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case_images: (A, B) Enhanced MRI scan of the liver lesion before surgery. (C-E) Histopathological finding (hematoxylin and eosin staining, Ki67, and beta-catenin), poorly differentiated intrahepatic sarcomatoid cholangiocarcinoma. Magnification, x400. Scale bar: 50 microm. (F) MRI scan of the liver lesion after surgery in February 2022.
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case_images: Enhanced abdominal magnetic resonance imaging (MRI) presented one tumor lesion (with a size of 6.5 x 6 x 5 cm) in segments V of liver (Figures 1A, B). Tumor biopsies from resected liver lesions revealed a poorly differentiated intrahepatic sarcomatoid cholangiocarcinoma (ISSC), which is a rare histopathology classification of iCCA (Figure 1C). CK19, CK7, CD34, Ki67 (50% positive rate, Figure 1D), and beta-catenin (Figure 1E) and negativity for AFP and hepatocyte specific antigen (Hep-Par-1). Chemotherapy with capecitabine was initiated in the second month after surgery, and no recurrence of the primary tumor had been found at the last follow-up in February 2022 (Figure 1F).
case_images: (A) PET-CT scan of the brain before liver surgery. (B) PET-CT scan of the brain 3 months after liver surgery.
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case_images: In July 2021 before the liver surgery, no extrahepatic metastasis was found in the brain of this patient (Figure 2A). However, on this presentation, PET-CT revealed a 1.1 cm x 0.6 cm mass in his right frontal lobe (Figure 2B).
case_images: (A) Brain MRI scan after treatment with camrelizumab and lenvatinib for 4 cycles. (B) Brain MRI scan after treatment with camrelizumab and lenvatinib for 16 cycles. (C) Timeline of the disease course and treatment before brain metastasis. (D) Timeline of the disease course and treatment after brain metastasis.
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case_images: After the first three-cycle treatment (approximately 2 months), the general condition of this patient remained stable, and the brain MRI presented a 0.8 x 0.7 mass in the right frontal lobe and little amount of surrounding edema (Figure 3A). During this period, the previous metastatic lesions in the brain regressed gradually until complete regression was examined after 16-cycle treatments in September 2021 (Figure 3B). Fortunately, immunotherapy plus targeted therapy was effective and well-tolerated until the tumor lesion in the brain totally disappeared (Figures 3C, D).