Durable Response to Combined Nivolumab, Lenvatinib, and Radiation Therapy Against Oligometastatic Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the most common type of liver cancer and is associated with major risk factors such as hepatitis B virus (HBV), hepatitis C virus (HCV), alcoholic fatty liver disease, and metabolic dysfunction-associated steatotic liver diseases. Despite the recent progress in systemic treatment regimens involving immunotherapies and targeted therapeutics, advanced HCC remains difficult to control. Moreover, with several treatment modalities currently available for HCC such as radiation therapy, transarterial chemoembolization (TACE), checkpoint immunotherapies, and multi-tyrosine kinase inhibitors, it is unclear what combination yields the greatest treatment efficacy and durability. Here, we present the case of a male patient in his 60s with HCV-associated cirrhosis diagnosed with HCC with a metastatic lesion to the T9 spine. Treatment with nivolumab and subsequently lenvatinib in addition was complicated by adverse effects including hand rash and kidney injury. Systemic therapy was stopped, and consolidative stereotactic body radiation therapy (SBRT) was delivered to the sites of the disease. The combination proved to be highly durable without any evidence of progression for over three years despite having stopped all therapy. All toxicities have resolved since, and the patient remains very active. This case demonstrates the feasibility of combining therapeutic modalities to achieve exceptional disease control in the setting of oligometastatic disease.