PMC10203512_01
CT scans and changes in liver function of 1st patient. (A) Arterial phase of CT before stereotactic therapy. A lesion (red triangle) measuring 1.5 cm x 1.0 cm in liver segment 4b. (B) Plain scan before stage 1 ALPPS. (C) Plain scan before stage 2 ALPPS. (D) Plain scan 7 days after stage 2 ALPPS. (E) Changes in liver function during ALPPS. After stage 1, TBil remained a stable level, whereas ALT transiently rose but quickly declined. After stage 2, TBil showed no inordinate increases and quickly returned to normal, and ALT showed no significant upturns. (F) Timeline of treatment process. ALPPS, associating liver partition and portal vein ligation for staged hepatectomy; ALT, alanine aminotransferase; CT, computer tomography; POD, postoperative day; TACE, transarterial chemoembolization; TBil, total bilirubin.
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Abdominal enhanced computed tomography (CT) indicated liver cirrhosis, a 14.9 cm x 11.8 cm mass located in the right liver and a 1.5 cm x 1.0 cm mass located in the left liver both with heterogeneous rapid enhancement of the mass in the arterial phase ( Figure 1A ). According to the BCLC strategy, transarterial chemoembolization (TACE) and a combination of the targeted drug (lenvatinib, 8 mg once a day) and ICIs (camrelizumab, 200 mg every three weeks) were performed ( Figure 1F ). ALT 37 U/L. The volume of FLR was 475 mL, as calculated by abdominal CT ( Figure 1B ). Twenty-one days after the first-stage surgery, abdominal CT indicated that the FLR increased to 576 mL ( Figure 1C ), and the rate of FLR/SLV was 46.8%, which could meet the needs of the body. Changes in liver function are shown in  Figure 1E .
PMC10203512_02
CT scans and changes in liver function of 2nd patient. (A) Arterial phase of CT after two courses of TACE. (B) Plain scan before stage 1 ALPPS. (C) Plain scan before stage 2 ALPPS. (D) Plain scan one month after stage 2 ALPPS. (E) Changes in liver function during ALPPS. After stage 1, TBil escalated within the normal level, whereas ALT transiently rose but quickly declined. After stage 2, TBil showed no inordinate increases, and ALT showed no significant upturns. (F) Timeline of treatment process. ALPPS, associating liver partition and portal vein ligation for staged hepatectomy; ALT, alanine aminotransferase; CT, computer tomography; POD, postoperative day; TACE, transarterial chemoembolization; TBil, total bilirubin.
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Abdominal enhanced CT showed a 16.2 cm x 11.2 cm mass situated in the right liver with inhomogeneous enhancement of the mass in the arterial phase and multiple intrahepatic metastatic lesions ( Figure 2A ). According to the BCLC-B stage, stereotactic therapy for HCC was performed (i.e., TACE combined with 8 mg lenvatinib once a day and 200 mg camrelizumab every three weeks,  Figure 2F ). Abdominal CT showed that the diameter of the lesion was reduced from 16.2 cm to 9.7 cm ( Figure 2B ) after three courses of TACE and ten cycles of camrelizumab. One month after the first-stage surgery, the volume of FLR was 473 mL, which was more hypertrophic than the baseline volume of FLR (356 mL) ( Figure 2C ). Changes in liver function are shown in  Figure 2E . Re-examination of CT one month after second-stage ALPPS indicated sufficient FLR ( Figure 2D ).