Transarterial chemoembolization combined with atezolizumab plus bevacizumab conversion therapy for intermediate-stage hepatocellular carcinoma: a case report and literature review

Abstract

Hepatocellular carcinoma (HCC) ranks as the sixth most common malignancy globally, with the majority of patients presenting at the initial diagnosis with locally advanced or metastatic disease, precluding the opportunity for curative surgical intervention. With the exploration and advancement of locoregional treatments, novel molecular-targeted therapies, anti-angiogenic agents, and immunomodulatory drugs, the management of HCC has seen an increase in objective response rates and prolonged duration of response significantly enhancing the potential for conversion to resectable disease in intermediate and advanced-stage unresectable HCC. Herein, we present a case of Barcelona Clinic Liver Cancer stage B unresectable HCC, where after two courses of treatment with transarterial chemoembolization combined with atezolizumab plus bevacizumab significant tumor reduction was achieved. Per Response Evaluation Criteria in Solid Tumors 1.1, partial response culminated in successful curative surgical resection. No drug-related adverse reactions occurred during hospitalization, and there has been no recurrence during the 11-month postoperative follow-up. For patients with Barcelona Clinic Liver Cancer stage B (intermediate-stage) unresectable HCC, the transarterial chemoembolization combined with atezolizumab plus bevacizumab regimen may offer improved therapeutic outcomes leading to a higher success rate of conversion therapy and, thus, improved survival.

Keywords: atezolizumab plus bevacizumab; conversion therapy; immunotherapy; intermediate-stage unresectable hepatocellular carcinoma; transarterial chemoembolization.

Figure 1

Imaging pictures. Before TACE combined with Atezo/Bev treatment, the abdomen enhanced CT revealed multiple tumors in the right liver, with the largest measuring approximately 10 cm × 7.50 cm. During the arterial phase, the tumors exhibited uneven enhancement, while during the venous phase, the degree of enhancement was relatively reduced (A, B). Following two courses of TACE combined with Atezo/Bev treatment, the abdomen enhanced CT indicated a significant reduction in the size of the right liver tumors compared to before, with the largest measuring approximately 6.9 cm × 6.2 cm. Patchy high-density shadows were observed internally, considered to be iodine oil deposition after TACE treatment, with no obvious enhancement on the enhanced scan (C, D). Three days after liver resection, the abdomen plain CT indicated postoperative changes in the right liver lobe, with a small amount of free gas around the liver and no significant fluid accumulation (E, F). One month after liver resection, the abdomen enhanced CT revealed postoperative changes in the right liver lobe, with no abnormal enhanced lesions in the liver parenchyma and a small amount of abdominal fluid (G, H). Six months after liver resection, the abdomen enhanced CT indicated the absence of the right liver lobe, with no abnormal enhanced lesions in the liver parenchyma and a small amount of abdominal fluid around the liver (I, J).

Figure 2

During the TACE procedure, the imaging showed staining of the right liver tumors.

Figure 3

Preoperative CT three-dimensional reconstruction model. The black arrow indicates the tumor, the red arrow indicates the portal vein, the yellow arrow indicates the inferior vena cava, and the green arrow indicates the abdominal aorta.

Figure 4

Specimen of tumor resection. Resection specimen of the tumor: there were a total of three tumors, with volumes of 6.9 cm × 6.2 cm × 6 cm, 5 cm × 4 cm × 3.8 cm, and 2.2 cm × 1.8 cm × 1.8 cm, respectively.

Figure 5

Pathological and immunohistochemical images. Histological staining of the tumor sections (HE ×100) revealed poorly differentiated hepatocellular carcinoma accompanied by extensive degeneration and necrosis. The tumor cells exhibited significant atypia, including the presence of giant cells, without satellite nodules, definite neural invasion, or intravascular tumor thrombi. Nodular cirrhosis was observed around the liver section, with partial hepatocyte cholestasis and fatty degeneration (A). AFP demonstrated a positive reaction (B ×100). HepPar-1 exhibited partial positive reaction (C ×100). Ki-67 positivity index was 60% (D ×100).

Figure 6

The graphical depiction of the dynamic shifts in AFP (A), AFP-L3% (B), and PIVKA-II (C) throughout the therapeutic course, along with the treatment timeline (D).