Remarkable Response to Immune Checkpoint Inhibitor Therapy in Advanced-Stage Hepatocellular Carcinoma: A Case Report

Advanced hepatocellular carcinoma (HCC) with extrahepatic metastases has a poor prognosis. Immune checkpoint inhibitors have recently become an important treatment option for certain types of cancer. A 58-year-old Kyrgyz male patient with a history of hepatitis B virus (HBV)-related liver cirrhosis for five years was referred to our hospital for liver transplant evaluation. However, a PET-CT (positron emission tomography-computed tomography) scan performed prior to evaluation revealed metastases in the lungs and lymph nodes in different parts of the body. Dynamic liver MRI (magnetic resonance imaging) was consistent with multicentric hepatocellular carcinoma (HCC). The patient had no history of variceal bleeding, hepatic encephalopathy, or ascites. Liver function tests were not elevated, and the baseline AFP (alpha-fetoprotein) level was 463 ng/mL, with a Child-Pugh score of 6 (A). Due to the presence of extrahepatic disease, the patient was not eligible for liver transplantation, and systemic treatment was planned. Systemic treatment was initiated with nivolumab 3 mg/kg + ipilimumab 1 mg/kg at 21-day intervals. These doses were started due to toxicity concerns. The first response evaluation showed an 80% reduction in intrahepatic disease burden and a marked reduction in the size and activity of other metastatic lesions. No side effects beyond grade 1 were observed in the patient. Thus, treatment was continued. In the second treatment response evaluation, although there was an increase in the metabolic activity of some extrahepatic lesions, the reduction in liver lesions was 50% less than the previous one. The patient's general condition was good, and he had no symptoms. The dual therapy started in July 2025 was continued in January 2026 with nivolumab 240 mg every two weeks. This case highlights an extraordinary response to dual immune checkpoint inhibition in metastatic HCC and demonstrates the potential of immunotherapy without compromising efficacy, with some dose adjustments to account for toxicity in selected patients with advanced disease.

Keywords: Case report, Hepatocellular carcinoma, Immunotherapy, Ipilimumab, Nivolumab