PMC9594877_01
Clinical images of hepatocellular carcinoma in an 89-year-old man. (A) The intrahepatic lesion shown in the plain CT. The contrast-enhanced CT showing the intrahepatic nodule (B) in the arterial phase and (C) in the portal phase at the initial diagnosis. (D and E) CT findings after TACE showing the complete response according to mRECIST criteria, and (F) later, several intrahepatic nodules were seen in both lobes.
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An 89-year-old Japanese man with no relevant past medical history was referred to our hospital from a community hospital in 2018 for the investigation of an accidentally detected intrahepatic nodule on plain computed tomography (CT); which was not suggestive of liver cirrhosis or fatty liver disease (Figure 1A). Contrast-enhanced CT (CECT) showed a hypervascular intrahepatic nodule 140 mm in diameter in the arterial phase (Figure 1B). Later, washout of the contrast medium was also detected in the portal phase (Figure 1C). Tumors (mRECIST) criteria (Figure 1D and E). The PIVKA-II level decreased to less than the upper limit of normal as shown in Figure 2. During the follow-up after the fourth-TACE, several intrahepatic hypervascular nodules were seen in both lobes on CECT (Figure 1F). Figure 1A-C). Furthermore, the serum anti-cytomegalovirus IgM antibody was negative, and cytomegalovirus antigen was not detected.
Changes in tumor markers and IL-17 level in this case are shown.
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Tumors (mRECIST) criteria (Figure 1D and E). The PIVKA-II level decreased to less than the upper limit of normal as shown in Figure 2. As shown in (Figure 2), the baseline serum IL-17 level was very low and did not increase during the systemic treatment.
Clinical images of hepatocellular carcinoma during the treatment. (A) The contrast-enhanced CT after lenvatinib therapy showing the complete response according to mRECIST criteria, and (B) later, multiple intrahepatic nodules were seen in both lobes. (C) After TACE was performed, intrahepatic nodules were exacerbated in both lobes in the contrast-enhanced CT. (D) CT findings after chemotherapy with atezolizumab and bevacizumab showing the complete response according to mRECIST criteria. (E) Colonoscopy showing friability and loss of vascular pattern from the rectum to the cecum. (F) Microscopic findings of the colonic specimen showing mild cryptitis described with arrows, but there was no diffuse mononuclear cell infiltration or basal plasmacytosis.
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No significant adverse events occurred, and the complete response evaluated according to the mRECIST criteria was achieved in 2 months, as seen on CECT (Figure 3A). However, a year and 4 months after initiating lenvatinib, multiple hypervascular nodules were detected (Figure 3B). However, it did not stop the progression of HCC (Figure 3C). ALBI grade was 1, a second cycle of chemotherapy with atezolizumab 1200 mg and bevacizumab 15 mg/kg body weight was initiated every 3 weeks. Although a complete response was achieved (Figure 3D), after the sixth cycle, he complained of increased frequency of stool to more than ten times daily. Colonoscopy revealed friability and loss of vascular pattern from the rectum to the cecum (Figure 3E). Furthermore, the pathological result of the colonic specimen revealed mild cryptitis, but there was no diffuse mononuclear cell infiltration or basal plasmacytosis (Figure 3F).