Liver transplantation following HCC rupture and long-term immunotherapy: a case report

Abstract

Introduction Liver transplantation (LT) provides a curative option for patients with cirrhosis and early-stage hepatocellular carcinoma (HCC). Recently, the use of immune checkpoint inhibitors (ICIs) has broadened treatment options for advanced HCC. Their role in downstaging and bridging to LT, especially in cases complicated by tumor rupture, is still under investigation. Herein, we report a case of a man with advanced HCC who underwent a successful LT after a prolonged treatment with ICIs. Case ReportA 54-year-old Caucasian male was admitted to a Spanish Hospital in June 2019 due to hypovolemic shock secondary to hemoperitoneum. A CT scan showed multifocal lesions within the liver (the majors being 8 cm in diameter at the VIIIs and 4 cm at the IIIs) with radiological features consistent with advanced HCC without biliary or vascular invasion; intraperitoneal bleeding was due to rupture of a nodule. AFP level was 219.8 ng/ml. The patient was then transferred to Our Center with a diagnosis of multifocal HCC in HCV-positive cirrhosis (see figure 1), with a preserved liver function (Child-Pugh A5). The patient underwent percutaneous intralesional injections of Pexa-Vec (3 injections) in the largest nodule and was started on Nivolumab 240 mg IV every 14 days. Both treatments were well tolerated, and no significant complications were recorded. HCV infection was treated using a direct-acting antiviral (sofosbuvir/velpatasvir), with SVR. The patient received a total of 93 ICIs infusions by May 2023. CT, MRI, and PET scans were then performed, which did not show the presence of active disease or portal vein thrombosis (see Figure 1). AFP levels were within the normal range. Considering the complete oncological response, the patient was subsequently screened for an LT, which was performed in September 2023, approximately 12 weeks after discontinuation of Nivolumab. As for July 2025, 21 months after LT, the patient is doing well; he has not experienced any episode of acute cellular rejection, and no radiological signs of HCC recurrence have been recorded. ConclusionsThis is the first case report on a successful LT performed after prolonged ICIs treatment for an advanced HCC with spontaneous intraperitoneal rupture. The positive outcome of LT challenges conventional concerns regarding peritoneal seeding and recurrence risks in ruptured HCC. Moreover, the case supports the emerging role of ICIs in managing advanced HCC, potentially extending transplant eligibility for carefully selected patients. Further research is ongoing to establish guidelines for integrating these therapies into long-term treatment LT protocols.