This study aimed to evaluate the efficacy of hepatectomy versus transcatheter arterial chemoembolization (TACE), both combined with targeted therapy and immunotherapy, in patients with spontaneously ruptured hepatocellular carcinoma (HCC).

We retrospectively reviewed the data of 78 patients with spontaneously ruptured HCC. Patients received targeted therapy and immunotherapy and were stratified into the hepatectomy group (n = 43) or TACE group (n = 35) based on the local treatment modality. Postoperative complications and long-term prognosis were compared.

Multivariable analysis identified TACE (hazard ratio [HR]: 3.394, 95% confidence interval [CI]: 1.777–6.483 for overall survival [OS]; HR: 4.763, 95% CI: 2.601–8.723 for event-free survival [EFS] and vascular invasion (VI) (HR: 3.141, 95% CI: 1.554–6.346 for OS; HR: 3.277, 95% CI: 1.713–6.269 for EFS) as independent risk factors for OS and EFS. An AFP level > 400 ng/mL (HR: 1.944, 95% CI: 1.075–3.518) was identified as an independent risk factor for EFS. The 1-, 3-, and 5-year OS rates for the hepatectomy and TACE groups were 88.4%, 53.9%, and 31.8% and 71.4%, 22.9%, and NA (p = 0.001), respectively, and the 1-, 3-, and 5-year EFS rates were 72.1%, 26.3%, and 23.0% and 45.7%, 0%, and 0% (p < 0.001). Multivariable analysis following propensity score matching showed that TACE, VI, and AFP > 400 ng/mL remained independent risk factors for OS and EFS. The incidence of complications associated with hepatectomy was significantly lower than that associated with TACE (p = 0.031). There were no significant differences between the groups regarding Grade Ⅲ/Ⅳ complications related to hepatectomy or TACE or any grade or Grade Ⅲ/Ⅳ complications related to targeted therapy and immunotherapy (p > 0.05).

Compared with TACE combined with targeted therapy and immunotherapy, hepatectomy combined with targeted therapy and immunotherapy is a safe and effective treatment for patients with spontaneously ruptured HCC. It does not increase the incidence of complications and offers improved long-term prognosis.