Surgical resection of vascular-invasive late-stage hepatocellular carcinoma following transarterial chemoembolization combined with lenvatinib and tislelizumab: Two case reports and literature review

Rationale: Hepatocellular carcinoma (HCC) with hepatic vein invasion poses significant treatment challenges and is associated with poor prognosis. Recent studies suggest that a combination of transarterial chemoembolization (TACE), targeted therapy, and immunotherapy may downstage advanced tumors, making surgical resection possible. Patient concerns: A 61-year-old female presented with a 3.7 × 3.1 cm hepatic mass invading the hepatic veins. A 75-year-old male exhibited a 6.7 × 5.1 cm liver tumor involving the right hepatic vein. Diagnoses: Both patients were diagnosed with advanced HCC with vascular invasion, confirmed by contrast-enhanced imaging and elevated alpha-fetoprotein (AFP) levels. Interventions: In case 1, the patient received 2 rounds of TACE and 3 cycles of lenvatinib plus tislelizumab. In case 2, the patient underwent 1 TACE session and 2 cycles of the same combination therapy. Both cases showed significant tumor shrinkage, allowing subsequent R0 surgical resection. Outcomes: Pathological evaluation following surgery revealed a major pathological response in both patients. Postoperative recovery was uneventful, and both patients remained disease-free during follow-up. Lessons: The combination of TACE, lenvatinib, and tislelizumab may offer an effective multimodal strategy for converting unresectable HCC with vascular invasion into resectable disease, potentially improving long-term outcomes.