Jake MacDonald, MD1, Garrett Cole, MD2, Nader Dbouk, MD1, Haider A.. Mejbel, MD1, Thuy-Van Hang, MD3 1Emory University School of Medicine, Atlanta, GA; 2Emory University Hospital, Atlanta, GA; 3Atlanta VA Medical Center, Atlanta, GA Introduction: Hepatocellular carcinoma (HCC) is the most common primary liver malignancy. Chronic liver diseases like hepatitis C virus (HCV) and cirrhosis are risk factors for developing HCC due to accelerated hepatic fibrosis. Although rare, spontaneous regression of HCC has been reported. We present a case of HCC regression in a patient with HCV/alcohol-associated cirrhosis following emergent transjugular intrahepatic portosystemic shunt (TIPS) placement for esophageal variceal bleed and initiation of direct acting antiviral (DAAs) for chronic HCV infection.
Case Description/
Methods: A 71-year-old male with a history of hypertension, HCV/ alcohol-related cirrhosis with ascites requiring biweekly large volume paracentesis, esophageal varices, and 4.6cm segment V HCC diagnosed December 2024 (Figure 1a) was referred for liver transplant evaluation. In January 2025, he was started on sofosbuvir/velpatasvir daily given his significantly decompensated disease. He was hospitalized the following month with variceal bleeding. Endoscopic therapy was unsuccessful, and he subsequently required emergent TIPS. In March, he underwent a repeat MRI abdomen as part of his transplant evaluation, and his HCC appeared non-viable despite not yet undergoing any locoregional therapy (Figure 1b). In May, he underwent orthotopic liver transplant. His explant demonstrated HCC with tumor necrosis and < 5% viable tumor that was about 0.5cm in aggregate (Figure 2). Discussion: This patient’s HCC regression following HCV treatment initiation and TIPS is likely related to portal pressure reduction and reduction of HCV burden. Achieving sustained virologic response (SVR) with DAA therapy significantly reduces liver inflammation and halts fibrogenesis. There have been documented cases of HCC regression after DAA-induced SVR, including a patient with extrahepatic metastases who experienced tumor regression post-SVR despite prior failure of systemic therapy. TIPS is often used to manage complications of portal hypertension like variceal bleeding and refractory ascites. Emerging data suggest that TIPS may create a less permissive environment for HCC given reduced blood flow to the lesion, which may contribute to improved survival and reduced HCC progression. While spontaneous regression of HCC is rare, HCV treatment and TIPS-induced hepatic recompensation may contribute to spontaneous regression in patients like ours. Further investigation is needed to better understand the effects of these management strategies on HCC.
Figure: Figure 1. MRI abdomen images of mass in liver. a. December 2024 - 4.6 cm segment V LI-RADS 5 mass, consistent with hepatocellular carcinoma. b. March 2025 - segment V lesion appears nonviable and smaller in size s/p TIPS and initiation of DAAs for HCV infection.
Figure: Figure 2. Pathology slides from explanted liver a. Liver explant showing well-developed cirrhosis with foci of HCC (H&E; X2) b. HCC, poorly differentiated, exhibiting tumor necrosis comprising 90% of the tumor mass (H&E; x4) c-e. The tumor cells are positive for arginase, hepPar1, and glypican 3 immunostains, respectively (IHC; x4)
Disclosures: Jake MacDonald indicated no relevant financial relationships. Garrett Cole indicated no relevant financial relationships. Nader Dbouk indicated no relevant financial relationships. Haider Mejbel indicated no relevant financial relationships. Thuy-Van Hang indicated no relevant financial relationships.
Jake MacDonald, MD1, Garrett Cole, MD2, Nader Dbouk, MD1, Haider A.. Mejbel, MD1, Thuy-Van Hang, MD3. P3865 - Vanishing Act: Spontaneous Regression of HCC After Starting HCV Treatment and Emergent TIPS Placement, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.
