Adaptive dosing of immunotherapy plus anti-angiogenic therapy in a nonagenarian with hepatocellular carcinoma: a case report with 10-year survival.

BACKGROUND: Elderly cancer patients, particularly those aged ≥90 years, are significantly underrepresented in clinical trials, leaving a critical evidence gap for this growing population. CASE PRESENTATION: We report a 90-year-old man with multiple comorbidities (coronary artery disease, hypertension, type 2 diabetes, hyperlipidaemia, hepatic steatosis, and hypothyroidism) and an ECOG performance status 2, who was diagnosed with hepatocellular carcinoma (HCC) in 2015. After initial microwave ablation in 2017 and for recurrence in 2021, he developed multifocal intrahepatic progression in January 2023 at age 97. Following progression on pembrolizumab monotherapy (100 mg q3w) and intolerance to lenvatinib combination, treatment was adapted to reduced-dose pembrolizumab (100 mg q3w) plus reduced-dose bevacizumab (3.75 mg/kg q3w)-approximately half and one-quarter of standard doses, respectively. He achieved partial response after three cycles with significant symptomatic improvement. As of March 2025 (age 99), he has completed 23 cycles with a progression-free survival of 15 months. He maintains functional independence, satisfactory symptom control (liver pain NRS 1-2), and only grade 1 fatigue, with no treatment-related hospitalizations. CONCLUSION: To our knowledge, this is the oldest reported patient with HCC to receive combined immunotherapy and anti-angiogenic therapy. This case suggests that with carefully adapted dosing-using approximately half-dose pembrolizumab and quarter-dose bevacizumab-a nonagenarian with multiple comorbidities may achieve prolonged disease control, challenging the conventional 'one-size-fits-all' dosing paradigm and highlighting the feasibility of individualized treatment strategies in the oldest-old population with HCC.