PMC5854926_01
Contrast-enhanced computed tomography (CECT) scan for initial diagnosis. The image shows a tumor 53 mm in size (arrowhead) and portal vein tumor thrombosis (PVTT) in the posterior branch of the portal vein (arrow). The tumor and suspected PVTT are slightly enhanced during the early-phase CECT (A) and are washed out during the equilibrium phase (B).
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Contrast-enhanced computed tomography (CECT) before admission revealed a 53-mm tumor in hepatic segments 6 and 7, and findings suggestive of PVTT in the right posterior portal vein (PV) (Fig. 1). The tumor and suspected PVTT were slightly enhanced during the early-phase CECT (Fig. 1A) and were washed out during the equilibrium phase (Fig. 1B).
Arterial phase of contrast-enhanced ultrasonography at diagnosis. Main tumor (arrowhead) and suspected portal vein tumor thrombosis (arrow) are well enhanced.
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US (Fig. 2). Upper gastrointestinal endoscopy and colonoscopy revealed nonspecific findings.
A) Contrast-enhanced computed tomography (CECT) scan 7 days after the initial CECT reveals tumor regression to 30 mm (arrowhead) in diameter and regression of portal vein tumor thrombosis (arrow). B) CECT findings 10 days after ligation of portal vein (PV). Tumor regression to 20 mm (arrowhead). Tumor thrombosis is no longer evaluable as a result of ligation of PV (arrow).
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Preoperative CT volumetry revealed that the tumor had shrunk to 30 mm and that the PVTT had regressed (Fig. 3A). Additionally, the tumor shrank to 20 mm (Fig. 3B), along with the levels of tumor markers (AFP, PIVKA-II: 643 ng/mL, 14 mAU/mL, respectively).
The graph illustrates changes in alpha-fetoprotein (AFP), percentage of the Lens culinaris agglutinin-reactive AFP isoform 3 (AFP-L3) and proteins induced by vitamin K absence or antagonist-II (PIVKA-II) levels from initial diagnosis to post resection. Serum AFP and PIVKA-II levels at initial diagnosis were 17,562 ng/mL and 153 mAU/mL, respectively, and decreased to 643 ng/mL and 14 mAU/mL prior to hepatectomy. AFP-L3 levels were normalized 4 months after surgery. Tumor marker levels remained within normal range after surgery.
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The AFP-L3 decreased to normal gradually, within 4 months after hepatectomy (Fig. 4).
Among the histopathological findings: grossly, the nodule was 22 x 20 mm with a thin fibrous capsule, and a thrombus was seen the right posterior portal vein (PV). The histological examination revealed that the nodule was mainly composed of granulation and necrotic tissue. A trabecular pattern and pseudoglandular structures of denucleated cells were reminiscent of moderately differentiated hepatocellular carcinoma. Viable tumor cells were not observed in either the nodule or tumor thrombus (A). Infiltrating inflammatory cells such as lymphocytes were observed both in the nodule and portal vein tumor thrombus (B). The PV around the nodule was filled with blood clot as a result of ligation of the PV (C). Immunohistochemical staining for alpha-smooth muscle actin revealed patency of the hepatic arteries and no arterial thrombosis (D).
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Immunohistochemical staining for alpha-smooth muscle actin revealed patency of the hepatic arteries without thrombosis (Fig. 5).
Contrast-enhanced computed tomography scan at 24 months after surgery. The patient is alive without recurrence. The arrows indicate liver cysts.
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The patient is alive without recurrence 24 months after surgery (Fig. 6).