Hepatic encephalopathy induced by Lenvatinib and anti-PD-1 mAb in a patient with advanced hepatocellular carcinoma: A case report

Previous studies have reported that the combinational therapy of Lenvatinib and anti-programmed cell death-1 (PD-1) monoclonal antibody (mAb) produced a longer overall survival in patients with hepatocellular carcinoma (HCC). The current case report presented a a patient with HCC who had hepatic encephalopathy (HE) following treatment with Lenvatinib and anti-PD-1 mAb. The 42-year-old patient was diagnosed with stage IVa HCC accompanied with cirrhosis and Child-Pugh C. Computed tomography (CT) imaging revealed collateral circulation of the portal vein, causing significant varicose veins in the gastric fundus, mesenteric varices and colon edema. The patient was administered 12 mg Lenvatinib once daily combined with 240 mg anti-PD-1 mAb. After 3 days of treatment, he presented with a disorder of psychoneurosis and blood ammonia (248 µg/dl; normal levels, 40-80 µg/dl). A cranial CT scan exhibited no significant abnormalities. The patient rapidly progressed from grade 1 to grade 3 HE. Lenvatinib treatment was discontinued. After admission to the intensive care unit, the patient's blood ammonia level dropped to 132 µg/dl, after which he was discharged. It was concluded that the portal vein collateral circulation in the patient with HCC may have caused HE development whilst receiving Lenvatinib and anti-PD-1 mAb combinational therapy.