Complete Radiologic Response of the Treated Lesion Following Sequential Transarterial Radioembolization, Chemoembolization, and External Beam Radiotherapy in a Large Hepatocellular Carcinoma with Portal and Hepatic Vein Invasion: A Case Report

Hepatocellular carcinoma (HCC) with macrovascular invasion is classified as Barcelona Clinic Liver Cancer stage C, for which systemic therapy is generally recommended.We report a 68-year-old male with chronic hepatitis B. Magnetic resonance imaging revealed a 9.1-cm HCC with tumor thrombi involving branches of the right hepatic vein and posterior segmental portal vein; staging showed no extrahepatic metastasis.Serum alpha-fetoprotein was within the reference range, whereas protein induced by vitamin K absence or antagonist-II (PIVKA-II) was elevated.After multidisciplinary review, transarterial radioembolization (TARE) was selected for this liver-confined tumor.TARE was performed, followed by consolidative conventional transarterial chemoembolization (cTACE) for persistent viable tumor and external beam radiotherapy (EBRT) to the vascular tumor thrombi.Follow-up computed tomography showed no residual arterial enhancement in the treated intrahepatic lesion, meeting modified Response Evaluation Criteria in Solid Tumors for complete response of the treated target lesion.PIVKA-II normalized after treatment, and hepatic function remained Child-Pugh class A and albuminbilirubin grade 1 throughout, and no treatment-related complication occurred.This case illustrates the feasibility of a TARE-based sequential strategy, with consolidative cTACE and EBRT, for local control in a highly selected patient with liver-confined HCC and segmental portal and hepatic vein tumor thrombosis.