Successful Rechallenge of Hepaftocellular Carcinoma with Atezolizumab and Bevacizumab Following Disease Progression

Systemic therapies to treat Hepatocellular Carcinoma (HCC), a cancer with traditionally poor prognosis, have greatly advanced in the last five years with the advent of immunotherapies. The immune checkpoint inhibitor atezolizumab and anti-angiogenic agent bevacizumab combination therapy is now recommended as first line treatment for unresectable HCC. Bevacizumab is associated with an increased risk of severe variceal or mucosal bleeding. We present a remarkable case of a patient with multifocal HCC being treated with combination atezolizumab and bevacizumab therapy. The patient experienced complete response to combination therapy. He then suffered a life-threatening gastrointestinal bleed secondary to Helicobacter pylori-associated gastric ulceration. Bevacizumab was interrupted for a period of 6 months, with continuing atezolizumab monotherapy. Serial endoscopies demonstrated re-epithelialisation of the ulcer. Following disease progression, bevacizumab was recommenced in combination with atezolizumab, leading to consequent partial response. This case highlights the synergistic efficacy of combination atezolizumab and bevacizumab therapy and the importance of risk stratification for patients with significant bleeding events on bevacizumab to guide the period of drug interruption and timely rechallenge with combination therapy.