PMC6252220_01
CT scan showing multiple liver metastases suggestive of hepatocellular carcinoma. The red arrow indicates the mass rupturing imminently.
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AFP was elevated to 588.9 ng/mL, whereas his carbohydrate antigen 19-9 (CA19-9) and carcinoembryonic antigen (CEA) levels were within the normal ranges. An abdominal computed tomography (CT) scan revealed multiple tumors on his liver suggestive of hepatocellular cancer with part of the tumor rupturing imminently (Figure 1).
CT scan showing the liver after TACE and HAIC. The red arrow indicates the site of the ruptured mass.
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The patient's AFP levels decreased from 588.9 to 291.7 ng/mL after one cycle of HAIC with 5FU/CDDP (Figures 2 and 3).
Timeline of patient course and treatment. The blue line indicates the AFP level. The patient received four cycles of chemotherapy with cape/CDDP. His AFP level increased from 297.1 to 4320 ng/mL. CT scans revealed the growth of liver metastases.
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The patient's AFP levels decreased from 588.9 to 291.7 ng/mL after one cycle of HAIC with 5FU/CDDP (Figures 2 and 3). AFP levels increased from 297.1 to 4320 ng/mL, and a CT scan revealed progression of the liver metastasis (Figure 3). As the lesion of the liver on S4 was at a high risk of rupturing and HAIC was effective in the previous treatment, we decided to perform TACE and HAIC to the liver metastasis again.
Gastrointestinal scope showing the Borrmann type 2 lesion on the pyloric portion of the lesser curvature that was histologically diagnosed as suspected hepatoid adenocarcinoma.
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Gastric biopsy. (a) Hematoxylin and eosin staining indicating suspected hepatoid adenocarcinoma. (b) Positive staining for SALL4. (c) Negative staining for AFP. (d) Focally positive staining for glypican3.
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AFP and positive for SALL4 and Glypican3 (Figure 5). A liver biopsy confirmed that the lesion was a liver metastasis. Analysis of the liver biopsy specimen revealed that the liver mass was metastatic carcinoma of the liver.
Hepatic biopsy. (a) Hematoxylin and eosin staining indicating that the lesion is a liver metastasis. (b) Positive staining for SALL4. (c) Focally positive staining for heterochromatin protein 1 (HP1).
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Immunohistological staining showed that the specimen was positive for SALL4 and heterochromatin protein 1 (HP1) (Figure 6).
After surgery, the patient received eight cycles of chemotherapy comprising PTX and RAM. His AFP levels decreased within the normal range and the lesion in the liver disappeared on a CT scan. After a three-month drug holiday, RAM monotherapy was initiated.
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AFP levels decreased to 2.9 ng/mL and a CT scan showed that the tumor had vanished (Figure 7). After a three-month drug holiday, chemotherapy with RAM as a maintenance therapy was resumed (Figure 7).