Aggressive Multidisciplinary Treatment for Unresectable Hepatocellular Carcinoma: The Achievement of a Pathologic Complete Response and Long-Term Survival

Hepatocellular carcinoma (HCC) with inferior vena cava (IVC) tumor thrombus is generally considered to be borderline resectable because of its poor prognosis.^1–5 This report describes a patient who underwent multidisciplinary treatment for HCC with massive IVC tumor thrombus.

The 56-year-old woman in this study had diffuse HCC of the medial and anterior segments. She received an explanation of the procedure and provided informed consent. A tumor thrombus was observed in the right atrium through the middle and left hepatic veins and in the anterior branch of the portal vein. The HCC was considered unresectable, and atezolizumab plus bevacizumab combination therapy was initiated. However, the tumor thrombus progressed to the right atrium after two courses. The treatment was changed to hepatic arterial infusion chemotherapy with cisplatin and three-dimensional conformal radiotherapy to the tumor thrombus in the right atrium, followed by systemic lenvatinib.

The patient’s tumor marker levels decreased significantly, and the tumor thrombus regressed into the IVC. Left hepatic trisegmentectomy and IVC tumor thrombectomy were performed.^6–8 Although Clavien-Dindo IIIa postoperative biliary leakage was observed, the patient was discharged on postoperative day 56. Pathologic findings showed no viable residual tumor cells in either the main tumor or the tumor thrombus, and the patient had a pathologic complete response. At this writing, the patient has been recurrence-free for 19 months since the initial treatment without any adjuvant therapy.

This report presents a case of unresectable HCC treated with multimodality therapy followed by salvage surgery. The patient achieved a long-term cancer-free and drug-free status through aggressive treatment. This patient’s experience offers hope for aggressive treatment of advanced HCC.