A case of a patient with advanced HCC with Vp4 on hemodialysis who responded to a multimodality treatment including hepatic arterial infusion, radiation therapy, immunotherapy, and molecular-targeted drugs.

We report a rare case of a 73-year-old woman on chronic hemodialysis who was diagnosed with unresectable advanced hepatocellular carcinoma (HCC) with Vp4 (portal vein tumor thrombosis in the main trunk) at the initiation of dialysis. Initial treatment consisted of hepatic arterial infusion chemotherapy with cisplatin (CDDP) as a one-shot infusion and radiotherapy targeting the main tumor and Vp4, followed by combination therapy with atezolizumab and bevacizumab (Atezo-Bev). Tumor markers decreased but complete response (CR) was not achieved. As second-line therapy, lenvatinib preceded by CDDP infusion (LEN-CDDP) was initiated, resulting in partial response (PR) by RECIST. Although conversion surgery was proposed, the patient declined, and treatment was temporarily discontinued. Upon tumor marker elevation, third-line therapy with durvalumab and tremelimumab (Dur-Tre) was started, leading to normalization of tumor markers and sustained CR by RECIST. The patient remains alive 19 months after initiation of treatment, with preserved liver function and stable dialysis status. This case demonstrates the feasibility and potential efficacy of combining locoregional and sequential systemic therapies, including immune checkpoint inhibitors and molecular-targeted agents, in dialysis patients with advanced HCC with Vp4, a population with poor prognosis and limited evidence.