A 58-year-old male patient complained abdominal discomfort for 2 months. He went to his local hospital and was diagnosed with HCC and Barcelona Clinic Liver Cancer (BCLC) stage C in March 2020. Then, transcatheter arterial chemoembolization (TACE) was performed.
In order to seek further diagnosis and treatment, he went to our hospital and was admitted in April 2020. He had a history of hepatitis B. On admission, physical examination showed tenderness over the right upper region area with a 5 cm palpable abdominal mass below the xiphoid process. Laboratory data were recorded as follows: alanine aminotransferase (ALT): 36 IU/L, aspartate transaminase (AST): 81 IU/L, albumin (ALB): 22.7 g/L, total bilirubin (TBIL): 9.7 mumol/L, prothrombin time (PT): 11.5 s, and HBV-DNA: 6.83 x 102 IU/ml. Among the tumor markers, alpha fetoprotein (AFP) was significantly elevated (1,649.0 mug/L), carbohydrate antigen 125 (CA125) was sightly increased (113.0 kU/L), and carcinoembryonic antigen (CEA) and carbohydrate antigen 199 (CA199) were normal. The cirrhosis was classified as Child-Pugh 7 and ALBI grade 3. The enhanced CT revealed small nodules in the middle and lower lobes of the lungs that were considered lung metastases, the tumor in the left lobe of the liver was considered HCC with multiple metastases in the right lobe of the liver, and tumor thrombosis was present in the left portal vein (Figure 1). The magnetic resonance imaging (MRI) showed the tumor in the left lobe of the liver with multiple metastases in the right lobe of the liver, and with tumor thrombosis in the left portal vein (Figure 2).
1. After MDT discussion, HCC with BCLC stage C and portal vein tumor thrombus (PVTT) classified VP3 and Cheng's type II was diagnosed, and we believe that radical surgical resection was impossible due to the low residual liver volume and lung metastases. He finally received conversion therapy. The procedure details are as follows: The patient received two cycles of transcatheter arterial embolization (TAE), hepatic arterial infusion chemotherapy (HAIC-Folfox) (the HAIC scheme was as follows: We selectively placed a microcatheter into the feeding arteries of the tumor. Then, the microcatheter was connected to the artery infusion pump to perform the following treatment: Day 1: oxaliplatin 85 mg/m2, leucovorin 400 mg/m2, and 5-fluorouracil 400 mg/m2 via intra-arterial infusion; day 2-3: 5-fluorouracil 2,400 mg/m2 via continuous intra-arterial infusion. After HAIC was completed, the catheter was removed, and compression was performed to achieve hemostasis. The patient was treated every 3 weeks), sorafenib (at a dose of 400 mg twice daily), and camrelizumab (200 mg intravenously every 3 weeks). At the end of HAIC treatment, we were disappointed to find that the tumor had rapidly progressed based on the modified Response Evaluation Criteria in Solid Tumors (mRECIST). Then, the patient received drug-eluting TACE (dTACE) once, sorafenib, and camrelizumab in July 2020. A month later, his liver function deteriorated (ALT: 33 IU/L, AST: 329 IU/L, ALB: 24.9 g/L, TBIL: 16.6 mumol/L, PT: 13.4 s, massive ascites), and the cirrhosis was classified as Child-Pugh 9 and ALBI grade 3. We had to interrupt TACE and only gave sorafenib and camrelizumab. Although he received systemic therapy, the tumors still rapidly progressed and we considered the possibility of tumor resistance. Among the tumor markers, AFP was significantly elevated (12,913.0 mug/L). Then, regorafenib (at a dose of 160 mg daily) was given. In September 2020, the patient received conventional TACE (cTACE) once, regorafenib, and camrelizumab. So far, he had received conversion therapy for half a year, and the treatment effect was not satisfactory. He returned to the local hospital to receive regorafenib every day and camrelizumab once every 3 weeks.
Until a year after his initial diagnosis, the patient found that the tumor and lung metastases had shrunk significantly in the local hospital. Then, he was admitted to our hospital again. On admission, physical examination showed no positive signs. Laboratory data were recorded as follows: ALT: 19 IU/L, AST: 27 IU/L, ALB: 34.2 g/L, TBIL: 8.4 mumol/L, and PT: 11.1 s. AFP was negative (8.1 mug/L). The cirrhosis was classified as Child-Pugh 5 and ALBI grade 2. The enhanced CT revealed there were multiple small nodules in both lungs, which were significantly reduced and shrunken compared to the previous CT. The tumor in the left lobe of the liver was significantly reduced, with local enhancement, and lipiodol deposition was seen. Multiple nodules in the right lobe of the liver had shrunk. And tumor thrombus had formed in the left and right branches of the portal vein (Figure 3). Based on these results, we judged that the patient had partial response (PR) and could be treated with radical surgery, according to the response evaluation in the mRECIST criteria. Then he received left hepatectomy, cholecystectomy, and portal vein incision and embolectomy. The pathological examination showed necrosis of a massive HCC with no tumor cells observed on the resection margins, and without metastasis in lymph nodes. The pathological diagnosis showed that the portal vein tumor thrombus had necrotic tissue (Figure 4). In the patient's postoperative maintenance therapy, the patient was given lenvatinib 8 mg orally once a day, and camrelizumab 200 mg intravenously once every 3 weeks. There was no clinical evidence of recurrence at 6 months after the resection. The AFP levels remained within the normal limits (Figure 5).
Abdominal computed tomography (CT) shows the tumor in the left lobe of the liver considered to be HCC with multiple metastases in the right lobe of the liver, and with tumor thrombosis in the left portal vein and lung metastases. The huge tumor in the left lobe of the liver.