Objective   By analyzing the clinical characteristics, treatment options, and prognosis of different stages of sarcomatoid hepatocellular carcinoma (SHC), this study aimed to improve clinicians' understanding of SHC.

  Methods  The clinical data of 24 patients with SHC between January 2015 and December 2019 from First Affiliated Hospital of Zhengzhou University were retrospectively analyzed. There were 16 men and 8 women with a median age of 55 years.

  Results  The clinical symptoms were mainly abdominal pain and fever; 66.7% of the patients had hepatitis virus infection and 79.2% had liver cirrhosis. Patients with stage Ⅲ-Ⅳ carcinoma accounted for 87.5% of the study population. The mean largest tumor diameter was 6.27cm. Patients who were followed up were treated at our hospital, of which one patient underwent liver transplantation, eight underwent surgery, three received locoregional therapy only, and the rest received best support care, chemotherapy, or targeted or combined immunotherapy. Computed tomography or magnetic resonance imaging showed abnormal findings, and biopsy or postoperative pathology was consistent with SHC. The median follow-up period was 4.8(1-39.7) months, and the median overall and disease-free survival of postoperative patients was 4.7 and 2.3 months, respectively. The median overall survival (OS) was 4.8 months for patients with stage Ⅲ-Ⅳ carcinoma.

  Conclusions  For patients with stage I SHC, surgical resection is the preferred treatment. Postoperative adjuvant therapy can benefit patients. For patients with stage Ⅲ-Ⅳ SHC, the benefits of surgery are limited. Systemic chemotherapy, oral targeted drug treatment, or local therapy is feasible for reducing the tumor burden. However, the prognosis of patients with SHC is generally poor, regardless of stage or therapeutic methods. Chemotherapy combined with targeted drugs and immunotherapy may become a new therapeutic direction for advanced SHC.