PMC8422947_01
Response evaluation during the clinical course including changes in imaging and quantitative data. (A) Preoperative abdominal-enhanced CT revealed a mass in the right posterior lobe of the liver (August 21, 2018). (B) CT showed multiple nodules in the liver and tumor thrombus in the right hepatic vein and the left portal vein (September 21, 2018). (C) CT indicated new nodules in the lower lobe of the right lung and the upper lobe of the left lung. The multiple original nodules in the lungs had grown (November 2, 2018). (D) CT indicated a complete response to pembrolizumab plus lenvatinib (February 2019). The pulmonary nodules had disappeared after treatment. (E) CT showed postoperative changes of liver cancer, abnormal density in the liver margin, and a few new inflammatory lesions in both lungs 4 months after treatment with pembrolizumab and lenvatinib (June 2019). (F) MRI showed no local active foci and multiple lymph nodes of different sizes in the hilar area and retroperitoneum (April 2020). (G) MRI showed a complete response to atezolizumab and bevacizumab (October 2020). The retroperitoneal lymph nodes had disappeared after treatment. (H) Graphical depiction of the change in alpha-fetoprotein (AFP) over time.
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Positron emission tomography-CT revealed a mass shadow with increased glucose metabolism in the lower right lobe of the liver, which was radiologically suspected for HCC, mild cirrhosis, and splenomegaly (Figure 1A). A month after the surgery, CT showed multiple nodules in the liver and tumor thrombus in the right hepatic vein and the left portal vein (Figure 1B). The AFP reached the highest level (8,221 ng/ml) (Figure 1H). A CT scan on November 2, 2018, revealed disease progression and the development of new pulmonary metastases (Figure 1C). A CT scan in February 2019 showed that the pulmonary nodules had disappeared, and the AFP values had returned to the normal range at the time (Figures 1D, E). AFP levels continued to increase (March 11, 2020, 46.63 ng/ml; and April 29, 2020, 134.5 ng/ml), and magnetic resonance imaging showed abdominal lymph node metastases (Figures 1F, H). After the patient failed to take TACE treatment on April 29, 2020, we informed the patient and her relatives about the treatment options and alternatives, and she started atezolizumab (a PD-L1 inhibitor, 120 mg) plus bevacizumab (700 mg) on June 2, 2020. After she received atezolizumab plus bevacizumab on July 10 and August 2, 2020, directional radiotherapy was performed. In October 2020, the treatment was discontinued due to side effects, but the patient experienced a complete response based on the 4-month scan (Figure 1G).
3D visualization pictures. (A-F) 3D visualization clearly reconstructed the hepatic vein, hepatic artery, portal vein, and tumor feeding artery. The 3D visualization pictures from different angles are presented.
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We received the results of 3D visualization based on the CT image and performed right hepatic resection to obtain the remnant liver volume on August 29, 2018 (Figures 2, 3A, B).
Intraoperative photos, postoperative tumor section, and pathological examination. (A) Massive hepatocellular carcinoma (HCC). The liver was examined laparoscopically. (B) The resected specimen was a carcinoma with a large amount of necrotic tissue. (C) Pathological diagnosis: massive HCC.
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We received the results of 3D visualization based on the CT image and performed right hepatic resection to obtain the remnant liver volume on August 29, 2018 (Figures 2, 3A, B). Histology of the resected tissues indicated poorly differentiated HCC (nodular, 9 x 7.5 x 6 cm) with satellite nodules and necrosis of the tumor and cirrhosis of the liver surrounding the carcinoma (Figure 3C).
The timeline with therapy and disease status. HCC, hepatocellular carcinoma; TACE, transcatheter arterial chemoembolization; CR, complete response.
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The patient's course is shown in Figure 4.