DEB-TACE Combined with Immunotherapy and Targeted Therapy for Advanced Hepatocellular Carcinoma with Scapular Metastasis: A Case Report

Abstract

Background

Advanced hepatocellular carcinoma (HCC) with massive intrahepatic tumors and bone metastases is associated with poor prognosis, and standard treatment options are limited. Bone metastases, particularly to rare sites such as the scapula, pose additional therapeutic challenges.

Case Presentation

We report a patient with a giant intrahepatic HCC and scapular metastasis. The patient received three sessions of drug-eluting bead transarterial chemoembolization (DEB-TACE) combined with systemic therapy using lenvatinib and camrelizumab. Marked radiological regression and improvement in tumor markers were observed. The patient remained progression-free at the last documented follow-up of 16 months.

Conclusion

The combination of DEB-TACE, lenvatinib, and camrelizumab for treating advanced hepatocellular carcinoma with scapular metastasis was shown to be feasible in this case and was associated with sustained disease control of both intrahepatic and extrahepatic lesions.

Introduction

Hepatocellular carcinoma (HCC) has high incidence and mortality rates worldwide.¹ Because the disease often develops insidiously, many patients are diagnosed at an intermediate or advanced stage, by which time the opportunity for curative surgery has been lost.^1,2 For patients with advanced HCC and extrahepatic spread, systemic therapy constitutes the principal treatment backbone. Transarterial chemoembolization (TACE), including drug-eluting bead TACE (DEB-TACE), is primarily a locoregional treatment and may be considered selectively for control of dominant intrahepatic tumor burden or symptomatic hypervascular lesions in individualized multidisciplinary management. For unresectable HCC, transarterial chemoembolization (TACE) is one of the standard treatments,among this drug-eluting beads TACE (D-TACE) has demonstrated superior local drug delivery and reduced systemic toxicity compared with conventional TACE.³

Bone metastases are a common site of extrahepatic spread in advanced HCC, second only to lung involvement, and are associated with pain, fractures, and decreased quality of life;⁴ Metastasis to the scapula is particularly rare, with only a few cases reported worldwide,^5,6 and may present as the initial symptom, highlighting the heterogeneity of HCC metastatic patterns. The management of such cases is challenging, as local and systemic disease must be addressed concurrently. Recent advances in systemic therapy, including immune checkpoint inhibitors (eg, PD-1 inhibitors) and anti-angiogenic targeted agents, have improved survival outcomes in advanced HCC.^7,8 Moreover, combining TACE with targeted therapy and immunotherapy has demonstrated synergistic effects, enhancing tumor response and prolonging progression-free survival in mid-to-late stage disease. In a study of DEB-TACE combined with apatinib and camrelizumab for massive hepatocellular carcinoma(HCC) revealed the objective response rates at 1, 3, 6, and 12 months were 65.71%, 71.43%, 65.71%, and 60.71%, respectively. The median progression-free survival (PFS) was 8.09 months, median overall survival was 20 months, and adverse reactions were manageable.⁹

The clinical interest of the present case lies not in the scapular metastatic site alone, which has previously been reported, but in the individualized multimodal management of a large intrahepatic HCC together with a symptomatic, hypervascular scapular metastatic lesion. Given the rarity of scapular metastasis in HCC and the limited evidence on combination therapy in such cases, this report aims to provide insight into the feasibility and efficacy of DEB-TACE combined with systemic targeted and immunotherapy.

Here, we present a case of a patient with advanced HCC and scapular metastasis who received DEB-TACE combined with systemic targeted therapy (lenvatinib) and immunotherapy (camrelizumab). Sustained disease control was observed during follow-up. This case illustrates the potential benefit of a multimodal approach for controlling both intrahepatic and extrahepatic lesions in advanced HCC.

Case Presentation

A 72-year-old male patient presented in November 2024 with a chief complaint of right shoulder pain for over two months, accompanied by nausea and vomiting for more than one month. His medical history was notable for chronic hepatitis C spanning over 30 years. At baseline, the patient had Child–Pugh class A liver function and an ECOG performance status of 1. Laboratory results showed a total bilirubin level of 12.0 μmol/L, serum albumin of 40 g/L, an INR of 0.97, a platelet count of 164 × 10⁹/L, and serum creatinine of 77 μmol/L. The patient had HCV-related cirrhosis and reported previous self-administered antiviral treatment, although details of the regimen and duration were unavailable. HCV RNA status was not documented.

Initial contrast-enhanced computed tomography (CT) and three-dimensional imaging demonstrated osteolytic destruction of the right scapula with a pathological fracture and an adjacent soft-tissue mass measuring approximately 7.3 × 4.8 × 6.8 cm, showing heterogeneous enhancement (Figure 1A–C). Enhanced CT of the upper abdomen revealed an 8.7 × 7.6 cm mass in the lower segment of the right hepatic lobe, with arterial-phase hyperenhancement, washout in the portal and equilibrium phases, and delayed pseudocapsule enhancement (Figure 1D–F). Portal vein tumor thrombus or other macrovascular invasion was absent. No histopathological biopsy was performed. The diagnosis of HCC was made according to established clinical diagnostic criteria, primarily on the basis of characteristic multiphasic contrast-enhanced imaging findings showing arterial-phase hyperenhancement with subsequent washout in the portal and delayed phases. The elevated serum AFP level and long-standing history of chronic hepatitis C further supported the clinical diagnosis.

Figure 1.

Imaging diagnosis of scapular area and hepatic mass. (A and B) contrast-enhanced computed tomography (ct) demonstrated osteolytic destruction of the right scapular with a pathological fracture and an adjacent soft-tissue mass measuring approximately 7.3 × 4.8 × 6.8 cm, showing heterogeneous enhancement. (C) Three-dimensional imaging of the scapular region. (D–F) Enhanced ct of the upper abdomen revealed an 8.7 × 7.6 cm mass in the lower segment of the right hepatic lobe, with arterial-phase hyperenhancement, washout in the portal and equilibrium phases, and delayed pseudocapsule enhancement. The arrow indicates the lesion.

Positron emission tomography–computed tomography (PET-CT) demonstrated clump-like and nodular lesions in the right hepatic lobe with heterogeneous metabolic activity, highly suggestive of primary liver cancer. Bone destruction was observed in the right scapula and T1 vertebra, with adjacent soft tissue involvement and increased metabolic uptake, consistent with metastatic disease. Laboratory evaluation revealed the following: carcinoembryonic antigen (CEA), 2.51 ng/mL; alpha-fetoprotein (AFP), 119.00 ng/mL; carbohydrate antigen 19–9 (CA19-9), 32.9 U/mL; carbohydrate antigen 125 (CA-125), 11.30 U/mL; and hepatitis C virus (HCV) IgG antibody, 56.100 S/CO. The disease was classified as China Liver Cancer (CNLC) stage IIIB, Barcelona Clinic Liver Cancer (BCLC) stage C, and American Joint Committee on Cancer/Union for International Cancer Control (AJCC/UICC) TNM stage IV.

Treatment and Follow-Up

The patient received three consecutive cycles of DEB-TACE starting on November 19, 2024. The second and third procedures were performed on December 11, 2024 and January 9, 2025, respectively. Systemic therapy was considered the treatment backbone because of extrahepatic metastatic disease. The addition of transarterial treatment was individualized in view of the dominant intrahepatic tumor burden, preserved liver function, performance status 1 point, and the symptomatic hypervascular scapular metastatic lesion with pathological fracture. The treatment strategy was discussed within a multidisciplinary team. All interventional procedures were performed under fluoroscopic guidance using local anesthesia (5 mL lidocaine). Angiography identified tumor supply from the right posterior hepatic artery for the hepatic lesion and from the thoracoacromial and posterior circumflex humeral arteries for the scapular metastatic lesion (Figure 2A–E). Superselective catheterization of the tumor-feeding arteries was performed, followed by embolization using CalliSpheres microspheres (300–500 μm) loaded with epirubicin. A total dose of 50 mg epirubicin was administered during each interventional procedure. Embolization was continued until a marked reduction in tumor blush and near-stasis of flow in the tumor-feeding arteries were achieved. Mild post-embolization syndrome occurred after the procedures, mainly consisting of mild abdominal pain and transient fever, and was managed conservatively. No severe procedure-related complications were observed. Oral lenvatinib (12 mg, once daily) was administered starting on postoperative day 3 after the first DEB-TACE. Camrelizumab (300 mg, once every three weeks) was administered following the second DEB-TACE. The treatment sequence was adjusted during the course of therapy according to the patient’s clinical status, liver function, treatment response, and tolerability. Lenvatinib was started after the first DEB-TACE to provide systemic antiangiogenic treatment, while camrelizumab was added after the second DEB-TACE once the patient had demonstrated adequate tolerance to the preceding treatment and maintained acceptable liver function. For the management of osseous metastatic disease, the patient received nonsteroidal anti-inflammatory drugs for symptomatic pain relief and bisphosphonate therapy for prevention of further skeletal destruction. No radiotherapy or orthopedic intervention was performed during the treatment course. The T1 vertebral lesion did not undergo a formal spinal stability assessment. The entire abdomen was inspected again with an enhanced CT scan after 2 cycles of DEB-TACE. The liver volume had lessen, the shadow of the large mass in the right lobe of the liver had decreased, and the mass itself was mainly necrotic with no appreciable enhancement (Figure 3A–F). Follow-up PET-CT demonstrated interval regression of the scapular metastatic lesion, with decreased FDG uptake (SUVmax, 5.9 to 3.2) and no residual abnormal focal hypermetabolism. The T1 vertebral metastatic lesion also showed a favorable treatment response, characterized by decreased FDG uptake (SUVmax, 5.3 to 2.5) together with partial sclerosis on CT, consistent with metabolic and morphologic response to treatment. (Figure 3G–H).

Figure 2.

Intraprocedural angiography during DEB-TACE. (A and B) DSA image of hepatic mass in the patient before and after D-TACE. (C–E) DSA images of scapular lesion obtained during D-TACE. The arrows point to the target vessels.

Figure 3.

Imaging follow-up before and after treatment. (A–C) Contrast-enhanced ct obtained on January 6, 2025, showing a large mass in the right hepatic lobe with heterogeneous arterial-phase hyperenhancement, washout on portal venous and delayed-phase images, and a peripheral enhancing pseudocapsule. (D–F) Follow-up contrast-enhanced ct obtained on March 5, 2026, demonstrating a reduction in tumor size and disappearance of residual arterial enhancement, consistent with a complete response according to mRECIST. (G) Baseline and follow-up PET-CT images of the right scapular metastatic lesion, demonstrating interval regression and decreased FDG uptake (SUVmax, 5.9 to 3.2). (H) Baseline and follow-up PET-CT images of the T1 vertebral metastatic lesion, demonstrating decreased FDG uptake (SUVmax, 5.3 to 2.5), consistent with a favorable metabolic response. (I) Timeline of the patient’s treatment course. The arrow indicates the lesion.

Clinically, the patient’s symptoms improved significantly, and tumor markers returned to normal ranges (Supplemental Figure 1). Treatment-related adverse events were monitored throughout therapy. Apart from the mild post-embolization symptoms described above, no clinically significant hepatic toxicity, hypertension, proteinuria, hand–foot skin reaction, or immune-related adverse events were observed during treatment. No lenvatinib dose reduction or interruption, or camrelizumab interruption or discontinuation, was required because of adverse events. According to RECIST 1.1, the measurable target-lesion response was classified as a partial response (PR), whereas the viable intrahepatic tumor component met complete-response (CR) criteria according to mRECIST, with no residual enhancement identified on follow-up contrast-enhanced CT. The scapular metastatic lesion also showed a favorable response, with reduction in the associated soft-tissue component, decreased enhancement, and reduced FDG uptake (SUVmax, 5.9 to 3.2). Similarly, the T1 vertebral metastatic lesion demonstrated decreased FDG uptake (SUVmax, 5.3 to 2.5) with interval partial sclerosis, consistent with treatment response. At the last adequate disease assessment, no radiographic progression had been documented, and the patient remained progression-free at approximately 16 months of follow-up (Supplemental Table 1).

Discussion

Hepatocellular carcinoma (HCC) frequently presents at advanced stages due to the lack of specific early symptoms, limiting the opportunity for curative surgery. Extrahepatic spread occurs in a significant proportion of patients, with bone representing the second most common metastases site after the lungs and lymph nodes, affecting approximately 13–16% of cases. Scapular involvement is an uncommon manifestation of HCC bone metastasis, and a scapular lesion as the initial presentation of HCC has been described in only a limited number of case reports.^5,10,11 This case underscores the heterogeneity of HCC metastasis patterns and highlights the need for clinicians to remain vigilant for atypical manifestations during diagnosis.

For advanced HCC with bone metastases, a comprehensive therapeutic strategy combining local and systemic treatments is recommended to control tumor progression, alleviate symptoms, and maintain quality of life. DEB-TACE, an improved form of TACE, provides sustained release of chemotherapeutic agents and prolonged vascular embolization, enhancing local drug concentration while minimizing systemic toxicity. Recent systematic reviews and meta-analyses have demonstrated that DEB-TACE outperforms conventional TACE (cTACE) in terms of complete response rate, partial response rate, disease control, and progression-free survival, while maintaining a comparable safety profile.³ Moreover, in massive HCC, DEB-TACE combined with targeted therapy and immunotherapy has shown superior efficacy and tolerability.^12,13

Management of the scapular metastasis was an important consideration in this case because the lesion was associated with pain, a pathological fracture, and a hypervascular soft-tissue mass. Selective embolization of its feeding arteries was intended to improve local disease control, while lenvatinib and camrelizumab provided systemic treatment for intrahepatic and extrahepatic disease, including the T1 vertebral lesion. This individualized approach was informed by the patient’s symptoms, vascular anatomy, preserved liver function, and performance status. However, the contribution of embolization to the observed response could not be separated from that of systemic therapy. Assessment of the bone lesions also required caution: regression of the scapular soft-tissue component and reduced metabolic activity suggested a treatment response but did not establish restoration of bone integrity or mechanical stability. Accordingly, the bone-lesion findings were described separately from the hepatic mRECIST CR.

Systemic therapy with multi-target tyrosine kinase inhibitors (TKIs) such as lenvatinib inhibits angiogenesis and modulates the tumor immune microenvironment,^14,15 while immune checkpoint inhibitors (ICIs) like camrelizumab activate the antitumor immune response.^16,17 The combination of TACE with TKIs and ICIs has a mechanistic rationale: TACE induced hypoxia and ischemia may increase PD-L1 expression and antigen release, enhancing immunotherapy sensitivity,^18,19 whereas TKIs can prevent post TACE angiogenic rebound, reducing recurrence risk.²⁰ Clinical studies, including the CHANCE series, have confirmed that this triple therapy improves objective response rates and prolongs progression-free survival in advanced HCC.^21,22

In the present case, a patient with massive intrahepatic HCC and scapular metastasis received DEB-TACE in combination with lenvatinib and camrelizumab, resulting in significant tumor regression, sustained AFP decline, and a progression-free survival (PFS) of 16 months. The patient tolerated treatment well and maintained regular follow-up, highlighting both efficacy and safety. Although sustained disease control was observed in this patient, the optimal duration of maintenance therapy with lenvatinib and camrelizumab remains uncertain. This single case does not support a specific treatment duration, and decisions regarding continuation should be individualized according to disease status, tolerability, and patient preferences.

Despite these promising results, the prognosis of HCC with bone metastases remains poor. SEER database analyses indicate a median overall survival of only 5 months for patients with liver cancer and bone metastases.²³ Thus, treatment goals should not only focus on prolonging survival but also on improving quality of life and managing bone related complications, including pain, fractures, and bleeding.

This report has several limitations. As a single case, it may not be generalizable, and the respective contributions of DEB-TACE, lenvatinib, and camrelizumab cannot be determined. The patient’s preserved liver function and relatively favorable performance status may have influenced treatment selection and outcomes, introducing potential selection bias. Assessment of bone metastases was also challenging, as improvements in the soft-tissue component and metabolic activity may not fully reflect residual bone damage or skeletal stability. Hepatic mRECIST CR should therefore be distinguished from the response of extrahepatic lesions. These findings should be interpreted cautiously and warrant further investigation in larger studies.

Conclusion

This case describes sustained disease control in an individual patient with advanced HCC, a large intrahepatic tumor, and scapular metastasis treated with DEB-TACE combined with lenvatinib and camrelizumab. The clinical course suggests that an individualized strategy integrating locoregional and systemic therapy may be feasible in advanced HCC, including rare scapular metastases. However, these findings are limited by the single case design, and larger prospective studies are needed to identify the optimal patient population, sequential treatment strategies, and predictive biomarkers to guide personalized therapy.

Funding Statement

There is no funding for this study.

Ethics Statement

This case report was reviewed and approved by the Ethics Committee of The Affiliated Hospital of Yanbian University.

Consent for Publication

Written informed consent for publication of the case details and all accompanying images was obtained from the patient, in accordance with the CARE guidelines.

Disclosure

The authors report no conflicts of interest in this work.