PMC10362861_01
2022.04.07 CT scan of the abdomen (blue arrows: lymph nodes; red arrows: tumors): Hepatic segment VIII occupancies, hepatocellular carcinoma with hemorrhage, multiple lymph nodes enlargement in the hepatogastric space, and retroperitoneum.
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The abdomen CT (2022.04.07) showed an occupancy in the VIII segment of the liver with a lesion of about 4 cm in size, with marginal enhancement and internal hemorrhage, which was considered to be HCC in the context of medical history (Figure 1). And there were large lymph node metastases between the liver and stomach located lateral to the common hepatic artery, on the SMA side, next to the renal artery, and on the abdominal aorta, which was not consistent with the diagnosis of primary hepatocellular carcinoma metastasis and needed a thorough examination to find its etiology (Figure 1).
2022.04.20 Small bowel capsule endoscopy: duodenitis, jejunum, ileum with scattered spots and small patches of erythema, inflammation.
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CT-guided liver puncture biopsy showed hepatocellular carcinoma with extensive necrosis; ultrasound endoscopic lymph node puncture biopsy of the hepatogastric space showed a large number of lymphatic anisocytic cells without malignancy, so the possibility of lymphoma was excluded; laparoscopic lymph node biopsy showed metastatic undifferentiated carcinoma; gastrointestinal PET-CT showed only liver lesions; small bowel capsule endoscopy showed normal (Figure 2); thyroid Ultrasound and laryngoscopy did not display any abnormality.
Change in AFP levels from April to July of patients.
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Alpha-fetoprotein decreased from the initial 13.78 ng/mL and was maintained at about 9 ng/mL (Figure 3). A repeat CT showed good iodine oil deposition on the top of the liver with no active tissue, as well as shrinking and new necrosis of lymph nodes in the hepatogastric space, necrosis of multiple lymph nodes in the mesentery over the renal artery, and only slightly enlarged lymph nodes in the gallbladder, so the patient's tumor was judged to be in remission (Figure 4).  
2022-07-08 CT plain scan of the abdomen (red arrows: residual lesions of the primary tumor; blue arrows: lymph nodes): Iodine oil mass deposition in hepatic segment VII mass, multiple lymph node metastases in the hepatogastric space and retroperitoneum, partially reduced lymph nodes in the hepatogastric space, and slightly enlarged lymph nodes next to the gallbladder compared to 2022-04-07CT.
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Alpha-fetoprotein decreased from the initial 13.78 ng/mL and was maintained at about 9 ng/mL (Figure 3). A repeat CT showed good iodine oil deposition on the top of the liver with no active tissue, as well as shrinking and new necrosis of lymph nodes in the hepatogastric space, necrosis of multiple lymph nodes in the mesentery over the renal artery, and only slightly enlarged lymph nodes in the gallbladder, so the patient's tumor was judged to be in remission (Figure 4).  
2022-08-16 CT scan of the abdomen (red arrows: residual lesions of primary tumors; yellow arrows: new tumors; blue arrows: lymph nodes): Right hepatic parietal cancer mass with increased marginal activity after TACE compared to 2022-07-08 and increased enlarged retroperitoneal lymph node metastasis.
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Change in AFP levels from April to September of patients.
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The patient's abdominal pain improved after the single drug addition of Icaritin Soft Capsules, and a review one month later showed a rapid decrease in Alpha-fetoprotein to 6.4 ng/mL (Figure 6).
2022-09-02 MRI (yellow arrows: new tumors; blue arrows: lymph nodes): Predominantly active anterior margin of hepatic segment VIII lesions is present. Multiple lymph node metastases in the hilar region, hepatogastric space, retroperitoneum, and cystic necrosis of some lymph nodes in the hepatogastric space.
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MRI showed that the primary foci were still active but significantly reduced in size, accompanied by the hepatogastric space, hepatic aortic side, and renal artery side lymph nodes, and nearly total cystic necrosis of the abdominal aortic side gonads (Figure 7).
2022-09-24 CT scan of the abdomen (yellow arrows: new tumors; blue arrows: lymph nodes): decreased marginal activity after TACE in the primary focus compared to the August 16 slice. And the similarity between retroperitoneal lymph nodes and hilar lymphatic effusion.
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This indicates that the patient had a sustained tumor remission after September 2 with one TACE and Icaritin soft gels at full dose (Figure 8). 
2022-10-25 CT scan of the abdomen (red arrows: residual lesions of the primary tumor; blue arrows: lymph nodes): The marginal activity of the right hepatic apex cancer mass after TACE seems to be slightly smaller than that of September 24. Multiple lymph node metastases in the posterior peritoneum and hilar region and some lymph nodes are slightly enlarged.
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Upon reexamination on October 25, abdominal CT showed continued remission of the primary foci and most metastatic lymph nodes, the patient continued Icaritin + chemotherapy, but the lymph nodes by the superior mesenteric artery increased to 6.3*4.3cm (Figure 9); two lymph nodes of 4cm in size nearby abdominal aorta showed a slight increase compared to past CT images of September, so after 4th MDT discussion, the second-line targeted drug was replaced with Regorafenib 120mg qd, d1-21, Q4W, and started packaged hepatic portal and retroperitoneal lymph node (GTV) SBRT on November 7.
Changes in overall AFP levels of patients.
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AFP had reached a new low level of 5.018 ng/mL (Figure 10). And on Dec 5th, the CT scan indicated a significant reduction in multiple lymph node metastases compared to the previous CT scan (Figure 11).
2022-12-05 CT scan of the abdomen (red arrows: residual lesions of the primary tumor; blue arrows: lymph nodes): Significant reduction in multiple lymph node metastases compared to October's CT scan.
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AFP had reached a new low level of 5.018 ng/mL (Figure 10). And on Dec 5th, the CT scan indicated a significant reduction in multiple lymph node metastases compared to the previous CT scan (Figure 11).