Hepatic arterial infusion chemotherapy combined with targeted immunotherapy and anticoagulation for hepatocellular carcinoma with right atrial tumor thrombus: a case report.

Background: Hepatocellular carcinoma (HCC) with right atrial tumor thrombus (RATT) carries a poor prognosis with limited therapeutic options. This case report demonstrates that multimodal therapy combining hepatic arterial infusion chemotherapy (HAIC), targeted immunotherapy, and anticoagulation can achieve durable clinical responses in this challenging condition. Case Description: We describe two male patients with advanced HCC (Barcelona Clinic Liver Cancer stage C) and RATT. The first case, a 67-year-old man, presented with extensive tumor thrombus extending to the right atrium. He was treated with a combination of HAIC (FOLFOX), lenvatinib, pembrolizumab, and nadroparin anticoagulation. Follow-up imaging after two months showed complete radiographic resolution of the RATT and marked regression of the intrahepatic lesion. The second case, a 63-year-old man with a history of hepatitis B, developed RATT after progressing on initial systemic therapies. He was subsequently treated with seven cycles of HAIC (FOLFOX) combined with sintilimab, bevacizumab, and peri-procedural anticoagulation. This resulted in a substantial reduction of the intracardiac thrombus. This patient maintained stable disease for 4 years since his initial HCC diagnosis, with the RATT remaining stable for 3 years. Conclusions: Multimodal therapy integrating HAIC with targeted immunotherapy and anticoagulation achieved exceptional tumor control in these HCC-RATT cases. This approach warrants further investigation to optimize protocols and improve outcomes in this difficult-to-treat population.