Is Alpps Still Appropriate for Large or Locally Advanced Hepatocellular Carcinoma in an Era of Targeted Agents and Immunotherapy? – a Case Series

Abstract

Background: Currently approved therapeutic options for large or locally advanced HCC still have limited efficacy. This study aimed to investigate the efficacy and safety of drug-eluting beads trans-arterial chemo-embolization (dTACE), portal vein embolization (PVE), tyrosine kinase inhibitor (TKI), and immune checkpoint inhibitors (ICI) for large or locally advanced HCC.

Methods: Large or locally advanced HCC patients who received the quadruple therapy (dTACE-PVE-TKI-ICI) between March 2019 and October 2020 at Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology were included. The treatment responses, resection rate, survival duration, survival status, and safety of the quadruple therapy were evaluated.

Results: All four cases responded well to the quadruple therapy. Patients #2 and #4 had complete tumor necrosis, while patients #1 and #3 presented large areas of tumor necrosis. The overall response rate was 4/4. The median increment in percentage future remnant liver volume was 25.9% (range 14.8%–30%) within two months. Patients #1–3 received radical laparoscopic hepatectomy, and patients #4 refused the following surgery for the complete tumor necrosis. All cases remained alive without any tumor recurrence during a median follow-up of 20 months (range, 13–29 months). No severe adverse events occurred during the therapy process.

Conclusion: The quadruple therapy is a feasible and effective strategy for increasing the resectability via downsizing the tumor while inducing future remnant liver hypertrophy, with manageable problems and improved long-term prognosis. In addition, it provokes the re-examination of the application of ALPPS in an era of molecular and immune treatments.

Funding Information: This work was supported by grants from National Natural Science Foundation of China (grants 81874149, 82003403).

Declaration of Interests: All authors have completed the ICMJE uniform disclosure form. The authors have no conflicts of interest to declare.

Ethics Approval Statement: Written informed consent for data use was obtained from all patients. The study was in accordance with the Declaration of Helsinki and the Ethics Committee approved the study protocol of Tongji Hospital, Tongji medical college, within Huazhong University of Science and Technology.

Keywords: hepatocellular carcinoma, Trans-arterial Chemo-embolization, portal vein embolization, tyrosine kinase inhibitor, immune checkpoint inhibitor