Camrelizumab plus sorafenib or apatinib achieved long-term survival in a patient with hepatocellular carcinoma and an Eastern Cooperative Oncology Group performance status of 3: a case report.

Background: Hepatocellular carcinoma (HCC) remains a global health burden, with limited therapeutic options for patients with poor Eastern Cooperative Oncology Group performance status (ECOG PS). Current guidelines recommend best supportive care (BSC) for patients with HCC and an ECOG PS ≥3, as systemic therapies such as tyrosine kinase inhibitors (TKIs) or immune checkpoint inhibitors (ICIs) are typically restricted to PS 0-1 population. To our knowledge, this may be the first reported case suggesting that targeted therapy combined with ICIs could be feasible and potentially beneficial in a patient with HCC and an ECOG PS of 3. Case Description: A 47-year-old male with hepatitis B-related HCC presented in August 2018 with an 80 mm × 69 mm right hepatic lobe tumor, an ECOG PS of 2, and Child-Pugh class A. He underwent curative resection and adjuvant transcatheter arterial chemoembolization (TACE). In December 2020, recurrence was noted with the tumor lesion measuring 130 mm × 120 mm with accompanying portal vein cancer thrombosis. His ECOG PS was 3 (bedridden >50% of the day), the alpha fetoprotein (AFP) level was >1,000 IU/mL, and the cancer antigen 125 (CA125) level was 118 U/mL. Despite contraindications, sorafenib was initiated but failed to improve symptoms or tumor markers. In February 2021, camrelizumab (21-day cycles) was added to ongoing sorafenib. By May 2021, the ECOG PS improved to 1, and he experienced partial response (PR) according to the Response Evaluation Criteria in Solid Tumors (RECIST) 1.1, and the tumor had shrunk to 87 mm × 64 mm. AFP normalized to 1.63 IU/mL by September 2023. Sorafenib was replaced with apatinib in February 2023 due to rash, but PR was maintained. At the follow-up in March 2025, the patient was alive with a 49-month progression-free survival (PFS) from camrelizumab initiation, stable disease (49 mm × 40 mm), and normal AFP and CA125 levels. Key baseline biomarkers included a neutrophil-to-lymphocyte ratio (NLR) of 3.67 and an albumin-bilirubin (ALBI) grade of 1. Treatment adherence was complicated by financial interruptions but resumed with a combination of apatinib plus camrelizumab. Conclusions: This case may provide preliminary support for the potential use of targeted therapy combined with immune checkpoint inhibitors in patients with HCC and an ECOG performance status of 3.