case_images: PMC8803907_01
case_images: Contrast-enhanced computed tomography at initial staging (Mar 2020). (A) The coronal slice shows two large hypodense lesions in the right liver lobe (orange arrows) and osteolytic lesions of lumbar vertebrae (green arrows). (B, C) Transversal slices display extended, hypointense lesions in the liver (orange arrows), as well as lesions in the pancreas (blue arrows) and the left kidney (yellow arrow).
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case_images: Computed tomography (CT) covering neck, thorax, abdomen, and pelvis confirmed large tumor masses in the right liver lobe of 10.9 x 9.7 x 13.6 and 14 x 13 x 16 cm (719 and 1,456 ml), compatible with hepatocellular carcinoma ( Figures 1A-C ). In addition, metastases were suspected in the left supradiaphragmatic recess, in both kidneys, pancreas, and skeleton ( Figures 1A-C ).
case_images: Response 18F-FDG PET scans acquired between Jun 2020 and Sep 2020 following 4 (A), 8 (B), and 9 (C) cycles of immunochemotherapy. The only remaining metabolically active lesion after 4 immune-chemotherapy cycles has been a circumscribed area in the right liver lobe. Under continued (B) and intensified immunochemotherapy (C), its metabolism increased while its volume decreased. DS, Deauville score; SUVmax, maximum standard uptake value; qPET, quantitative positron emission tomography; HUmean, average value of Hounsfield Units.
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case_images: Figure 2A ). For all other lesions 18F-FDG/PET showed a complete metabolic response (DS 1). The liver lesion had further decreased (4.8 x 4.8 x 6.9 cm = 79 ml), whereas its metabolism had increased (DS5, qPET 2.87) ( Figure 2B ). Figure 2C ). For histopathology analysis, an ultrasound-guided core needle biopsy was performed.
case_images: Macroscopic and microscopic presentation of the 18F-FDG-PET-positive residual in the right liver lobe (A-D). (A) The in situ view demonstrates the liver segments V and VIII which are mostly necrotic and remodeled. (B) Macroscopic resectate of liver segments V and VIII. (C) Microscopic view of the liver resectate shows normal liver parenchyma on the right (green arrow) and extended area of necrosis on the left (black arrow). No evidence of large, polymorphous lymphoma cells. (D) Granulation zone with macrophages, small lymphocytes, and hemorrhagic remnants on the right, and an area of necrosis on the left (D corresponds to a close-up of the black circled area visible on C). No evidence of large, polymorphous lymphoma cells.
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case_images: Histopathology and immune-histochemical analyses of the removed liver segments (V/VIII) revealed only necrosis surrounded by numerous macrophages and small lymphocytes without any evidence of lymphoma cells ( Figure 3 ).