Hepatocellular carcinoma (HCC) is a malignant tumor that poses a serious threat to human health. The burden of HCC in China is substantial, and most patients are diagnosed at intermediate or advanced stages, with a 5-year survival rate of only 14.4%. Conversion therapy aims to transform initially unresectable HCC into resectable disease to improve patient prognosis, but it faces numerous challenges in clinical practice. First, Chinese HCC patients differ significantly from those in North America, Japan, and other regions in terms of tumor characteristics and etiology, necessitating exploration of localized conversion therapy strategies suitable for Chinese patients. Second, the target population for conversion therapy remains unclear, with controversies over the distinction and patient selection between neoadjuvant and conversion therapies, and a lack of high-level evidence to guide practice. Third, the selection of conversion therapy regimens is challenging, as there are many drug options but no unified standards, and the choice and timing of combined local therapies are difficult to determine, requiring further clinical validation. Moreover, post-conversion treatment strategies are contentious; it remains unclear whether patients achieving radiological or clinical complete response should undergo surgery, preoperative prediction of complete pathological response is difficult, and postoperative sequential strategies and regimen selection are not well defined. Future efforts should focus on identifying biomarkers, conducting multicenter, large-sample, prospective clinical trials, and standardizing treatment protocols and processes to improve the prognosis and quality of life of HCC patients.