PMC9773375_01
CT scans of the liver, posterior pancreas head and kidneys (A-D) Multiple intrahepatic space-occupying lesions; (E) Mass in posterior pancreas head; (F) Right renal mass. Abdominal CT scans were taken on baseline scan, baseline + 6 weeks (after first session: pembrolizumab and radiotherapy), baseline + 9 weeks (after second session: pembrolizumab plus lenvatinib), baseline + 12 weeks (after third session: pembrolizumab plus TACE) and baseline + 36 weeks (after synchronous partial resection of the liver and partial right nephrectomy).
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The enhanced abdominal CT scan was repeated which confirmed a mass measuring 8.0*4.5 cm at posterior pancreas head which was highly suggestive of malignant tumor. The scan also revealed multiple intrahepatic masses with dimensions ranging 1 to 3 cm, right renal mass which portrayed malignant feature, cholelithiasis, and cholecystitis ( Figure 1 ). The right renal mass was also smaller compared to the previous scan ( Figure 1 ). Overall shrinkage in all lesions was observed through CT scan ( Figure 1 ). AFP and PIVKA-II levels were 249 mug/L and 76.28 mAU/mL respectively while other markers were within normal limits. Abdominal CT showed lipiodol deposition, and hepatic pneumatosis at segment VIII of the liver as well as further shrinkage of the aforementioned lesions ( Figure 1 ).
Pathological result of lesions (A-C) Histology of lesions in liver, (D-F) Histology of lesions in posterior pancreas head, (G-I) Histology of lesions in kidney. Both A and C showed atypical cell distributed in sheet manner (H&E staining, 200X); Immunohistochemistry result of samples in (B) GPC-3 (+), (C) CK19 (+), (E) Herpar1 (+) and (F) CK19 (+) indicate tumor cell differentiation of hepatic or hepatoid origin. Histopathological examination in (G) revealed clear-cell renal carcinoma, Furhman grade 2 with maximum diameter of 1.7 cm and negative margine (H&E staining, 200X); Immunohistochemical stain reveals positive marking result in AMACR (H) and CAIX (I), indicate tumor cell differentiation of renal origin.
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BUS-guided liver mass biopsy was also performed and Pathology test result of the liver indicated a poorly differentiated HCC while the immunohistochemistry test result showed HepPar1 (+), Arg-1 partial (+), GPC-3 (+), AFP (+), CK7 partial (+), CK19 (+), ki-67 (+) 50% ( Figure 2 ). Partial (+), CK19 (+), ki-67 (+) 50% ( Figure 2 ). Pathology of the right renal mass was unavailable as renal biopsy was strongly denied by both the patient and his family. Subsequently, he underwent synchronous partial resection of the liver and partial right nephrectomy about 10 weeks ago (baseline + 36 weeks) with the pathology test result of the renal lesion indicated a clear-cell renal carcinoma while the immunohistochemistry test result showed CK (+), Vim (+), CD10 (+), CAIX (+), AMACR partial (+), PAX8 partial (+), Ki-67 (+) 3% ( Figure 2 ).