A 54-year-old female patient was admitted to Lanzhou University Second Hospital on October 31, 2016 because of "intermittent upper abdominal pain and discomfort for 1 month." Symptoms became worse after eating greasy food. She did not receive any treatment before the admission. Because the above symptoms gradually worsened, the patient went to the local clinic. CT of the abdomen reveals space-occupying liver lesions, which was considered more as hepatic hydatid disease. For further diagnosis, the patient visited our hospital. The patient has been a carrier of HBV since childhood and has not been tested for HBV DNA or received antiviral treatment. At the same time, her mother and siblings are both HBV carriers, and she has a history of life in a pastoral area in her childhood. Appendectomy was performed because of acute appendicitis in 2009, and postoperative recovery was fine.
Laboratory examination results were as follows: white blood cells (WBC) 3.7 x 10 9 per L, red blood cells (RBC) 4.32 x 1012 per L, platelet (PLT) 119 x 109 per L, T bilirubin (TBiL) 11.7 mumol/L (normal range: 3.8-25.8 mumol/L), direct bilirubin (DBiL) 5.4 mumol/L (0-6.8 mumol/L), alanine aminotransferase (ALT) 359 U/L (0-50 U/L), aspartate aminotransferase (AST) 200U/L (0-50 U/L). Alpha-fetoprotein (AFP) was 1,210 ng/ml (0-7 ng/ml). Test of HBsAg, HBeAg, Anti-HBe and Anti-HBc were positive, while test of Anti-HBs was negative. Level of HBV DNA was 5.32 x 103 IU/ml (Normal <1.0 x 102 IU/ml). Casoni test was positive. Enhanced CT of the abdomen (Figures 1A,B) suggested malignant liver tumor and hepatic hydatid disease, but no abnormalities were found in gastroscopy and colonoscopy.
The patient had a history of HBV infection and did not receive regular antiviral treatment, and AFP was significantly increased. Combined with imaging enhancement mode, she was diagnosed as having HCC and chronic HBV infection. In addition, considering the facts that the patient had a life history in a pastoral area, the Casoni test was positive, and the abdominal CT showed obvious calcification in the liver-occupying space, she was diagnosed as having hepatic hydatid disease.
She underwent an operation on November 10, 2016. During the surgery, we found that the liver indicated signs of cirrhosis, and that the tumor and hydatid cysts were located in the right anterior lobe, adjacent to the right and middle hepatic veins. Therefore, hepatic Segment 5, 8 segment resection, hepatic hydatid internal capsule removal, and cholecystectomy (Figures 2a-d) were performed. She was discharged 8 days after the operation. Pathological results were infiltrating moderately differentiated hepatocellular carcinoma of the liver, with tumor thrombus in the vessel, accompanied by hydatid infection. Chronic cholecystitis was found without cancer invasion (Figures 3a,b). After being discharged from the hospital, she received long-term oral entecavir (0.5 mg/day) antiviral therapy and oral albendazole (0.4 g/day) for 6 months.
She underwent re-examination every 3 months after the surgery. In May 2017, the level of AFP increased to 895.5 ng/ml, and the first cycle of transcatheter arterial chemoembolization (TACE) treatment (oxaliplatin 150 mg + epirubicin 30 mg) was given. TACE was performed 3 times on June 27, August 7, and September 20, 2017, and AFP dropped to 3.73 ng/ml. In August 2019, AFP rose to 122.5 and 246.3 ng/ml in October 2019, but there was no evidence of recurrence of HCC in magnetic resonance imaging (MRI). The fifth TACE treatment was performed in October 2019, and there were no obvious signs of tumor staining during the TACE. AFP decreased to 182.7 ng/ml 1 month later. In March 2020, AFP elevated to 204.3 ng/ml, and the patient was advised to continue treatment, but she refused further treatment because of economic factors. In December 2020, AFP rose to 700.7 ng/ml. The recent follow-up was done in September 2021, and the patient was fine and received oral entecavir only.