PMC8149128_01
Axial abdominal MRI images throughout treatment course. A. MRI on day of diagnosis showing heterogeneous hepatomegaly compatible with diffuse tumor involvement; portal vein thrombosis also present. B. MRI after initial chemotherapy regimen demonstrating persistent hepatomegaly with mild improvement of intrahepatic disease burden; residual mild enhancement in portal vein, proximal mesenteric vein, and splenic vein. C. MRI 14 weeks after Y-90 treatment showing mixed response of intrahepatic tumor and extensive tumor growth within the portal venous system with distension of superior mesenteric vein and splenic vein. D. MRI prior to salvage EBRT showing mixed response to salvage chemotherapy with areas of tumor progression in liver segments 5 and 8 and the splenoportal system
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MRI showed a large heterogeneous liver with innumerable confluent multiseptated lesions compatible with diffuse involvement, portal vein thrombosis, and grade 1 esophageal and gastric varices (Fig. 1A). Follow-up MRI showed persistent hepatomegaly with slight decrease in the extent of intrahepatic disease (e.g., conglomerate right lobe lesions measured 5.6 x 5.3 cm from 6.5 x 6.7 cm) and a mild enhancement of surrounding veins (Fig. 1B). MRI 14 weeks later showed mixed response within the liver with extensive tumor growth in unirradiated portal venous branches causing distension of the superior mesenteric vein and splenic vein (Fig. 1C). Follow-up MRI 8 weeks after initiating salvage chemotherapy showed areas of decreased tumor bulk, likely reflecting treatment response, but multiple other areas of tumor progression, particularly within segments 5 and 8 and the splenoportal system (Fig. 1D).
Yttrium-90 mapping angiogram demonstrating extensive tumor involvement throughout both hepatic lobes with lung shunt 6.2%
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Mapping angiogram (Fig. 2) demonstrated extensive tumor throughout both hepatic lobes.
External beam radiation therapy plan showing intrahepatic volume treated with 30 Gy in 10 fractions and extrahepatic volume treated to 42 Gy in 14 fractions
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Decision was made to proceed with definitive EBRT to all known disease, including 42 Gy in 14 fractions to the extrahepatic disease and a dose-reduction to 30 Gy in 10 fractions to the intrahepatic tumor due to the prior Y-90 treatment (Fig. 3).