A 72-year-old female patient developed a gallbladder tumor in December 2017 due to pain in the right upper quadrant. The biopsy showed poorly differentiated adenocarcinoma. She was diagnosed as stage IIIA gallbladder carcinoma (T3N1M0) bacause of lymph node metastases at hepatic hilar and pancreatic head by positron emission tomography (PET) scan. Since the patient had been previously diagnosed with rheumatic heart disease and diabetes, irreversible electroporation ablation was performed. The patient's abdominal pain was relieved after ablation and she then received oral tegafur (a fluoropyrimidine derivative) chemotherapy. In September 2018, the patient developed severe pain in her upper right abdomen, with vomiting associated with the inability to eat, and a subsequent rapid reduction in body weight. After being admitted to our hospital, the patient was diagnosed with heart failure (class IV heart function), severe anemia, and hypoproteinemia. A computed tomography (CT) examination revealed gallbladder tumors (6.3 x 4.9 cm), multiple spotted high-density lesions in the liver parenchyma, tumor invasion of the duodenum, accompanied by gallbladder-duodenal descending fistula, multiple enlarged lymph nodes around the pancreatic head (maximum 2.7 x 2.1 cm), and compression of the inferior vena cava. Moreover, the gallbladder cancer had progressed to stage IV (T4N1aM0). On the second day after admission, the patient entered the Intensive Care Unit and received both symptomatic and systemic supportive treatments, including parenteral nutrition, an infusion of albumin, red blood cells, insulin, cardiotonic diuretics, and antibiotics, as well as gastrointestinal catheter drainage.
This patient was enrolled in a hydrogen therapy clinical trial (NCT03818347) on October 24, 2018. The inhalation of hydrogen gas via a hydrogen oxygen atomizer (AMS-H-03, Asclepius Meditec, Shanghai, China) was initiated simultaneously with symptomatic treatments. Initially, the patient underwent hydrogen inhalation for 2 h/day (3 L/min), and was gradually increased to 6 h/day. In addition to continuing to administer the above symptomatic and systemic supportive treatments, no routine anti-cancer therapy was provided. Post-treatment evaluations included: 1) adverse reactions: referred to in the Common Terminology Standard Version 5.0 (CTCAE 5.0). Adverse events were classified and scored weekly after treatment initiation. Laboratory indicators included peripheral blood cell subsets, serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TB), and gamma-glutamyl transpeptidase (GGT), and expression of tumor markers; 2) clinical symptoms and PS scores; 3) imaging changes: the tumor response was measured using computed tomography (CT) according to the RECIST 1.1 guidelines, and the tumor response was classified as complete remission (CR), partial remission (PR), stable disease (SD), or progressive disease (PD).
Following hydrogen inhalation, the patient's daily agitation gradually decreased and disappeared completely after two weeks. In addition, the patient's sleep time was extended from 4-5 h/day to 8-10 h/day within two weeks. No adverse reactions related to hydrogen inhalation were observed during the first three months. The patient's upper abdominal pain persisted, requiring the daily use of analgesics prior to hydrogen treatment; however, after two weeks of hydrogen inhalation, the pain gradually decreased and painkillers were no longer required. The PS score gradually decreased from 4 points prior to hydrogen treatment to 1 point after two and a half months. By the end of April 2019, the patient had a PS score of 0 and had resumed normal diet and activity. The disease has been continuously relieved for 10 months and has exhibited increased improvement.
During the entire period of hydrogen treatment, serum levels of ALT, AST, TB, and GGT exhibited no abnormalities; the red blood cell count and hemoglobin levels stopped decreasing; and the interval between blood transfusions was extended from one week before hydrogen inhalation to two weeks. Moreover, these two indexes began to increase continuously one month later (Figure 1A), and the blood transfusion was completely stopped after two months. The level of serum total protein and albumin began to rise after supportive treatments and continued to increase after hydrogen inhalation, reaching a normal range after two and a half months, at which time, supplements were no longer required (Figure 1B). In the two weeks before hydrogen treatment, the peripheral blood leukocyte count was significantly increased due to the intestinal fistula. The leukocyte count decreased to the upper limit of the reference range after antibiotic treatment and continued to decrease after hydrogen inhalation, falling to normal levels after 1.5 months (Figure 1C left). The total number of lymphocytes was low at the time of admission, and the number began to rebound after one and a half months of hydrogen inhalation, returning to normal after two and a half months (Figure 1C right).
Serum CA19-9, AFP, and CEA were all elevated at the time of admission (2, 1.8, and 8 times the upper limit of the reference values, respectively). Following hydrogen inhalation, the three markers did not decline and the AFP even exceeded the level at the time of admission; however, these levels rapidly declined afterwards, and all fell to within the normal reference range after two and a half months (Figure 2).
Abdominal CT images were analyzed at different time points before and after hydrogen treatment (Figure 3A). Before hydrogen treatment, the sum of the diameter of multiple tumors was 12.2 cm. After hydrogen treatment for: 1) one month, the sum was 16.7 cm (37% increase compared with pretreatment, PD); 2) two and a half months, the sum was 12.9 cm (6% increase compared with pretreatment, SD); and 3) six months, the total was 8.1 cm (33% decrease compared with pretreatment, PR) (Figure 3B).
The patient was tested for immunological function before hydrogen treatment, as well as at six and nine months after treatment. In the terminally differentiated CD8+ T cells, the proportion of exhausted cells was 46.8% at two weeks before treatment, 31.3% at six months after treatment, and 27.6% after nine months (Figure 4).