Surgical resection of vascular-invasive late-stage hepatocellular carcinoma following transarterial chemoembolization combined with lenvatinib and tislelizumab: Two case reports and literature review

Abstract

Rationale: Hepatocellular carcinoma (HCC) with hepatic vein invasion poses significant treatment challenges and is associated with poor prognosis. Recent studies suggest that a combination of transarterial chemoembolization (TACE), targeted therapy, and immunotherapy may downstage advanced tumors, making surgical resection possible.

Patient concerns: A 61-year-old female presented with a 3.7 × 3.1 cm hepatic mass invading the hepatic veins. A 75-year-old male exhibited a 6.7 × 5.1 cm liver tumor involving the right hepatic vein.

Diagnoses: Both patients were diagnosed with advanced HCC with vascular invasion, confirmed by contrast-enhanced imaging and elevated alpha-fetoprotein (AFP) levels.

Interventions: In case 1, the patient received 2 rounds of TACE and 3 cycles of lenvatinib plus tislelizumab. In case 2, the patient underwent 1 TACE session and 2 cycles of the same combination therapy. Both cases showed significant tumor shrinkage, allowing subsequent R0 surgical resection.

Outcomes: Pathological evaluation following surgery revealed a major pathological response in both patients. Postoperative recovery was uneventful, and both patients remained disease-free during follow-up.

Lessons: The combination of TACE, lenvatinib, and tislelizumab may offer an effective multimodal strategy for converting unresectable HCC with vascular invasion into resectable disease, potentially improving long-term outcomes.

Keywords: HCC; TACE; gallbladder; hepatic vein; immunohistochemistry; immunotherapy; lenvatinib; liver metastasis.

Figure 1.

Changes in imaging and laboratory tests for case 1 during clinical treatment. Enhanced CT images before the introduction of TACE. In the portal venous phase (A) and on the unenhanced scan (B), a 3.7 × 3.1 cm mass is visible between the right hepatic vein and the middle hepatic vein. Enhanced CT images after the introduction of TACE. In the portal venous phase (C) and on the unenhanced scan (D), coagulative necrosis of the lesion is visible, with clearer hepatic vein contours than before. Changes in AFP levels during TACE combined with targeted immunotherapy (E). (F) Timeline of the treatment process. TACE = transarterial chemoembolization.

Figure 2.

Changes in imaging and laboratory tests for case 2 during clinical treatment. Enhanced MRI images before the introduction of TACE. In the arterial phase (A), venous phase (B), and diffusion-weighted imaging (C), a 6.7 × 5.1 cm tumor is visible with unclear boundaries with the middle hepatic vein and the right hepatic vein, showing restricted diffusion. Enhanced MRI images after the introduction of TACE. In the arterial phase (D), venous phase (E), and diffusion-weighted imaging (F), the lesions appear smaller than before, with some areas still considered to be active, and the venous contours are relatively clear. Changes in AFP and abnormal prothrombin enzyme levels during TACE combined with targeted immunotherapy (G). (H) Timeline of the treatment process. TACE = transarterial chemoembolization.