PMC8563693_01
Initial imaging examination. (A-D) Dynamic abdominal computed tomography (CT): (A) multiple variable sized tumor lesions in both hepatic lobes with hypodensity in precontrast image, (B) persistent poor enhancement showed in arterial phase, (C) portal venous phase taken on November 26, 2015, original tumor lesions indicated by red asterisk symbol, and (D) delayed-postcontrast phase. (E, F) L-spine MRI showed multiple tumor lesions indicated by blue asterisk symbol. (E) Fluid attenuated inversion recovery (FLAIR) T1-weighted MRI. (F) Fast relaxation fast spin echo (FRFSE) T2-weighted MRI. (G) Tc-99m MDP whole body bone scan showed multiple increased tracer uptake in the skeletal system, compatible with multiple bone metastases.
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Poorly differentiated HCC or cholangiocarcinoma should be suspected ( Figures 1A-D ). The spinal magnetic resonance imaging (MRI) scan suggested multiple bony lesions and favored bony metastasis ( Figures 1E, F ). A whole-body bone scan revealed multiple sites of increased tracer uptake in the skeletal system and suspicious bone metastases ( Figure 1G ). They contrasted with the initial one ( Figure 1C ) taken on November 26, 2015, which showed that she had several lesions in both hepatic lobes. We used hepatic veins as a landmark to verify that the pictures showing little lesions ( Figure 3C ) and no lesions ( Figure 3D ) are in the same section as the initial one showing multiple lesions ( Figure 1C ).
Photomicrograph of liver pathology. (A-C: liver biopsy; D-F: liver pathology after left partial segmentectomy). (A) Necrosis and fibrin shown on liver biopsy. Hematoxylin and eosin stain; magnification, 40X. (B) Higher magnification of necrosis and fibrin shown on liver biopsy. Hematoxylin and eosin stain; magnification, 100X. (C) Organizing hematoma (indicated by asterisk symbol in the photomicrograph) shown on the left side. The normal liver parenchyma shown on the right side. Hematoxylin and eosin stain; magnification, 40X. (D) Higher magnification of the hematoma. No viable cell can be identified. Hematoxylin and eosin stain; magnification, 100X. (E) Another view of the hematoma. Hematoxylin and eosin stain; magnification, 100X. (F) Focal chronic inflammation and fibrosis shown on liver. Hematoxylin and eosin stain; magnification, 200X. Scale bar = 100 microns.
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On November 30, 2015, she underwent a liver core biopsy, which showed necrosis, but no cancer cells ( Figures 2A, B ). The pathological report documented organizing hematoma with fibrosis, and no evidence of malignancy was found ( Figures 2C-E ). The pathological report showed patchy foci of necrosis with marked fibrosis and chronic inflammation ( Figure 2F ).
Post treatment imaging findings (A) Photomicrograph of spine pathology. Focal necrosis shown on L3 spine biopsy. No evidence of malignancy can be found. Hematoxylin and eosin stain; magnification, 100X. (B) Necrotic bone (indicated by black asterisk symbol in the photomicrograph) shown on spine biopsy. Hematoxylin and eosin stain; magnification, 200X. (C) Dynamic abdominal CT portal venous phase taken on February 9, 2017. Original tumor lesions indicated by red asterisk symbol. (D) Dynamic abdominal CT portal venous phase taken on December 12, 2018. (E) Initial coronal CT of L-spine taken on November 26, 2015. (F) The followed coronal CT of L-spine taken on December 12, 2018.
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Bone biopsies of the second and third lumbar vertebrae were performed, and the results were L2 biopsy: fibrosis, L3 biopsy: focal necrosis and new bone formation ( Figures 3A, B ). Follow-up CTs were performed on February 9, 2017 ( Figure 3C ) and December 12, 2018 ( Figure 3D ), respectively. Results showed little tumor ( Figure 3C ) and then no tumor ( Figure 3D ), respectively, after treatment. We used hepatic veins as a landmark to verify that the pictures showing little lesions ( Figure 3C ) and no lesions ( Figure 3D ) are in the same section as the initial one showing multiple lesions ( Figure 1C ). Initial coronal CT of L-spine ( Figure 3E ) showed multiple mixed osteoblastic and lytic change in L-spine bony structure, with pathological fracture of L3-4, suggestive bony metastasis. The followed one ( Figure 3F ) revealed focal lytic change of L-spine and no progression of compression fracture, nor more trabecular destruction of L-spine vertebral body.
Timeline of treatment process and patient's corresponding serum AFP levels. DAA, direct-acting antiviral agents.
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It was clinically determined that her liver tumor, complicated by bone metastasis and nerve compression, had completely regressed.  Figure 4  illustrates the timeline of the complete treatment procedure and the corresponding serum AFP levels.