Pathologic Complete Response to Neoadjuvant Dual Checkpoint Blockade with Durvalumab Plus Tremelimumab in Advanced-Stage HCC: A Case Report.

Abstract

Current guidelines recommend systemic therapy for patients with Barcelona Clinic Liver Cancer (BCLC) Stage C hepatocellular carcinoma (HCC). However, this population is highly heterogeneous regarding tumor burden, vascular invasion, liver function, and performance status, enabling opportunities for individualized, multimodal strategies. We report the case of a 72-year-old male with a 10 × 7.5 cm HCC and portal vein infiltration involving both the right anterior and left portal branches, in the setting of a past hepatitis C. Due to extensive vascular invasion, the tumor board advised primary systemic therapy with dual immune checkpoint inhibition using Durvalumab and Tremelimumab. After four months of neoadjuvant immunotherapy, restaging showed a partial response with stable liver function. Due to this favorable outcome, the tumor board reassessed resectability and recommended secondary resection. The patient underwent a robotic two-stage hepatectomy with ligation of the right anterior and left portal branches (ALPPS), followed by completion left trisectionectomy 14 days later. Final pathology revealed a complete pathologic response to immunotherapy. At twelve months, the patient remained recurrence-free, with preserved liver function and improved quality of life. This case highlights the potential of neoadjuvant dual checkpoint blockade to induce tumor regression in selected patients with BCLC-C HCC, thereby expanding surgical candidacy even in the presence of macroscopic vascular invasion. Combined with advances in robotic hepatectomy, such multimodal approaches may redefine resectability criteria.