Hepatic arterial infusion chemotherapy via arterial infusion port combined with Atezolizumab and Bevacizumab for conversion therapy of advanced hepatocellular carcinoma:A case report and literature review

Hepatic arterial infusion chemotherapy via arterial infusion port combined with Atezolizumab and Bevacizumab for conversion therapy of advanced hepatocellular carcinoma:A case report and literature review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Hepatic arterial infusion chemotherapy via arterial infusion port combined with Atezolizumab and Bevacizumab for conversion therapy of advanced hepatocellular carcinoma:A case report and literature review Jiaxuan Liu, Zichun Zhao, Yulong Tian, Haibo Shao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7149598/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background: The effectiveness of combination therapies with multiple mechanisms of action in treating advanced hepatocellular carcinoma(HCC) has been highlighted by the observed synergistic antitumor effects. The conversion therapy of hepatic arterial infusion chemotherapy(HAIC) with Atezolizumab and Bevacizumab in HCC have rarely been reported. This case reports a conversion therapy of HAIC combined with Atezolizumab and Bevacizumab for hepatocellular carcinoma. Case description: A 58-year-old male patient, with CT diagnosed as a parenchymal liver mass one week before admission, suggested consideration of hepatocellular carcinoma. Magnetic resonance imaging (MR) of the liver in our hospital revealed a huge tumor in the right lobe of the liver with large vascular invasion, suggesting a malignant lesion. We performed the HAIC at the implanted arterial infusion port in the right groin region. The patient achieved a complete response after four cycles of FOLFOX-HAIC combined Atezolizumab withBevacizumab and then removed the intrahepatic lesion by transformation therapy, with no recurrence at 17 months after surgery, which continued until the submission of this article. Progression-free survival was 21 months. Conclusion: The combined approach of FOLFOX-HAIC via transarterial infusion port with Atezolizumab and Bevacizumab showed promising results with the potential to improve treatment compliance in certain patients while providing the opportunity for radical surgical resection of advanced HCC. Given these encouraging results, further research on this combination treatment regimen is necessary, and we need to accumulate more experience to better understand its efficacy and potential wider use in the clinical setting. hepatocellular carcinoma hepatic arterial infusion chemotherapy arterial infusion port targeted therapy immunotherapy conversion therapy case report Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Hepatocellular carcinoma (HCC) is a common cancer and a leading cause of cancer-related death worldwide [1]. Although early disease can be cured by resection, liver transplantation or ablation, many patients show unresectable disease with short survival and poor prognosis [2] . Patients with advanced HCC (BCLC stage C) have a poor overall survival of 6-8 months. Importantly, portal vein tumor thrombosis (PVTT) was found in 10– 40% of HCC patients, which was strongly associated with tumor recurrence and tumor progression, with a significantly reduced median survival time (2–4 months) [3]. HAIC with oxaliplatin, fluorouracil and leucovorin calcium (FOLFOX) regimen alone or in combination with Systemic treatment is recommended in patients refractory to TACE or patients with locally advanced HCC [4]. A randomized phase III trial of the FOLFOX-HAIC regimen versus TACE for large hepatocellular carcinoma showed that FOLFOX-HAIC had higher objective response rates, PFS, and OS than TACE therapy [5].However, the survival benefit of FOLFOX-HAIC alone is still limited. The combination of Atezolizumab (anti-programmed death ligand 1,PD-L1) and Bevacizumab (anti-vascular endothelial growth factor ,VEGF) has become the new standard of treatment for patients with unresectable hepatocellular carcinoma [6] .The conversion therapy of hepatic arterial infusion chemotherapy(HAIC) with Atezolizumab and Bevacizumab in HCC have rarely been reported. Therefore, we report a patient with unresectable advanced HCC with vascular invasion who received FOLFOX-HAIC combined with Atezolizumab and Bevacizumab through the arterial infusion port, finally, the patient was successfully transferred to radical resection with no signs of recurrence. Case description A 58-year-old male,found intrahepatic parenchymal mass due to abdominal distension on September 2022, previous chronic hepatitis C for 25 years with regular antiviral therapy. Preoperative blood routine and tumor marker examination found HCVAb (+), HCV Load <1.50E1, AFP 48.3ng/ml, vitamin K absence or antagonist II (PIVKA-II) 24147.87 mAU/mL. Liver MR suggested: hepatocellular carcinoma in the right lobe of the liver, about 9.7cm * 8.9cm, with thrombus formation in the right hepatic vein, inferior vena cava vein and portal vein (Figure 1, A-D) . The patient was diagnosed as: (1)hepatocellular carcinoma, Barcelona Clinic Liver Cancer(BCLC) C stage; (2)formation of cancer thrombus in the right hepatic vein, inferior vena cava and right posterior portal artery; (3)liver function was Child-PughA; (4)chronic hepatitis C. The patient was discussed by the MDT team of the Interventional Radiology Department of the First Affiliated Hospital of China Medical University and suggested the combination of FOLFOX-HAIC + Atezolizumab + Bevacizumab(FOLFOX-HAIC+A+B) . On 10 October 2022, the patient underwent hepatic artery DSA angiography: successful puncture of the right femoral artery with seldinger technique, 4F arterial sheath and 4Fsimon catheter for selective hepatic angiography, Shvisible tumor staining in the right lobe of the liver, Blood is supplied by the right hepatic artery, Delayed visible hepatic artery-venous fistula and cancer thrombus formation. The tip of the catheter to the right hepatic artery and the end of the artery port were implanted 3cm below the right inguinal ligament. The special 22G needle was successfully inserted into the arterial port. DSA angiography showed good catheter position (Figure 2, A-B) . FOLFOX-HAIC was started through the femoral artery infusion port after returning to the ward. The amount of chemotherapy was calculated based on the patient surface area: oxaliplatin 85mg/m2 (2h,130mg), leucovorin calcium 400mg/m2 (1h,350mg), rapid infusion of 5-fluorouracil (5-FU) 2400 mg /m2 (46h,4500mg), every three weeks with the same next dose. After discharge, the patient received intravenous Atezolizumab + Bevacizumab, and the specific regimen of Atezolizumab + bevacizumab was: atentilizumab 1200mg + bevacizumab 500mg every three weeks. Considering the tumor burden and the toxicity of chemotherapy-targeted immunotherapy, the patient was treated with liver protection and symptomatic treatment. The patient was reviewed after 3 cycles of FOLFOX-HAIC + Atezolizumab + Bevacizumab: AST, ALT, TBIL, AFP and PIVKA-II were within normal range; tumor staining basically disappeared after hepatic artery angiography (Figure 2E) . The enhanced MR of the liver showed that the tumor size and activity were significantly reduced, and the tumor thrombus significantly withdrew in the hepatic vein and portal vein (SupplementaryFigure 1) . The patient had no obvious adverse effects during the hospitalization. According to the consensus of Chinese experts, we believe that this patient met the criteria for salvage hepatectomy[7]. After excluding surgical contraindications, right hemihepatectomy and cholecystectomy were performed on February 13,2023: there was a tumor of about 7*7*6cm in the V segment of the right lobe of the liver, with red and white surface, clear boundaries, and involving the gallbladder bed. The tumor was completely removed along the capsule( Figure 3 ). The residual blood supply to the liver performed well after tumor resection. Postoperative pathology indicated that the tumor thrombus of the right half liver and the right liver vein showed large necrosis, complete tumor necrosis,and no residual tumor tissue, which was consistent with the changes after interventional treatment of HCC (complete response,CR, Figure 3 ). According to the consensus of experts on liver cancer transformation, after successful complete resection of liver cancer transformation, adjuvant treatment should be continued for more than 6 months, and drug withdrawal should be considered after two consecutive imaging examinations without tumor recurrence and metastasis, and tumor markers remain normal for 3 months[7]. Therefore, the patient was given 1200mg Atezolizumab and 500mg Bevacizumab every three weeks. March 2023, July 2023, April 2024, July 2024 (17 months after surgery) liver enhanced MR: no tumor recurrence, tumor markers AFP, and PIVKA-II remained normal.Changes in AFP and PIVKA-II are shown in SupplementaryFigure 2,3. Changes in tumor markers and liver function are shown in Table 1 . During the whole treatment, the patient achieved complete tumor remission after four treatments of FOLFOX-HAIC combined with Atezolizumab and Bevacizumab, with no adverse effects during and after surgery, good liver function, no adverse events related to immunotherapy, and the patient was still in postoperative follow-up.The whole case is chronological in Figure 4 . Discussion The HCC practice guidelines of the Japanese Society of Hepatology have recognized HAIC as an effective treatment for locally advanced HCC, particularly suitable for patients with greater tumor burden with vascular invasion[8]. HAIC is a transarterial treatment that directly injects chemotherapeutic agents into tumor-associated hepatic artery branches to increase local concentrations, thereby rapidly reducing tumor burden and reducing systemic toxicity[9,10]. As a first-line treatment for unresectable large HCC, HAIC-FOLFOX has been demonstrated to show better tumor response, longer PFS and lower toxicity compared with TACE[5]. HAIC has been widely adopted as an alternative to several Asian HCC guidelines[11]. More importantly, since the patient in FOLFOX-HAIC program must be left in bed for 48 hours, it may cause great inconvenience to the patient's life. Based on experience with poor patient compliance, implantable systems are widely used in HAIC therapy[12] and have been written by the Japanese Society of Interventional Radiology guidelines[13]. On the one hand, HAIC with port system is usually suitable for patients with multiple intrahepatic lesions or vascular invasion, and on the other hand, patient activities are not restricted during treatment, improving compliance with many long-term HAIC regimens. With the consent of the patient and his family, we chose to perform FOLFOX-HAIC through the femoral artery infusion port, which avoided multiple puncture and catheterization of the femoral artery and significantly shortened the time of subsequent surgery. Importantly, this approach allows patients to safely and easily receive repeated injections of chemotherapy drugs without compromising their quality of life.In this study, HAIC was treated by the arterial infusion port, and the patient had no obvious postoperative discomfort, and the transarterial infusion port also significantly improved the patient's comfort and satisfaction. The effectiveness of combination therapies with multiple mechanisms of action in the treatment of advanced HCC has been highlighted by the observed synergistic antitumor effects[9,14]. FOLFOX-HAIC has a wide range of anti-tumor activity, with more pronounced inhibitory effects and stronger cytotoxic activity on DNA synthesis in tumor cells. It can also induce immunogenic tumor cell death (ICD). Activation of this process indicates the potential advantage of systemic therapy of FOLFOX-HAIC combined with immune checkpoint inhibitors (ICIs), promoting the upregulation of programmed death ligand 1 (PD-L1) and programmed death 1(PD1) in tumor cells in the immune microenvironment of HCC, thus reducing tumor burden[14,15] . The synergistic action of Atezolizumab + Bevacizumab may normalize tumor blood vessels, combat intratumoral hypoxia, and enhance the efficacy of FOLFOX chemotherapeutic agents[16]. Taken together, these findings underscore the potential of combining local and systemic therapies to significantly benefit this patient population. For patients with advanced HCC, active and effective multidisciplinary combination therapy is an important guarantee for satisfactory efficacy; resection is an important means for long-term survival after successful transformation, which can not only eliminate potential residual tumor cells, but also postoperative pathological examination can provide guidance for adjuvant therapy. Combining FOLFOX-HAIC with Atezolizumab and Bevacizumabhas yielded satisfactory results. Given these encouraging results, further research on this combination treatment regimen is necessary. Declarations Data availability statement The original contributions presented in the study are included in the article/Supplementary Material. Further inquiries can be directed to the corresponding authors. Ethics statement The studies involving humans were approved by The First Affiliated Hospital of China Medical University (Ethical Number:AF-SOP-07-1.2-01) . The participant provided his written informed consent to participate in this study. Author contributions Jiaxuan Liu: Conceptualization, Data curation, Investigation, Writing – original draft. Zichun Zhao: Formal analysis, Software, Writing – original draft. Haibo Shao: Data curation, Funding acquisition, Methodology, Resources, Supervision, Visualization, Writing – review & editing. Yulong Tian: Data curation, Funding acquisition, Methodology, Supervision, Writing – review & editing. Funding The author(s) declare financial support was received for theresearch, authorship, and/or publication of this article. This research was supported by the Natural Science Foundation of Liaoning Province(2023JH2/101700078) and The National Natural Science Foundation of China(No.82372070; No.82072037). Consent for publication Written informed consent was obtained from the patient for publication of this case report, and the accompanying images. Conflict of interest The authors declare no competing interests. References Bray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2024;74:229-63. Llovet JM, Kelley RK, Villanueva A, Singal AG, Pikarsky E, Roayaie S, et al. Hepatocellular carcinoma. Nat Rev Dis Primers 2021;7:6. Han K, Kim JH, Ko GY, Gwon DI, Sung KB. Treatment of hepatocellular carcinoma with portal venous tumor thrombosis: A comprehensive review. World J Gastroenterol 2016;22:407-16. Xie DY, Zhu K, Ren ZG, Zhou J, Fan J, Gao Q. A review of 2022 Chinese clinical guidelines on the management of hepatocellular carcinoma: updates and insights. Hepatobiliary Surg Nutr 2023;12:216-28. Li QJ, He MK, Chen HW, Fang WQ, Zhou YM, Xu L, et al. Hepatic Arterial Infusion of Oxaliplatin, Fluorouracil, and Leucovorin Versus Transarterial Chemoembolization for Large Hepatocellular Carcinoma: A Randomized Phase III Trial. J Clin Oncol 2022;40:150-60. Childs A, Aidoo-Micah G, Maini MK, Meyer T. Immunotherapy for hepatocellular carcinoma. JHEP Rep 2024;6:101130. Zhao HT, Cai JQ. Chinese expert consensus on neoadjuvant and conversion therapies for hepatocellular carcinoma. World J Gastroenterol 2021;27:8069-80. Kudo M, Kawamura Y, Hasegawa K, Tateishi R, Kariyama K, Shiina S, et al. Management of Hepatocellular Carcinoma in Japan: JSH Consensus Statements and Recommendations 2021 Update. Liver Cancer 2021;10:181-223. Zhang TQ, Geng ZJ, Zuo MX, Li JB, Huang JH, Huang ZL, et al. Camrelizumab (a PD-1 inhibitor) plus apatinib (an VEGFR-2 inhibitor) and hepatic artery infusion chemotherapy for hepatocellular carcinoma in Barcelona Clinic Liver Cancer stage C (TRIPLET): a phase II study. Signal Transduct Target Ther 2023;8:413. Iwamoto H, Shimose S, Shirono T, Niizeki T, Kawaguchi T. Hepatic arterial infusion chemotherapy for advanced hepatocellular carcinoma in the era of chemo-diversity. Clin Mol Hepatol 2023;29:593-604. Zhao M, Guo Z, Zou YH, Li X, Yan ZP, Chen MS, et al. Arterial chemotherapy for hepatocellular carcinoma in China: consensus recommendations. Hepatol Int 2024;18:4-31. Jiang X, Aljbri A, Liu J, Shang L, Tian Y, Shao H. Hepatic arterial infusion chemotherapy with implantable arterial access port for advanced-stage hepatocellular carcinoma: a case report. Front Oncol 2024;14:1401882. Ueshima K, Komemushi A, Aramaki T, Iwamoto H, Obi S, Sato Y, et al. Clinical Practice Guidelines for Hepatic Arterial Infusion Chemotherapy with a Port System Proposed by the Japanese Society of Interventional Radiology and Japanese Society of Implantable Port Assisted Treatment. Liver Cancer 2022;11:407-25. Wang Y, Zhao L, Zhang Z, Liu P. Immunogenic cell death inducers and PD-1 blockade as neoadjuvant therapy for rectal cancer. Oncoimmunology 2024;13:2416558. Liu P, Chen J, Zhao L, Hollebecque A, Kepp O, Zitvogel L, et al. PD-1 blockade synergizes with oxaliplatin-based, but not cisplatin-based, chemotherapy of gastric cancer. Oncoimmunology 2022;11:2093518. Liu X, Lu Y, Qin S. Atezolizumab and bevacizumab for hepatocellular carcinoma: mechanism, pharmacokinetics and future treatment strategies. Future Oncol 2021;17:2243-56. Tables Table1. The result of blood test Item Before first HAIC (2022.09) Before second HAIC (2022.10) Before third HAIC (2022.11) Before fourth HAIC (2022.12) Four follow-up After surgery (2023.03-2024.07) Normal range Unit AFP 48.9 6.84 2.26 1.71 2.01 ~ 5.21 0.00-7.00 ng/ml PIVKA-II 24147.87 2032.78 26.07 26.98 27.01 ~ 29.21 0.00-40.00 mAU/mL AST 52 38 26 26 25 ~ 29 15-40 U/L ALT 70 40 40 32 26 ~ 33 9-50 U/L PT 13.7 14.5 14.1 14.3 12.6 ~ 13.1 11.0-13.7 s TBIL 16.7 13.4 8.7 9.8 10.2~13 0.0-26.0 Umol/L AFP: Alpha-fetoprotein; PIVKA-II:vitamin K absence or antagonist II; TBIL:Total bilirubin; PT:Prothrombin time; ALT:Alanine aminotransferase; AST:Aspartate transaminase. Additional Declarations No competing interests reported. Supplementary Files SupplementaryMaterial.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 18 Sep, 2025 Reviews received at journal 29 Aug, 2025 Reviewers agreed at journal 28 Aug, 2025 Reviews received at journal 26 Aug, 2025 Reviewers agreed at journal 17 Aug, 2025 Reviewers invited by journal 16 Aug, 2025 Editor invited by journal 08 Aug, 2025 Editor assigned by journal 24 Jul, 2025 Submission checks completed at journal 24 Jul, 2025 First submitted to journal 17 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7149598","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":504785884,"identity":"ea140831-fb65-43ee-83e0-88b097d63608","order_by":0,"name":"Jiaxuan Liu","email":"","orcid":"","institution":"The First Hospital of China Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jiaxuan","middleName":"","lastName":"Liu","suffix":""},{"id":504785885,"identity":"b4dda938-e1e8-4a35-beca-d16b7ff931cd","order_by":1,"name":"Zichun Zhao","email":"","orcid":"","institution":"The First Hospital of China Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zichun","middleName":"","lastName":"Zhao","suffix":""},{"id":504785886,"identity":"b81cab24-a5fc-4ff5-a64b-ee427f607fc9","order_by":2,"name":"Yulong Tian","email":"","orcid":"","institution":"The First Hospital of China Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yulong","middleName":"","lastName":"Tian","suffix":""},{"id":504785887,"identity":"3c542044-0eeb-449d-8aee-53de72af5df1","order_by":3,"name":"Haibo Shao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA00lEQVRIiWNgGAWjYBACAwbGNiB1gIGBvYHxQAJpWngOMBCrhYENokUiAUQSAczZD7c9+PDnjjy/5OMHBx62Hc5jYD98dAM+LZY9ie2GM9ueGc6cnWZwILHtcDEDT1raDbwOAyqT5m04zLjhdgJYS2KDBI8Zfi3nH7ZJ8/w5bL/h5vEPRGq5AbSFh+1w4oYbPMTacuMhyC+Hk2f25BQcSDiXnthG0C/n058BQ+ywbT/78Y0Pf5RZJ/azHz6GVwsqYGSDRBMp4A+J6kfBKBgFo2BEAADdkFp0wVNe3wAAAABJRU5ErkJggg==","orcid":"","institution":"The First Hospital of China Medical University","correspondingAuthor":true,"prefix":"","firstName":"Haibo","middleName":"","lastName":"Shao","suffix":""}],"badges":[],"createdAt":"2025-07-17 13:38:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7149598/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7149598/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89976297,"identity":"cbe3dfa8-a22b-4411-9e30-e7fbfc770d59","added_by":"auto","created_at":"2025-08-27 06:00:51","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":240788,"visible":true,"origin":"","legend":"\u003cp\u003eMR images of the pre-treatment lesions. A：The axial position showed a 9.7cm * 8.9cm significantly enhanced tumor in the right lobe of the liver at the hepatic artery phase. B：The enhancement of the right liver tumor decreased in the portal phase and the right posterior branch of the portal vein was invaded. C： Formation of inferior vena cava and right hepatic venous tumour thrombus. D： Coronary position shows a giant tumor in the right lobe of the right lobe.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7149598/v1/1f26298fb37a7cf1bd7a84f5.jpg"},{"id":89976303,"identity":"6ebfa371-58c5-42ca-b1e8-91efd0a79db2","added_by":"auto","created_at":"2025-08-27 06:00:52","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":392429,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of DSA images before and after combination therapy and the arterial infusion port implantation. A: First combination treatment of hepatic artery angiography. There were large lesions in the right lobe of the liver and blood was supplied by the right hepatic artery. B: Location and shape of the arterial infusion port implantation. C: Hepatic artery angiography with the second combination therapy: significantly decreased tumor staining. D: Third combination treatment of hepatic angiography: tumor staining was significantly lower than before. E: Hepatic angiography of the fourth combination treatment: the tumor staining basically disappeared.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7149598/v1/8dc4d021db3c2d6977289b78.jpg"},{"id":89976301,"identity":"ad54a9c0-45ce-468b-a358-7e4cb5e7ca55","added_by":"auto","created_at":"2025-08-27 06:00:52","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":337527,"visible":true,"origin":"","legend":"\u003cp\u003eImage of the excised specimen.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7149598/v1/173d0148bc1f39eba5a77bdb.jpg"},{"id":89976304,"identity":"512ce7bb-f15d-4180-9bd5-a4241310e53f","added_by":"auto","created_at":"2025-08-27 06:00:52","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":578803,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of the whole case changing according to the time. A: Tumor of the right hepatic lobe and invasion of the posterior portal vein (red arrow); black arrow represents the right hepatic vein tumour thrombus. B: For the first combined treatment of hepatic arteriography and arterial infusion port implantation, the right lobe of the liver tumor was supplied by the right hepatic artery (red arrow). The black arrow pointed to the location and shape of the arterial port. C: The second combination treatment of hepatic angiography, the tumor staining decreased compared with anterior. D: In the third combination treatment, the tumor staining was reduced compared with the anterior staining. E: In the fourth combination treatment of hepatic angiography, the tumor staining basically disappeared. F: Surgical resection specimen, complete necrosis of liver tumor. G,H,I,J: Four MR examinations after surgery showed no tumor status.\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7149598/v1/c8a7b951a16acd0ec8a89c52.jpg"},{"id":89977360,"identity":"c87023a7-7deb-4d1f-9706-a75f425cd351","added_by":"auto","created_at":"2025-08-27 06:09:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2032210,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7149598/v1/12aec85a-13de-424c-85b8-e5dd469c3d22.pdf"},{"id":89976296,"identity":"945e25b5-062f-42e3-802f-19404065d05e","added_by":"auto","created_at":"2025-08-27 06:00:51","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":312624,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-7149598/v1/85d3374c4f5c059b707b519e.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Hepatic arterial infusion chemotherapy via arterial infusion port combined with Atezolizumab and Bevacizumab for conversion therapy of advanced hepatocellular carcinoma:A case report and literature review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHepatocellular carcinoma (HCC) is a common cancer and a leading cause of cancer-related death worldwide [1]. Although early disease can be cured by resection, liver transplantation or ablation, many patients show unresectable disease with short survival and poor prognosis [2] . Patients with advanced HCC (BCLC stage C) have a poor overall survival of 6-8 months. Importantly, portal vein tumor thrombosis (PVTT) was found in 10\u0026ndash; 40% of HCC patients, which was strongly associated with tumor recurrence and tumor progression, with a significantly reduced median survival time (2\u0026ndash;4 months) [3]. HAIC with oxaliplatin, fluorouracil and leucovorin calcium (FOLFOX) regimen alone or in combination with Systemic treatment is recommended in patients refractory to TACE or patients with locally advanced HCC [4]. A randomized phase III trial of the FOLFOX-HAIC regimen versus TACE for large hepatocellular carcinoma showed that FOLFOX-HAIC had higher objective response rates, PFS, and OS than TACE therapy [5].However, the survival benefit of FOLFOX-HAIC alone is still limited.\u003c/p\u003e\n\u003cp\u003eThe combination of Atezolizumab (anti-programmed death ligand 1,PD-L1) and Bevacizumab (anti-vascular endothelial growth factor ,VEGF) has become the new standard of treatment for patients with unresectable hepatocellular carcinoma [6] .The conversion therapy of hepatic arterial infusion chemotherapy(HAIC) with Atezolizumab and Bevacizumab in HCC have rarely been reported. Therefore, we report a patient with unresectable advanced HCC with vascular invasion who received FOLFOX-HAIC combined with Atezolizumab and Bevacizumab through the arterial infusion port, finally, the patient was successfully transferred to radical resection with no signs of recurrence.\u003c/p\u003e"},{"header":"Case description","content":"\u003cp\u003eA 58-year-old male,found intrahepatic parenchymal mass due to abdominal distension on September 2022, previous chronic hepatitis C for 25 years with regular antiviral therapy. Preoperative blood routine and tumor marker examination found HCVAb (+), HCV Load \u0026lt;1.50E1, AFP 48.3ng/ml, vitamin K absence or antagonist II (PIVKA-II) 24147.87 mAU/mL. Liver MR suggested: hepatocellular carcinoma in the right lobe of the liver, about 9.7cm * 8.9cm, with thrombus formation in the right hepatic vein, inferior vena cava vein and portal vein\u003cstrong\u003e\u0026nbsp;(Figure 1, A-D)\u003c/strong\u003e. The patient was diagnosed as: (1)hepatocellular carcinoma, Barcelona Clinic Liver Cancer(BCLC) C stage; (2)formation of cancer thrombus in the right hepatic vein, inferior vena cava and right posterior portal artery; (3)liver function was Child-PughA; (4)chronic hepatitis C. The patient was discussed by the MDT team of the Interventional Radiology Department of the First Affiliated Hospital of China Medical University and suggested the combination of FOLFOX-HAIC + Atezolizumab + Bevacizumab(FOLFOX-HAIC+A+B) .\u003c/p\u003e\n\u003cp\u003eOn 10 October 2022, the patient underwent hepatic artery DSA angiography: successful puncture of the right femoral artery with seldinger technique, 4F arterial sheath and 4Fsimon catheter for selective hepatic angiography, Shvisible tumor staining in the right lobe of the liver, Blood is supplied by the right hepatic artery, Delayed visible hepatic artery-venous fistula and cancer thrombus formation. The tip of the catheter to the right hepatic artery and the end of the artery port were implanted 3cm below the right inguinal ligament. The special 22G needle was successfully inserted into the arterial port. DSA angiography showed good catheter position\u003cstrong\u003e\u0026nbsp;(Figure 2, A-B)\u003c/strong\u003e. FOLFOX-HAIC was started through the femoral artery infusion port after returning to the ward.\u003c/p\u003e\n\u003cp\u003eThe amount of chemotherapy was calculated based on the patient surface area: oxaliplatin 85mg/m2 (2h,130mg), leucovorin calcium 400mg/m2 (1h,350mg), rapid infusion of 5-fluorouracil (5-FU) 2400 mg /m2 (46h,4500mg), every three weeks with the same next dose. After discharge, the patient received intravenous Atezolizumab + Bevacizumab, and the specific regimen of Atezolizumab + bevacizumab was: atentilizumab 1200mg + bevacizumab 500mg every three weeks. Considering the tumor burden and the toxicity of chemotherapy-targeted immunotherapy, the patient was treated with liver protection and symptomatic treatment.\u003c/p\u003e\n\u003cp\u003eThe patient was reviewed after 3 cycles of FOLFOX-HAIC + Atezolizumab + Bevacizumab: AST, ALT, TBIL, AFP and PIVKA-II were within normal range; tumor staining basically disappeared after hepatic artery angiography\u003cstrong\u003e(Figure 2E)\u003c/strong\u003e. The enhanced MR of \u0026nbsp;the liver showed that the tumor size and activity \u0026nbsp;were significantly reduced, and the tumor thrombus significantly withdrew in the hepatic vein and portal vein\u003cstrong\u003e(SupplementaryFigure 1)\u003c/strong\u003e. The patient \u0026nbsp;had no obvious adverse effects during the hospitalization. According to the consensus of Chinese experts, we believe that this patient met the criteria for salvage hepatectomy[7]. After excluding surgical contraindications, right hemihepatectomy and cholecystectomy were performed on February 13,2023: there was a tumor of about 7*7*6cm in the V segment of the right lobe of the liver, with red and white surface, clear boundaries, and involving the gallbladder bed. The tumor was completely removed along the capsule(\u003cstrong\u003eFigure 3\u003c/strong\u003e). The residual blood supply to the liver performed well after tumor resection. Postoperative pathology indicated that the tumor thrombus of the right half liver and the right liver vein showed large necrosis, complete tumor necrosis,and no residual tumor tissue, which was consistent with the changes after interventional treatment of \u0026nbsp;HCC (complete response,CR,\u003cstrong\u003eFigure 3\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eAccording to the consensus of experts on liver cancer transformation, after successful complete resection of liver cancer transformation, adjuvant treatment should be continued for more than 6 months, and drug withdrawal should be considered after two consecutive imaging examinations without tumor recurrence and metastasis, and tumor markers remain normal for 3 months[7]. Therefore, the patient was given 1200mg Atezolizumab and 500mg Bevacizumab every three weeks. March 2023, July 2023, April 2024, July 2024 (17 months after surgery) liver enhanced MR: no tumor recurrence, tumor markers AFP, and PIVKA-II remained normal.Changes in AFP and PIVKA-II are shown in \u003cstrong\u003eSupplementaryFigure 2,3.\u003c/strong\u003eChanges in tumor markers and liver function are shown in \u003cstrong\u003eTable 1\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eDuring the whole treatment, the patient achieved complete tumor remission after four treatments of FOLFOX-HAIC combined with Atezolizumab and Bevacizumab, with no adverse effects during and after surgery, good liver function, no adverse events related to immunotherapy, and the patient was still in postoperative follow-up.The whole case is chronological in \u003cstrong\u003eFigure 4\u003c/strong\u003e.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe HCC practice guidelines of the Japanese Society of Hepatology have recognized HAIC as an effective treatment for locally advanced HCC, particularly suitable for patients with greater tumor burden with vascular invasion[8]. HAIC is a transarterial treatment that directly injects chemotherapeutic agents into tumor-associated hepatic artery branches to increase local concentrations, thereby rapidly reducing tumor burden and reducing systemic toxicity[9,10]. As a first-line treatment for unresectable large HCC, HAIC-FOLFOX has been demonstrated to show better tumor response, longer PFS and lower toxicity compared with TACE[5]. HAIC has been widely adopted as an alternative to several Asian HCC guidelines[11]. More importantly, since the patient in FOLFOX-HAIC program must be left in bed for 48 hours, it may cause great inconvenience to the patient's life. Based on experience with poor patient compliance, implantable systems are widely used in HAIC therapy[12]\u0026nbsp;and have been written by the Japanese Society of Interventional Radiology guidelines[13]. On the one hand, HAIC with port system is usually suitable for patients with multiple intrahepatic lesions or vascular invasion, and on the other hand, patient activities are not restricted during treatment, improving compliance with many long-term HAIC regimens. With the consent of the patient and his family, we chose to perform FOLFOX-HAIC through the femoral artery infusion port, which avoided multiple puncture and catheterization of the femoral artery and significantly shortened the time of subsequent surgery. Importantly, this approach allows patients to safely and easily receive repeated injections of chemotherapy drugs without compromising their quality of life.In this study, HAIC was treated by the arterial infusion port, and the patient had no obvious postoperative discomfort, and the transarterial infusion port also significantly improved the patient's comfort and satisfaction.\u003c/p\u003e\n\u003cp\u003eThe effectiveness of combination therapies with multiple mechanisms of action in the treatment of advanced HCC has been highlighted by the observed synergistic antitumor effects[9,14]. FOLFOX-HAIC has a wide range of anti-tumor activity, with more pronounced inhibitory effects and stronger cytotoxic activity on DNA synthesis in tumor cells. It can also induce immunogenic tumor cell death (ICD). Activation of this process indicates the potential advantage of systemic therapy of FOLFOX-HAIC combined with immune checkpoint inhibitors (ICIs), promoting the upregulation of programmed death ligand 1 (PD-L1) and programmed death 1(PD1) in tumor cells in the immune microenvironment of HCC, thus reducing tumor burden[14,15]\u003cstrong\u003e.\u003c/strong\u003e The synergistic action of Atezolizumab + Bevacizumab may normalize tumor blood vessels, combat intratumoral hypoxia, and enhance the efficacy of FOLFOX chemotherapeutic agents[16]. Taken together, these findings underscore the potential of combining local and systemic therapies to significantly benefit this patient population.\u003c/p\u003e\n\u003cp\u003eFor patients with advanced HCC, active and effective multidisciplinary combination therapy is an important guarantee for satisfactory efficacy; resection is an important means for long-term survival after successful transformation, which can not only eliminate potential residual tumor cells, but also postoperative pathological examination can provide guidance for adjuvant therapy. Combining FOLFOX-HAIC with Atezolizumab and Bevacizumabhas yielded satisfactory results. Given these encouraging results, further research on this combination treatment regimen is necessary.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe original contributions presented in the study are included in the article/Supplementary Material. Further inquiries can be directed to the corresponding authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe studies involving humans were approved by The First Affiliated Hospital of China Medical University\u003cstrong\u003e(Ethical Number:AF-SOP-07-1.2-01)\u003c/strong\u003e. The participant provided his written informed consent to participate in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJiaxuan Liu: Conceptualization, Data curation, Investigation, Writing\u0026nbsp;\u0026ndash; original draft. Zichun Zhao: Formal analysis, Software, Writing \u0026ndash; original draft. Haibo Shao: Data curation, Funding acquisition, Methodology, Resources, Supervision, Visualization, Writing \u0026ndash; review \u0026amp; editing. Yulong Tian: Data curation, Funding acquisition, Methodology, Supervision, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) declare financial support was received for theresearch, authorship, and/or publication of this article. This research was supported by the Natural Science Foundation of Liaoning Province(2023JH2/101700078) and The National Natural Science Foundation of China(No.82372070; No.82072037).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report, and the accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2024;74:229-63.\u003c/li\u003e\n\u003cli\u003eLlovet JM, Kelley RK, Villanueva A, Singal AG, Pikarsky E, Roayaie S, et al. Hepatocellular carcinoma. Nat Rev Dis Primers 2021;7:6.\u003c/li\u003e\n\u003cli\u003eHan K, Kim JH, Ko GY, Gwon DI, Sung KB. Treatment of hepatocellular carcinoma with portal venous tumor thrombosis: A comprehensive review. World J Gastroenterol 2016;22:407-16.\u003c/li\u003e\n\u003cli\u003eXie DY, Zhu K, Ren ZG, Zhou J, Fan J, Gao Q. A review of 2022 Chinese clinical guidelines on the management of hepatocellular carcinoma: updates and insights. Hepatobiliary Surg Nutr 2023;12:216-28.\u003c/li\u003e\n\u003cli\u003eLi QJ, He MK, Chen HW, Fang WQ, Zhou YM, Xu L, et al. Hepatic Arterial Infusion of Oxaliplatin, Fluorouracil, and Leucovorin Versus Transarterial Chemoembolization for Large Hepatocellular Carcinoma: A Randomized Phase III Trial. J Clin Oncol 2022;40:150-60.\u003c/li\u003e\n\u003cli\u003eChilds A, Aidoo-Micah G, Maini MK, Meyer T. Immunotherapy for hepatocellular carcinoma. JHEP Rep 2024;6:101130.\u003c/li\u003e\n\u003cli\u003eZhao HT, Cai JQ. Chinese expert consensus on neoadjuvant and conversion therapies for hepatocellular carcinoma. World J Gastroenterol 2021;27:8069-80.\u003c/li\u003e\n\u003cli\u003eKudo M, Kawamura Y, Hasegawa K, Tateishi R, Kariyama K, Shiina S, et al. Management of Hepatocellular Carcinoma in Japan: JSH Consensus Statements and Recommendations 2021 Update. Liver Cancer 2021;10:181-223.\u003c/li\u003e\n\u003cli\u003eZhang TQ, Geng ZJ, Zuo MX, Li JB, Huang JH, Huang ZL, et al. Camrelizumab (a PD-1 inhibitor) plus apatinib (an VEGFR-2 inhibitor) and hepatic artery infusion chemotherapy for hepatocellular carcinoma in Barcelona Clinic Liver Cancer stage C (TRIPLET): a phase II study. Signal Transduct Target Ther 2023;8:413.\u003c/li\u003e\n\u003cli\u003eIwamoto H, Shimose S, Shirono T, Niizeki T, Kawaguchi T. Hepatic arterial infusion chemotherapy for advanced hepatocellular carcinoma in the era of chemo-diversity. Clin Mol Hepatol 2023;29:593-604.\u003c/li\u003e\n\u003cli\u003eZhao M, Guo Z, Zou YH, Li X, Yan ZP, Chen MS, et al. Arterial chemotherapy for hepatocellular carcinoma in China: consensus recommendations. Hepatol Int 2024;18:4-31.\u003c/li\u003e\n\u003cli\u003eJiang X, Aljbri A, Liu J, Shang L, Tian Y, Shao H. Hepatic arterial infusion chemotherapy with implantable arterial access port for advanced-stage hepatocellular carcinoma: a case report. Front Oncol 2024;14:1401882.\u003c/li\u003e\n\u003cli\u003eUeshima K, Komemushi A, Aramaki T, Iwamoto H, Obi S, Sato Y, et al. Clinical Practice Guidelines for Hepatic Arterial Infusion Chemotherapy with a Port System Proposed by the Japanese Society of Interventional Radiology and Japanese Society of Implantable Port Assisted Treatment. Liver Cancer 2022;11:407-25.\u003c/li\u003e\n\u003cli\u003eWang Y, Zhao L, Zhang Z, Liu P. Immunogenic cell death inducers and PD-1 blockade as neoadjuvant therapy for rectal cancer. Oncoimmunology 2024;13:2416558.\u003c/li\u003e\n\u003cli\u003eLiu P, Chen J, Zhao L, Hollebecque A, Kepp O, Zitvogel L, et al. PD-1 blockade synergizes with oxaliplatin-based, but not cisplatin-based, chemotherapy of gastric cancer. Oncoimmunology 2022;11:2093518.\u003c/li\u003e\n\u003cli\u003eLiu X, Lu Y, Qin S. Atezolizumab and bevacizumab for hepatocellular carcinoma: mechanism, pharmacokinetics and future treatment strategies. Future Oncol 2021;17:2243-56.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable1.\u003c/strong\u003eThe result of blood test\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"669\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.62332%;\"\u003e\n \u003cp\u003eItem\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.9581%;\"\u003e\n \u003cp\u003eBefore first HAIC\u003c/p\u003e\n \u003cp\u003e(2022.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.5561%;\"\u003e\n \u003cp\u003eBefore second HAIC\u003c/p\u003e\n \u003cp\u003e(2022.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4529%;\"\u003e\n \u003cp\u003eBefore\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ethird HAIC\u003c/p\u003e\n \u003cp\u003e(2022.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0972%;\"\u003e\n \u003cp\u003eBefore\u0026nbsp;\u003c/p\u003e\n \u003cp\u003efourth HAIC\u003c/p\u003e\n \u003cp\u003e(2022.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2362%;\"\u003e\n \u003cp\u003eFour follow-up After surgery\u003c/p\u003e\n \u003cp\u003e(2023.03-2024.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6129%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNormal\u0026nbsp;range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4634%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eUnit\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.62332%;\"\u003e\n \u003cp\u003eAFP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.9581%;\"\u003e\n \u003cp\u003e48.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.5561%;\"\u003e\n \u003cp\u003e6.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4529%;\"\u003e\n \u003cp\u003e2.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0972%;\"\u003e\n \u003cp\u003e1.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2362%;\"\u003e\n \u003cp\u003e2.01 ~ 5.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6129%;\"\u003e\n \u003cp\u003e0.00-7.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4634%;\"\u003e\n \u003cp\u003eng/ml\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.62332%;\"\u003e\n \u003cp\u003ePIVKA-II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.9581%;\"\u003e\n \u003cp\u003e24147.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.5561%;\"\u003e\n \u003cp\u003e2032.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4529%;\"\u003e\n \u003cp\u003e26.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0972%;\"\u003e\n \u003cp\u003e26.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2362%;\"\u003e\n \u003cp\u003e27.01 ~ 29.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6129%;\"\u003e\n \u003cp\u003e0.00-40.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4634%;\"\u003e\n \u003cp\u003emAU/mL\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.62332%;\"\u003e\n \u003cp\u003eAST\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.9581%;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.5561%;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4529%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0972%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2362%;\"\u003e\n \u003cp\u003e25 ~ 29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6129%;\"\u003e\n \u003cp\u003e15-40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4634%;\"\u003e\n \u003cp\u003eU/L\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.62332%;\"\u003e\n \u003cp\u003eALT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.9581%;\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.5561%;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4529%;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0972%;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2362%;\"\u003e\n \u003cp\u003e26 ~ 33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6129%;\"\u003e\n \u003cp\u003e9-50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4634%;\"\u003e\n \u003cp\u003eU/L\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.62332%;\"\u003e\n \u003cp\u003ePT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.9581%;\"\u003e\n \u003cp\u003e13.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.5561%;\"\u003e\n \u003cp\u003e14.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4529%;\"\u003e\n \u003cp\u003e14.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0972%;\"\u003e\n \u003cp\u003e14.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2362%;\"\u003e\n \u003cp\u003e12.6 ~ 13.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6129%;\"\u003e\n \u003cp\u003e11.0-13.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4634%;\"\u003e\n \u003cp\u003es\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7.62332%;\"\u003e\n \u003cp\u003eTBIL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.9581%;\"\u003e\n \u003cp\u003e16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.5561%;\"\u003e\n \u003cp\u003e13.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4529%;\"\u003e\n \u003cp\u003e8.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0972%;\"\u003e\n \u003cp\u003e9.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2362%;\"\u003e\n \u003cp\u003e10.2~13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6129%;\"\u003e\n \u003cp\u003e0.0-26.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4634%;\"\u003e\n \u003cp\u003eUmol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAFP: Alpha-fetoprotein; PIVKA-II:vitamin K absence or antagonist II; TBIL:Total bilirubin; PT:Prothrombin time; ALT:Alanine aminotransferase; \u0026nbsp;AST:Aspartate transaminase.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dion","sideBox":"Learn more about [Discover Oncology](https://www.springer.com/12672)","snPcode":"","submissionUrl":"","title":"Discover Oncology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"hepatocellular carcinoma, hepatic arterial infusion chemotherapy, arterial infusion port, targeted therapy, immunotherapy, conversion therapy, case report","lastPublishedDoi":"10.21203/rs.3.rs-7149598/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7149598/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThe effectiveness of combination therapies with multiple mechanisms of action in treating advanced hepatocellular carcinoma(HCC) has been highlighted by the observed synergistic antitumor effects. The conversion therapy of hepatic arterial infusion chemotherapy(HAIC) with Atezolizumab and Bevacizumab in HCC have rarely been reported. This case reports a conversion therapy of HAIC combined with Atezolizumab and Bevacizumab for hepatocellular carcinoma.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase description: \u003c/strong\u003eA 58-year-old male patient, with CT diagnosed as a parenchymal liver mass one week before admission, suggested consideration of hepatocellular carcinoma. Magnetic resonance imaging (MR) of the liver in our hospital revealed a huge tumor in the right lobe of the liver with large vascular invasion, suggesting a malignant lesion. We performed the HAIC at the implanted arterial infusion port in the right groin region. The patient achieved a complete response after four cycles of FOLFOX-HAIC combined Atezolizumab withBevacizumab and then removed the intrahepatic lesion by transformation therapy, with no recurrence at 17 months after surgery, which continued until the submission of this article. Progression-free survival was 21 months.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e The combined approach of FOLFOX-HAIC via transarterial infusion port with Atezolizumab and Bevacizumab showed promising results with the potential to improve treatment compliance in certain patients while providing the opportunity for radical surgical resection of advanced HCC. Given these encouraging results, further research on this combination treatment regimen is necessary, and we need to accumulate more experience to better understand its efficacy and potential wider use in the clinical setting.\u003c/p\u003e","manuscriptTitle":"Hepatic arterial infusion chemotherapy via arterial infusion port combined with Atezolizumab and Bevacizumab for conversion therapy of advanced hepatocellular carcinoma:A case report and literature review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-27 06:00:43","doi":"10.21203/rs.3.rs-7149598/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-18T14:05:23+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-29T04:41:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"177079794821508945964525517647448903792","date":"2025-08-28T07:32:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-26T04:38:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"102627870397640982263729741405064302721","date":"2025-08-17T11:29:34+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-16T08:31:33+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-08T05:23:26+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-24T06:38:55+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-24T06:35:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Oncology","date":"2025-07-17T13:30:18+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dion","sideBox":"Learn more about [Discover Oncology](https://www.springer.com/12672)","snPcode":"","submissionUrl":"","title":"Discover Oncology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e9ff3be2-7ce5-4315-9fc8-012c3b4baf3c","owner":[],"postedDate":"August 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-18T15:53:38+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-27 06:00:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7149598","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7149598","identity":"rs-7149598","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}