Combination Therapy of Transarterial Chemoembolization, Lenvatinib, and PD-1 Inhibitors Achieves Significant Tumor Response in Hepatocellular Carcinoma with Bile Duct Tumor Thrombus: A Case Report

Combination therapy plays a critical role in optimizing surgical outcomes for patients with locally advanced hepatocellular carcinoma (HCC) complicated by bile duct tumor thrombus (BDTT). Current neoadjuvant strategies integrate local and systemic modalities to reduce tumor burden and recurrence rate. However, the combination of transarterial chemoembolization (TACE), lenvatinib, and PD-1 inhibitors (triple therapy) as a neoadjuvant regimen for HCC with BDTT has not been previously reported. Here, we present the case of a 61-year-old man with HBV-associated HCC and BDTT, initially deemed high-risk for direct resection due to tumor size (7 cm) and biliary involvement. The patient underwent one session of TACE followed by two months of lenvatinib (12 mg/day) and sintilimab (200 mg every 3 weeks). Post-treatment contrast-enhanced MRI revealed complete resolution of BDTT and partial response of the primary tumor. Subsequent right hemihepatectomy confirmed extensive tumor necrosis (>90%) with negative margins. At 15-month follow-up, surveillance imaging showed no recurrence. The patient experienced only grade 1 hypertension, managed without treatment interruption. This case highlights the potential of triple therapy as a neoadjuvant approach to downstage advanced HCC with BDTT, enabling curative resection while maintaining a manageable safety profile. Further studies are warranted to validate its efficacy in larger cohorts and define optimal treatment protocols.