Laparoscopic Extended Left Hepatectomy and Portal Vein Thrombectomy for Advanced Hepatocellular Carcinoma After Second-Line Conversion Therapy.

Résumé

BACKGROUND: Hepatocellular carcinoma with portal vein tumor thrombus (HCC-PVTT) is correlated with poor prognosis. Recent advances in first-line therapies have enabled some patients with HCC-PVTT to become candidates for curative resection. However, over 50% of patients experience disease progression during initial treatment, and subsequent second-line options remain limited. Furthermore, reports on radical resection in patients with HCC-PVTT after second-line therapy are scarce. Herein, this case highlights the successful downstaging of HCC-PVTT with second-line therapy, followed by laparoscopic hepatectomy and portal vein thrombectomy.METHODS: A 56-year-old patient with HCC-PVTT involving the main and left portal veins initially received camrelizumab, apatinib, and systemic FOLFOX (oxaliplatin, fluorouracil, leucovorin). After 3 cycles, the PVTT progressed to the right portal vein. The multidisciplinary team recommended switching to second-line therapy with regorafenib, adebrelimab, and hepatic arterial infusion chemotherapy.RESULTS: The patient experienced progression after first-line therapy (tumor enlargement, PVTT extension), and second-line therapy achieved notable shrinkage of both the tumor and the PVTT. After 5 cycles, surgical resection was feasible. Laparoscopic extended left hepatectomy with portal vein thrombectomy was completed in 340 minutes, with 100 mL blood loss. Pathology revealed HCC with extensive necrosis. Postoperative regorafenib and adebrelimab was administered for 3 cycles, and the patient remains recurrence free to date.CONCLUSION: This case report highlights that, for patients with HCC-PVTT with first-line therapy resistance, actively applying second-line therapy can still yield an opportunity for radical resection. It also suggests the feasibility of laparoscopic extended hepatectomy with thrombectomy, emphasizing the value of individualized, multidisciplinary strategies for improving outcomes in complex HCC cases.