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Preoperative abdominal enhancement CT and Primovist MRI revealed a large liver space-occupying lesion. (A) CT arterial phase image: a heterogeneously enhanced mass located in the liver (arrow) (2018-09). (B) We circled the largest cross-sectional area of liver tumor necrosis (arrow) (2019-02). (C) Preoperative Primovist MRI image, multiple lesions (arrow), maximum tumor size:13.0x8.5 cm (2019-03).
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On September 26, 2018, the abdominal enhancement CT revealed that a large round-like mixed density mass in the liver, with a maximum section of 15.0x10.8 cm (Figure 1A). CT on October 30, 2018: a liver lesion of 14.0x10.0 cm in size, From November 22, 2018, to March 05, 2019, patients with lenvatinib (8mg orally every day) combined with nivolumab injection (140mg intravenously every 2 weeks) treatment. Changes in tumor diameter, platelet, AFP and the maximum cross-sectional square of necrosis during the half-year period of treatment (Figure 1B, Table 1). On March 15th, she visited our hospital again, AFP: 167899ng/mL, Primovist MRI: The liver revealed a lesion with a large piece of long T1 and a slightly longer T2 signal, about 13.0x8.5 cm, and see more than one satellite nodule (Figure 1C), this mass can also be seen on CT.
3D visualization pictures. (A) We pre-cut along the right side of the left hepatic vein (1) based on the 3D visualization results. (B) 3D visualization clearly reconstructs the hepatic vein (1), hepatic artery (2), portal vein (3), and tumor feeding artery (4).
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We received the results of 3D visualization based on the CT image using the software (Mixed reality Surgical Planning Simulation System) and performed the extended right hepatectomy to obtain the remnant liver volume (Figure 2A and B, Table 2). 
Intraoperative photos, postoperative tumor section and pathological examination pictures. (A) Massive hepatocellular carcinoma, Liver resection by Ultrasonic Harmonic Scalpel. (B) The section revealed a carcinoma with a large number of necrotic tissues. (C) Pathological diagnosis: massive hepatocellular carcinoma, x100.
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The size is about 12.0x10.0 cm, solid and soft, with mild adhesion to the diaphragm (Figure 3A). After the tumor was dissected: the section showed a size of 12.5x11.0x10.0 cm gray yellow gray red tender nodules, a large number of necrotic tissue in the middle, and see more than one satellite nodule, the larger diameter of 3.0 cm (Figure 3B). The pathological report showed that the cancer cells were arranged in a flaky arrangement, and the nuclear fission was easy to see and had microvascular invasion (Figure 3C).