A Huge Hepatocellular Carcinoma With Major Arteriovenous Shunt Successfully Treated With Chemoembolization Plus Lenvatinib Therapy Followed by Radiotherapy

Background/Aim: Large hepatocellular carcinoma (HCC) (defined as ≥10 cm) is associated with a poor prognosis in both resectable and unresectable patients. Liver resection and multidisciplinary treatment are recommended for solitary huge and multiple huge HCCs, respectively.

Case Report: The patient presented with a hypervascular HCC measuring over 10 cm in the right liver lobe and a suspected hypovascular tumor in the medial segment. He had nonB-nonC hepatitis with metabolic disease together with untreated 3-vessel coronary artery disease. Transarterial chemoembolization (TACE) and lenvatinib treatment were performed in parallel with coronary stent treatment. The treatment for HCC was effective, with the tumor’s contrast enhancement almost completely disappearing and the protein induced by the absence of vitamin K or antagonist-II level decreasing from 91,616 mAU/ml to 152 mAU/ml. After portal vein embolization, the tumor became resectable; however, the patient did not consent to a major hepatectomy. Only contrast-enhanced ultrasonography showed viable tumor tissue near the hepatic hilar Glissonean capsule. These tumors were contraindicated for thermal ablation; therefore, intensity-modulated radiation therapy (30 Gy/10 fractions) was performed. Percutaneous microwave ablation was successfully applied to another growing HCC in the medial segment. Three years after the initial treatment, the patient remains well and free of disease.

Conclusion: For patients who are contraindicative for immune checkpoint inhibitors or major liver resection, TACE plus lenvatinib followed by radiotherapy is safe and potentially an optimal treatment option.