A 48-year-old man with no relevant medical history was admitted to our hospital for acute abdominal pain and fatigue on September 12, 2016. Palpation of the right quadrant of the patient showed tenderness, but the test of Murphy sign was negative. On the second day after admission, the patient underwent computerized tomography (CT) scan, showing a 5.5 cm x 5.1 cm lesion adjacent to the liver capsule (Figure 1). Combined with the results of pathological biopsy, the patient was diagnosed with ICC.
Based on the history, symptoms, signs, and auxiliary examination, the patient was diagnosed with ICC II (AJCC-UICC TNM stage: 8) and cachexia (ECOG score: 2). Meanwhile, after multidisciplinary consultation, the surgical treatment was not recommended due to the poor nutritional status. Hence, the interventional treatment was recommended after improving the nutritional status of the patient. Finally, transcatheter arterial chemoembolization (TACE) was performed on the patient on September 18, 2016. Briefly, the catheter was superselectively intubated into the tumor supplying artery through the skin. And the end of the tumor supplying artery was embolized with iodized oil emulsion (10 mL) containing chemotherapy drugs (epirubicin hydrochloride needle 10 mg). The patient had no apparent discomfort after surgery. The patient's liver function was re-examined after 3 days of treatment, with TB: 11 micromol/L, ALT: 20 U/L, AST: 19 U/L, and ALB: 30 g/L.
CT scan of the liver was performed 1 month after TACE treatment. The results showed abnormal right lobe with margin atrophy. The patchy mixed density shadow was observed in the right posterior lobe of liver, and speckled shadow of iodide deposition were observed at the edge (Figure 2). Furthermore, it was assessed as disease stability (SD) by modified Response Evaluation Criteria in Solid Tumor (mRECIST) criteria.
These results suggested that ICC is not sensitive to TACE treatment. After a multidisciplinary consultation and discussion, the patient underwent minimally interventional therapy with iodine-125 seed implantation. Briefly, based on preoperative CT scan, treatment planning system (TPS; Beijing Hang Kelin Technology Development Co., LTD) was used to simulate approximate dose distribution of solid tumor at prescribed dose and to determine the particle number and spatial distribution (V100 >= 95% and D90 >= 100%). In order to prevent the particles from entering the blood vessels and migrating, the total radiation dose was 120 Gy, the particle spacing was about 1 cm, and the particles were implanted 1 cm away from the large blood vessels. 3D printing templates were made by TPS before treatment The radioactive particles were placed percutaneously through a 3D-printed template under CT guidance. Complications were observed after operation, including whether there was bleeding under the liver capsule, large blood vessels and whether there was particle displacement or gas embolism in the heart. Moreover, a CT scan was performed after the surgery to make sure the surgery went well. The instruments used in the present operation included pistol type particle implantation device (Figure 3), 18G particle implantation needle, and iodine-125 radioactive particles with an activity of 2.22E + 7 Bq (Beijing Atomic Technology Co., LTD).
In order to avoid bleeding, only two injections were used. We adjusted the needle in the liver for multi-point ablation, always avoiding penetrating the liver capsule. The frame heads were adjusted to fan shape, and iodine-125 seeds were planted so that they were distributed in a fan shape with a distance of 1 cm between each two seeds (Figure 4).
After 3 months of treatment, CT scan showed that the lesion was atrophic (Figure 5). The mRECIST assessment showed complete remission (CR). The patient's liver function was re-examined on January 1, 2021, and the important clinical indicators of liver function results were as follows: TB: 11.2 mumol/L, ALT: 2018 U/L, AST: 16.9 U/L, and ALB: 47 g/L. Moreover, re-examinations after discharge showed that the lesions were completely necrotic and no signs of recurrence until last CT scan on January 1, 2021 (Figure 6), and mRECIST assessment was CR.