Conversion therapy of a giant HCC with portal vein thrombus and inferior vena cava tumor thrombus

Abstract Background The prognosis of HCC combined with portal and hepatic vein tumor thrombus is poor, with a median survival time of only about 2.7-3 months [1], and treatment requires the cooperation of the MDT team. Prof. Cheng's team gives treatment recommendations based on the classification of portal vein thrombosis and hepatic vein thrombosis. For portal vein tumor thrombus involving the main trunk of the portal vein (PVTT III) and hepatic vein tumor thrombus involving the inferior vena cava, a combination of radiotherapy, TACE, and surgical resection is recommended according to the patient's liver function [2, 3]. The combination of targeted therapy and immune therapy has progressed to become the first-line recommended treatment for advanced HCC [4]. Conversion therapy or conversion surgery (CS) is a surgical strategy developed to improve long-term survival in patients with initially unresectable tumors, aiming at R0 resection after stage reduction by non-surgical treatment [5].CS has also been reported in HCC, radical resection of partially unresectable HCC (UR-HCC) has been achieved through transcatheter arterial chemoembolization (TACE), portal vein embolization, and oral administration of molecular targeted drugs [6.7]. In recent years, the efficacy of atilizumab combined with bevacizumab (Atez + Bev) in the treatment of UR-HCC has been confirmed [8–10]. The above therapeutic advances have brought hope for advanced HCC, but the efficacy is still limited. In our center, a patient with giant HCC combined with portal vein tumor thrombus and hepatic vein tumor thrombus was treated with TACE, radiotherapy, targeted therapy and immunotherapy, and was continuously given Epimedium soft capsules for oral regulation. After 7 months of conversion therapy, the patient's tumor shrank and the tumor thrombus subsided significantly. The pathology of surgical resection was in complete remission, and there was no progression in the postoperative follow-up for 7 months, which provided a basis for the future strategy of combined conversion therapy. CONCLUSION In this case, atezolizumab, bevacizumab, icaritin soft capsules combined with radiotherapy and TACE had a good effect. For patients with hepatocellular carcinoma combined with hepatic vein/inferior vena cava tumor thrombus, adopting a high-intensity, multimodal proactive strategy under the guidance of MDT is an important attempt to break through the current treatment dilemma.