Endoscopic Innovation Treatment Strategy in Hepatocellular Carcinoma ( HCC ) Patients Before Immunotherapy: A Case Series Study in Unselected Patients

Hepatocellular carcinoma remains a major problem in Asia as well as globally. Most patients present at the late stage of the disease. Currently, several types of immunotherapy (IT) have been studied for its efficacy in treating hepatocellular carcinoma, such as atezolizumab and bevacizumab, which work as inhibitors in checkpoints and inhibitors in VEGF, respectively. In recent studies, this specific combination of therapy has shown a better progression free survival (PFS) rate and overall survival (OS) compared to the current therapy sorafenib. However, this treatment modality carries several potential adverse effects, such as gastrointestinal bleeding and bleeding esophageal varices (BOV). We present a series of seven HCC patients, where six patients had esophageal varices and one patient had large gastroesophageal varices who underwent endoscopy evaluation and therapeutic endoscopy including endoscopic ultrasound guided before IT. All patients underwent IT after therapeutic endoscopy within less than a week. No bleeding was observed during and after IT. These cases demonstrate the endoscopic ultrasound method in HCC patients.