Liver Transplantation Following Hepatocellular Carcinoma Rupture and Long-Term Immunotherapy: A Case Report.
This case report describes a 54-year-old man with ruptured, multifocal unresectable HCC who received intralesional Pexa-Vec plus prolonged nivolumab, maintained stable disease for four years, underwent liver transplantation after a 12-week immunotherapy washout, and had no reported recurrence or graft rejection at 24 months.
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This case report describes a 54-year-old man with ruptured, multifocal unresectable HCC who received intralesional Pexa-Vec plus prolonged nivolumab, maintained stable disease for four years, underwent liver transplantation after a 12-week immunotherapy washout, and had no reported recurrence or graft rejection at 24 months.
Research significance
The reported single-patient outcome suggests that oncolytic virotherapy combined with PD-1 blockade may provide prolonged disease control and potentially bridge selected advanced HCC patients to transplantation; however, treatment attribution, optimal washout, transplant safety, and generalizability remain unproven and require larger prospective studies.
Source abstract
AIM: To report a case of advanced hepatocellular carcinoma (HCC) complicated by tumor rupture, successfully downstaged with combined oncolytic immunotherapy (Pexa-Vec) and a PD-1 inhibitor (Nivolumab), ultimately enabling liver transplantation (LT). This report highlights the potential role of immune checkpoint inhibitors (ICIs) as bridging therapy in otherwise ineligible patients. METHODS: A 54-year-old male with HCV-related cirrhosis presented with multifocal, unresectable HCC (BCLC C) complicated by hemoperitoneum. Surgery was not indicated. He was enrolled in a Phase I/IIa trial of intralesional Pexa-Vec and intravenous Nivolumab (240 mg every 14 days). Percutaneous biopsies confirmed Edmondson-Steiner grade 2 HCC. Clinical, laboratory, and imaging follow-up were performed throughout therapy. Pre-transplant screening was performed after 4 years of stable disease. RESULTS: The patient received three intralesional Pexa-Vec injections and 93 cycles of Nivolumab over four years, with only mild, transient adverse events. Imaging showed stable disease without extrahepatic spread. Pre-LT evaluation confirmed preserved liver function (Child-Pugh A5, ECOG 0). Immunotherapy was suspended 12 weeks before LT, and LT was performed successfully in September 2023. Post-transplant follow-up (24 months) revealed no recurrence of HCC or graft rejection. HCV was eradicated with direct-acting antivirals. Explant pathology showed complete necrosis in injected nodules and regressive changes in other lesions. CONCLUSIONS: ICIs alone or in combination with oncolytic immunotherapy may serve as novel downstaging strategies in advanced, ruptured HCC. Successful LT with long-term disease-free survival challenges traditional concerns about peritoneal seeding. Larger studies are required to define optimal patient selection, timing, and safety of pre-transplant ICIs. A 54-year-old man with advanced, ruptured liver cancer had an unexpectedly stable course over four years while receiving immunotherapy and an oncolytic virus. He later underwent a liver transplant and remains cancer-free two years later, illustrating the unpredictable nature of some severe liver cancer cases. CLINICAL TRIAL REGISTRATION: Not applicable.