PMC10365095_01
Computed tomography (CT) scans and three-dimensional reconstruction at initial diagnosis. (A) A large lesion (the red arrow head) in the right lobe of the liver, measuring about 19.3 x 14.6 x 13.2 cm. The middle hepatic vein (the black arrow) ran almost along the edge of the lesion. (B) The future liver remnant (FLR, the light green area), followed right hemi-hepatectomy divided by standard liver volume (SLV), was 51.47%, which was well-tolerated for hepatectomy, although the surgical margin was nearly zero. (C) If extended right hemi-hepatectomy were to be performed, the FLR (the yellow area)/SLV would be 25.78%, with an extremely high risk of post-hepatectomy liver failure.
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F1
Contrast-enhanced computed tomography (CT) scans revealed a mass located in the right lobe of the liver (Figure 1A), measuring approximately 19.3 x 14.6 x 13.2 cm, with enhancement in the arterial phase and rapid washout in the portal phase, suggesting a diagnosis of primary liver cancer. The ratio of FLR to standard liver volume (SLV) after anatomical right hemi-hepatectomy was 51.47% (Figure 1B), which was well-tolerated for hepatectomy (>40%). However, the middle hepatic vein ran almost along the edge of the lesion (Figure 1A). By contrast, an extended right hemi-hepatectomy would probably result in insufficient FLR (Figure 1C, FLR/SLV = 25.78%, far <40%), with a high risk of PHLF.
Hepatic artery infusion chemotherapy and portal vein embolization. (A) The tumor was mainly fed by both right and left hepatic arteries, so the infusion microcatheter was selectively placed into the common hepatic artery (the red arrow head). (B) The right branch of the portal vein before embolization (the white arrow). (C) The right branch of the portal vein after embolization (the white arrow).
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F2
The infusion microcatheter was selectively placed into the common hepatic artery, which was the main feeding artery to the tumor (Figure 2A). After 3 days of HAIC, biological glue was utilized to embolize the right branch of the portal vein (Figures 2B,C), resulting in a brief increase in alanine transaminase (ALT) to 338.6
Computed tomography (CT) scans and three-dimensional reconstruction after portal vein embolization (PVE) and multimodality therapy. (A) The tumor remarkably regressed (the white arrow), with complete disappearance of intratumoral enhancement on the artery phase. (B) The distance between the tumor and the middle hepatic vein (the red arrow head) was significantly extended. (C) The ratio of future liver remnant (the light green area) to the standard liver volume (SLV) was 67.74%, which was well-tolerated for hepatectomy.
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F3
After 5 weeks of multimodality therapy, follow-up CT scans showed remarkable regression of the tumor with complete disappearance of intratumoral enhancement on the artery phase (Figure 3A) and increased distance between the tumor and the middle hepatic vein (Figure 3B). The FLR/SLV reached 67.74% (Figure 3C), and the Child-Pugh score was 5, which met the requirements of the surgery.
Gross and histopathological findings of the resected specimen. The gross (A) and cut (B) surface of the tumor showed the solid tumor with obvious hemorrhage and necrosis. (C) Microscopic finding of the liver mass showed abundant infiltration of lymphocytes and complete tumoral necrosis without any viable alive tumor cells.
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F4
The gross of the resected specimen showed obvious hemorrhage and necrosis of the tumor (Figures 4A,B). Postoperative pathology revealed an encapsulated tumor with massive hyalinization, necrosis, lymphocyte, and granulocyte infiltration, and no viable tumor cells (Figure 4C).
The timeline of clinical events. HCC, hepatocellular carcinoma; FLR, future liver remnant; SLV, standard liver volume; HAIC, hepatic artery infusion chemotherapy; ALT, alanine transaminase; AST, aspartate aminotransferase; PVE, portal vein embolization.
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F5
The timeline of clinical events is shown in Figure 5.