PMC9760471_01
The changes in various indicators with the courses of treatment.
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B with positive e antigen for more than ten years and had not received formal treatment. Blood biochemical examinations on admission indicated slightly elevated liver function tests (Child-pugh A, ECOG-PS 1), while there was a significant elevation of alpha-fetoprotein (AFP) levels, 77180.4 ng/ml (Fig. 1c). As shown in Fig. 1, 1 month after surgery, the liver function index returned to normal values and the AFP decreased to 8670 ng/ml. AFP level remained 85100.6 ng/ml (Fig. 1c). Amazingly, two courses of immune checkpoint inhibitors (ICI) programmed cell death protein 1 (PD-1) inhibitors Opdivo followed at 1 September 2018, the patient's general condition took a favorable turn and the level of AFP (86209.8 ng/ml), decreased compared to the previous level.
Ultrasound imaging of the portal vein. (a) Preoperative portal vein ultrasound: there was a slightly strong echo mass in the main portal vein, about 13 x 34 mm in size. The right branch was full of blood flow signals, while the left branch was unclear. (b) One month after the operation, portal vein ultrasound showed that the main portal vein carcinoma thrombus was formed and the right portal vein was full of blood signals. (c) Two months after the operation, the portal vein trunk and right branch were filled with blood flow, and no obvious lesion was seen. (d) At 45 months after surgery, the portal vein blood flow is smooth and the blood flow rate is normal.
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And this examination also reported a slightly stronger echo mass and striped blood flow signal in the main portal vein, suggesting portal thrombus (Fig. 2a). MRI indicated no obvious abnormalities in the remnant liver, but there was portal vein tumor thrombosis (Fig. 2b). Multiple lung nodules were found on follow-up CT examination, which were considered metastatic tumors (Fig. 4a).
Tumor histopathology. (a) Postoperative pathology: poorly differentiated hepatocellular carcinoma, accompanied by haemorrhage and necrosis, with tumor thrombus visible in the vessels, involving less than 5 vessels. (b) Alpha-fetoprotein expression was positive. (c) Hepatocyte was positive, indicating the origin of hepatocytes. (d) P53 expression was positive and proliferation ability was high. (e) CD10 expression was negative. (f) CD34 expression was positive in sinusoidal endothelium suggesting hepatocellular carcinoma. (g) Ki-67 expression was 50%, indicating active tumor proliferation. (h) Phospholipamide glycol proteoglycan 3 was positive, increasing evidence of hepatocellular carcinoma. (i) Hepatitis B surface antigen was negative, indicating no current infection of hepatitis B.
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Postoperative pathology revealed poorly differentiated hepatocellular carcinoma accompanied by vascular carcinoma thrombus (AJCC pT4N0M0, IIIB) (Fig. 3).
Changes in chest CT and maximum tumor volume in patients. (a) One month after surgery, there were multiple nodules in both lungs, and the larger ones were located under the pleura of the dorsal segment of the right lower lung, about 2.7 x 2.3 x 1.8 cm. (b) One year after the operation, the lesions increased and enlarged, and the larger ones were located under the pleura of the dorsal segment of the right lower lung, about 3.7 x 3.1 x 3.2 cm. (c) At 19 months after surgery, the lesions of both lung nodules were similar to those before, and the larger ones were about 3.7 x 3.1 x 3.2 cm. (d) At 32 months after surgery, the lesions of multiple metastases in both lungs were reduced compared with before, and the larger ones were about 3.5 x 2.1 x 3.2 cm. (e) At 45 months after surgery, there were multiple metastases in both lungs, some lesions were slightly reduced compared with the previous ones, and the larger ones were located under the pleura of the posterior basal segment of the lower lobe of the right lung, about 2.8 x 1.3 x 1.7 cm.
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MRI indicated no obvious abnormalities in the remnant liver, but there was portal vein tumor thrombosis (Fig. 2b). Multiple lung nodules were found on follow-up CT examination, which were considered metastatic tumors (Fig. 4a). Moreover, imaging suggests that the number of chest metastatic tumors was significantly lower than before and the efficacy was evaluated as a partial response (Fig. 4; Fig. 5).
Chest radiographs and changes in maximum tumor volume. (a) Preoperative chest x-ray: double foci of inferior pulmonary fibrosis; thickening of the right inferior pleura. (b) Three months after the surgery: multiple metastases in both lungs, the largest nodule was located in the lower lobe of the right lung, about 2.5 x 3.6 cm. (c) After 4 courses of chemotherapy and HAIC: the nodules in both lungs were increased and enlarged. The largest nodule was located in the lower lobe of the right lung, about 3.5 x 3.3 cm. (d) After 1 course of immunotherapy: the nodules in both lungs were increased and enlarged. The largest one is located in the lower lobe of the right lung, which was about 4.9 x 4.5 cm in size. (e) 45 months after surgery: the nodules in both lungs were significantly reduced, and the larger nodules were located in the lower lobe of the right lung with a size of about 3.2 x 3.5 cm.
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Whereas the lung metastasis tumor increased distinctly from the previous period (Fig. 5b) still accompanied by cough, and the AFP level rose from 8670 ng/ml in the early postoperative to 20979.16 ng/ml.