case_images: PMC9035916_01
case_images: Early phase (a-g) and hepatocellular phase (h-n) of EOB-MRI preoperatively (a), at the start of treatment (b, e, i, l), 8 weeks (c, f, j, m), and 16 weeks (d, g, k, n) later. After 8 and 16 weeks of treatment, hyperintensity disappeared in both tumors in the early phase, and CR was diagnosed by mRECIST. In the hepatocellular phase, the low signal area showed a reduction of 30% or more and thus a PR by RECIST version 1.1. EOB-MRI, Gd-EOB-DTPA-enhanced magnetic resonance imaging; CR, complete response; PR, partial response; RECIST, Response Evaluation Criteria in Solid Tumors; mRECIST, modified Response Evaluation Criteria in Solid Tumors.
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case_images: PMC9035916_01_cro-0015-0318-g01.jpg
case_images: F1
case_images: The tumor was unevenly stained at the margin and inside in the arterial phase (Fig. 1a), had some washout from the portal vein phase, low signal in the hepatocellular phase (Fig. 1h), and high signal in the diffusion-weighted image. Eight weeks after the start of lenvatinib, evaluation was performed by Gd-EOB-DTPA-enhanced magnetic resonance imaging (shown in Fig. 1b-g, i-n).
case_images: Pathological findings of surgical specimens (a-d) and specimens obtained by percutaneous liver biopsy for lesions that occurred after surgery (e-g). Pathological findings of surgical specimens revealed a mixture of cord-like HCC components (HE staining (a), positive hepatocyte staining (b)) and cholangiocarcinoma component (HE staining (c), positive CK19 staining (d)), proliferating as a glandular tube with abundant fibrous tissue, diagnosed as combined hepatocellular cholangiocarcinoma. e Pathological findings of specimens obtained by percutaneous liver biopsy revealed that tumor cells proliferated in a cord-like, alveolar-like, and solid manner and showed a histological image similar to poorly differentiated HCC. In immunostaining, tumor cells were not stained with the hepatocyte (f) but strongly stained with CK19 (g) (scale bar, 200 mum).
case_images: cro-0015-0318-g02.jpg
case_images: PMC9035916_01_cro-0015-0318-g02.jpg
case_images: F2
case_images: In the pathological diagnosis of the surgical specimen, a mixture of cord-like HCC components with positive hepatocyte staining and a cholangiocarcinoma component that formed a glandular tube with abundant fibrous tissue and positive for CK19 staining were seen, so the patient was diagnosed with combined hepatocellular-cholangiocarcinoma (Fig. 2a-d). HCC, which grew in a cord-like, alveolar-like, and solid manner (shown in Fig. 2e). However, because no clear sinusoid-like structures or pseudoglandular cavity formation was observed, and it was atypical, immunostaining was also carried out with the result that the tumor cells were not stained with the hepatocyte (shown in Fig. 2f) but strongly with CK19 (shown in Fig. 2g).
case_images: Change of tumor markers (CA19-9 and AFP) through the pre- and postoperative course. AFP, alfa-fetoprotein; CA19-9, carbohydrate antigen 19-9.
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case_images: PMC9035916_01_cro-0015-0318-g03.jpg
case_images: F3
case_images: The hypointensity in the hepatocellular phase was reduced by more than 30%, which resulted in assigning a partial response according to Response Evaluation Criteria in Solid Tumors version 1.1. This state has been maintained 7 months after the start of lenvatinib, and treatment is ongoing (shown in Fig. 3).