Aggressive surgical resection and immunotherapy for metastatic omental tumor in hepatocellular carcinoma patient after liver transplantation: a case report

Objectives Omental metastasis is an uncommon manifestation of hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT), and optimal management remains undefined. Immune checkpoint inhibitors (ICIs), particularly atezolizumab combined with bevacizumab, have become first-line systemic therapy for advanced HCC; however, their post‐transplant use is controversial because of potential graft rejection and limited real-world data. Case presentation We report a 67‐year-old woman with stage IIIA HCC who underwent segment 6 hepatectomy and subsequently developed intrahepatic recurrence in segments 2 and 7, leading to living donor liver transplantation (LDLT). Five years after LDLT, surveillance identified a solitary omental mass in the right upper quadrant. The patient underwent complete surgical debulking followed by adjuvant atezolizumab plus bevacizumab under adjusted immunosuppression with close graft surveillance. To assess safety, a post‐treatment liver allograft biopsy was performed and demonstrated low programmed death ligand‐1 (PD‐L1) expression. The patient experienced no clinical or biochemical evidence of rejection and has achieved a progression‐free survival of 24 months with fully preserved graft function. Conclusions This case illustrates the potential feasibility of integrating curative-intent metastasectomy with carefully selected ICI therapy for rare extrahepatic recurrence of HCC after LT. It points out the need for individualized, multidisciplinary decision-making that considers the interval from transplant to ICI initiation, the immunosuppressive strategy, and allograft biomarkers such as PD-L1. While further studies are needed, this experience suggests that, in highly selected scenarios, adjuvant ICI after complete resection of isolated omental metastasis may achieve durable disease control without compromising graft integrity.