PMC8044844_01
Abdominal MRI scan at different treatment phases. (A, B) Images at initial diagnosis. (C, D) Images after 2nd course. Arrowheads indicate viable tumor lesions near the RHV. (E, F) Images before surgery. (G, H) Images at 4-month after surgery. (I) Timeline of treatment process. RHV, right hepatic vein; MHV, middle hepatic vein; LHV, left hepatic vein; RALP, right anterior lobe pedicle.
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Contrast-enhanced magnetic resonance imaging (MRI) identified a huge irregular lesion with satellite nodules, around 15x12 cm in diameter, located in segment 7 (S7) and S8 ( Figures 1A, B ). The right hepatic vein (RHV) was surrounded by the tumor, and the middle hepatic vein (MHV) was closely attached to the tumor ( Figure 1A ). The right anterior lobe pedicle (RALP) was involved by the tumor near the first liver hilum ( Figure 1B ). MRI identified significant shrink and massive necrosis of the tumor ( Figures 1C, D ). Meanwhile, the MHV detached from the tumor, and the tumor-involved site of RALP departed from the first liver hilum. Nevertheless, the RHV was found adhered to the tumor and enhanced lesions still existed along the RHV, which indicated high risk of residual tumor cells along the vein once performing right anterior lobe resection ( Figure 1C ). Two weeks after receiving tislelizumab, MRI revealed a complete radiological response (rCR) with clear tumor border and relieved tumor compression along the RHV ( Figures 1E, F ). Four months after surgery, blood test showed normal AFP and des-gamma-carboxy prothrombin levels and enhanced abdominal MRI revealed no sign of tumor recurrence in the liver ( Figures 1G, H ). A timeline of the treatment process was displayed in  Figure 1I .
Dynamic changes in tumor marker levels, systemic inflammation index and liver function during treatment process. AFP, alpha-fetoprotein; DCP, des-gamma-carboxy prothrombin; NLR, neutrophil-lymphocyte ratio.
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A relieved tumor load was reflected by the decreased levels of AFP, des-gamma-carboxy prothrombin and neutrophil-lymphocyte ratio ( Figure 2 ). Increased albumin and prealbumin levels as well as shortened prothrombin time indicated improved liver function ( Figure 2 ).
Representative pathological findings of resected specimens (H&E staining). (A) Complete necrosis of the tumor. (B) Massive infiltration of lymphocytes in the tumor-nontumor interface. (C) Typical granulomatous inflammation in the nontumor liver. Magnification is showed in the lower left corner. T, tumor; NT, nontumor liver.
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The tumor tissues showed complete necrosis, and the surrounding nontumor tissues presented massive infiltration of lymphocytes and extensive granulomatous inflammation ( Figure 3 ).