metastatic CRC,it is generally agreed that these patients are best served at tertiary centers with an expert multidisciplinary team.

Modified stomach-partitioning gastrojejunostomy for initially unresectable advanced gastric cancer with outlet obstruction: A case report

BACKGROUND Chemotherapy followed by gastrojejunostomy remains the main treatment for unresectable gastric cancer(GC)in the middle-or lower-third regions with gastric outlet obstruction(GOO).Radical surgery is performed as part of a multimodal treatment strategy for selected patients who respond well to chemotherapy.This study describes a case of successful radical resection with completely laparoscopic subtotal gastrectomy after a modified stomach-partitioning gastrojejunostomy(SPGJ)for obstruction relief,in a patient with GOO.CASE SUMMARY During the initial esophagogastroduodenoscopy,an advanced growth was detected in the lower part of the stomach,which caused an obstruction in the pyloric ring.Following this,a computed tomography(CT)scan revealed the presence of lymph node metastases and tumor invasion in the duodenum,but no evidence of distant metastasis was found.Consequently,we performed a modified SPGJ,a complete laparoscopic SPGJ combined with No.4sb lymph node dissection,for obstruction relief.Seven courses of adjuvant capecitabine plus oxaliplatin combined with Toripalimab(programmed death ligand-1 inhibitor)were administered thereafter.A preoperative CT showed partial response;therefore,completely laparoscopic radical subtotal gastrectomy with D2 lymphadenectomy was performed after conversion therapy,and pathological complete remission was achieved.CONCLUSION Laparoscopic SPGJ combined with No.4sb lymph node dissection was an effective surgical technique for initially unresectable GC with GOO.

Neoadjuvant treatment strategies for intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma(ICC)is the second most common primary liver malignancy and is increasing in incidence.Long-term outcomes are optimized when patients undergo margin-negative resection followed by adjuvant chemotherapy.Unfortunately,a significant proportion of patients present with locally advanced,unresectable disease.Furthermore,recurrence rates are high even among patients who undergo surgical resection.The delivery of systemic and/or liver-directed therapies prior to surgery may increase the proportion of patients who are eligible for surgery and reduce recurrence rates by prioritizing early systemic therapy for this aggressive cancer.Nevertheless,the available evidence for neoadjuvant therapy in ICC is currently limited yet recent advances in liver directed therapies,chemotherapy regimens,and targeted therapies have generated increasing interest its role.In this article,we review the rationale for,current evidence for,and ongoing research efforts in the use of neoadjuvant therapy for ICC.

Radio-granular hydrogels for image-guided tumor brachytherapy

Transarterial radioembolization(TARE),derived from transarterial chemoembolization,embolizes tumor blood vessels and elicits tumor brachytherapy by using radionuclide-loaded microspheres,a promising therapeutic modality for locally advanced hepatocellular carcinoma(HCC)[1,2].However,the implementation of TARE in the clinic has been hampered by the lack of efficient radioembolization agents[3,4].

Superstable homogeneous lipiodol-ICG formulation:initial feasibility and first-in-human clinical application for ruptured hepatocellular carcinoma

The most common treatment of spontaneous tumor rupture hemorrhage(STRH)is transcatheter arterial embolization(TAE)followed by liver resection,and surgical navigation using near-infrared fluorescence is effective method for detecting hidden lesions and ill-defined tumor boundaries.However,due to the blockage of the tumor-supplying artery after effective TAE treatment,it is difficult to deliver sufficient fluorescent probes to the tumor region.In this study,we report on the successful application of superstable homogeneous intermixed formulation technology(SHIFT)in precise conversion hepatectomy for ruptured hepatocellular carcinoma(HCC).A homogeneous lipiodol-ICG formulation obtained by SHIFT(SHIFT-ICG)was developed for clinical practice for STRH.A ruptured HCC patient received the combined protocol for embolization and fluorescence surgical navigation and exhibited excellent hemostatic effect.Lipiodol and ICG were both effectively deposited in the primary lesion,including a small metastatic lesion.In follow-up laparoscopic hepatectomy,SHIFT-ICG could clearly and precisely image the full tumor regions and boundaries in real time,and even indistinguishable satellite lesions still expressed a remarkable fluorescence intensity.In conclusion,the simple and green SHIFT-ICG formulation can be effectively used in emergency embolization hemostasis and later precise fluorescence navigation hepatectomy in patients with ruptured HCC bleeding and has high clinical application value.