Robotic Parenchyma-Sparing Repeat Hepatectomy After Durvalumab Plus Tremelimumab for Recurrent Hepatocellular Carcinoma Abutting the Left Glissonean Pedicle Following Prior Atezolizumab-Bevacizumab Failure: A Case Report

Immune checkpoint inhibitor (ICI)-based combination therapies have expanded the treatment options for hepatocellular carcinoma (HCC), and tumor shrinkage achieved with these regimens can make limited, parenchyma-sparing resection possible.We report the case of a 67-year-old man with multiple HCCs who had received atezolizumab plus bevacizumab without response and then underwent portal vein embolization followed by open right hepatectomy.Forty-eight months after hepatectomy, magnetic resonance imaging revealed new HCC lesions in segments 3 and 4 of the remnant left liver; the segment 4 lesion abutted the main left Glissonean pedicle, which had to be preserved.Durvalumab plus tremelimumab was administered for three courses and produced marked tumor shrinkage, separating the tumor from the pedicle.Robotassisted partial resection of segments 3 and 4 was performed with indocyanine green fluorescence guidance, despite dense adhesions from the previous surgery.The patient was discharged without post-hepatectomy liver failure or complications.Pathology showed well-differentiated HCC without vascular invasion.The patient is alive without recurrence and without systemic therapy 69 months after the initial diagnosis.This case suggests that durvalumab plus tremelimumab can be effective even after atezolizumab-bevacizumab failure, that patient selection for first-line ICI combinations remains an important open question, and that robotic parenchyma-sparing hepatectomy is a reasonable surgical option after systemic therapy.