Massive Hepatocellular Carcinoma with Insufficient Future Liver Remnant Achieved Complete Response After Two-Stage Hepatectomy Combined with Hepatic Arterial Infusion Chemotherapy and Lenvatinib-sintilimab: A Case Report

Abstract: Massive hepatocellular carcinoma (HCC) is not suitable for radical surgery due to the factors of high tumor burden and poor postoperative liver function tolerance. There are few reports on the conversion therapy for HCC with insufficient future liver remnant (FLR) volume using a combination of two - stage hepatectomy (TSH), hepatic arterial infusion chemotherapy (HAIC), and lenvatinib - sintilimab. We report a case of a 62-year-old male with massive HCC (81mm× 11.5mm× 95mm). At the initial diagnosis, the ratio of his FLR to standard liver volume (SLV) was 34%. After multidisciplinary team (MDT) discussion, the patient decided to undergo conversion therapy. After three formal cycles (9 weeks) of conversion therapy, the FLR/SLV ratio increased to 65%, and then right hepatectomy was performed. The lesion achieved a partial response (PR) according to the modified Response Evaluation Criteria in Solid Tumors (mRECIST) criteria. The second hepatectomy was successfully performed, and there was no recurrence during the 36-month postoperative follow-up. In this case, portal vein ligation (PVL) surgery, HAIC, and targeted immunotherapy contributed to the conversion therapy of HCC through different dimensions, including mechanical blood flow blockage, local chemotherapy, and immune regulation, laying the foundation for the safety of radical surgery and long-term postoperative survival. Keywords: conversion therapy, massive hepatocellular carcinoma, insufficient future liver remnant, portal vein ligation, hepatic arterial infusion chemotherapy