Abstract
Hepatocellular carcinoma (HCC) complicated by portal vein tumor thrombosis (PVTT) is associated with limited therapeutic options and poor survival. Immune checkpoint inhibitors, especially when combined with tyrosine kinase inhibitors (TKIs), locoregional therapies, or radiotherapy, are reshaping the management of advanced HCC; however, the optimal way to integrate these modalities, particularly in patients with vascular invasion and low programmed death-ligand 1 (PD-L1) expression, remains uncertain. Herein, we describe a 52-year-old man with advanced HCC complicated by PVTT who initially received transarterial chemoembolization (TACE), hepatic resection, and adjuvant lenvatinib but later developed postoperative recurrent disease, including a right perirenal lesion and a synchronous right subpleural metastatic lesion. He then achieved a durable complete response and long-term survival with an immunotherapy-centered regimen combining radiotherapy, lenvatinib, and tislelizumab. This case suggests that an immunotherapy-based multimodal regimen integrating TACE, surgery, TKI therapy, radiotherapy, and programmed cell death protein 1 (PD-1) blockade can achieve deep and durable remission in selected patients with advanced HCC and low PD-L1 expression.