Multimodal Conversion Therapy Enabling Curative Resection in Giant Hepatocellular Carcinoma with Arteriovenous Fistula: A Case Report.

Background: Giant hepatocellular carcinoma (GHCC) with arteriovenous fistula (AVF) is often considered a surgical no-go zone, lacking a standardized conversion therapy. This paper reports a case in which the implementation of sequential, integrated multimodal therapy, simultaneously targeting the tumor's biological behavior and the fistula's abnormal hemodynamics, successfully achieved substantial downstaging of the tumor, ultimately accomplishing curative resection. Case Presentation: A 38-year-old male patient presented with recurrent abdominal distension and was diagnosed GHCC complicated by AVF, as confirmed by computed tomography (CT). The patient underwent tumor downstaging through a multimodal therapeutic approach, which integrated targeted therapy, immunotherapy, hepatic artery infusion chemotherapy (HAIC), transcatheter arterial chemoembolization (TACE), and radiotherapy. This comprehensive treatment strategy subsequently facilitated curative surgical resection. To date, the patient has attained an overall survival duration of 32 months. Conclusion: This case suggests that a sequential multimodal strategy may enable downstaging and potential curative resection in selected patients; however, validation in larger cohorts is required.