Right-To-Left Stage Migration in Advanced Hepatocellular Carcinoma: A Case Report of a Successful Multimodal Approach.

INTRODUCTION: Hepatocellular carcinoma (HCC) is the most common primary liver malignancy. Over the last decade, the therapeutic landscape of advanced HCC has substantially evolved following the introduction of immune checkpoint inhibitor-based combinations, including anti-programmed death ligand 1 (PD-L1) plus anti-vascular endothelial growth factor agents and dual immune checkpoint blockade strategies targeting programmed death 1 (PD-1) and cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4). Nevertheless, the optimal timing and integration of locoregional therapies following systemic treatment remain poorly defined, particularly in patients achieving major radiological responses. In this setting, multidisciplinary evaluation is essential to guide individualized therapeutic strategies.

CASE PRESENTATION: Herein we present the case of a 68-year-old male with advanced HCC. First-line systemic treatment with atezolizumab plus bevacizumab was administered for 6 cycles, resulting in a major radiological and biochemical response. Following multidisciplinary discussion, selective transarterial embolization was performed as consolidative locoregional treatment. At the last follow-up evaluation at 42 months, the patient remained alive with no evidence of disease recurrence.

CONCLUSION: Our case highlights the potential role of a multidisciplinary therapeutic strategy in selected patients with advanced HCC. The integration of systemic immunotherapy-based treatment with consolidative locoregional therapy may enable successful downstaging and durable disease control, suggesting a possible role of leftward treatment stage migration in advanced unresectable HCC.

CORE TIP: The optimal integration of systemic immunotherapy and locoregional treatment in advanced HCC represents a novel field. No clear evidence has yet been provided regarding the role of systemic therapy as induction in BCLC stage C. Our case report suggests that atezolizumab plus bevacizumab and multidisciplinary approach could improve survival outcomes and treatment definition in selected, advanced HCC patients: it also highlights the importance of interdisciplinary interactions and collaboration in order to ensure the correct therapeutic sequencing.