case_images: PMC11165049_01
case_images: Imaging pictures. Before TACE combined with Atezo/Bev treatment, the abdomen enhanced CT revealed multiple tumors in the right liver, with the largest measuring approximately 10 cm x 7.50 cm. During the arterial phase, the tumors exhibited uneven enhancement, while during the venous phase, the degree of enhancement was relatively reduced (A, B). Following two courses of TACE combined with Atezo/Bev treatment, the abdomen enhanced CT indicated a significant reduction in the size of the right liver tumors compared to before, with the largest measuring approximately 6.9 cm x 6.2 cm. Patchy high-density shadows were observed internally, considered to be iodine oil deposition after TACE treatment, with no obvious enhancement on the enhanced scan (C, D). Three days after liver resection, the abdomen plain CT indicated postoperative changes in the right liver lobe, with a small amount of free gas around the liver and no significant fluid accumulation (E, F). One month after liver resection, the abdomen enhanced CT revealed postoperative changes in the right liver lobe, with no abnormal enhanced lesions in the liver parenchyma and a small amount of abdominal fluid (G, H). Six months after liver resection, the abdomen enhanced CT indicated the absence of the right liver lobe, with no abnormal enhanced lesions in the liver parenchyma and a small amount of abdominal fluid around the liver (I, J).
case_images: fimmu-15-1358602-g001.jpg
case_images: PMC11165049_01_fimmu-15-1358602-g001.jpg
case_images: f1
case_images: CT of the upper abdomen revealed multiple liver lesions, with the largest measuring 10 cm in diameter consistent with HCC and multiple intrahepatic metastases ( Figures 1A, B ). Considering the medical history, serological markers, and imaging examinations, intrahepatic cholangiocarcinoma and benign liver tumors were excluded. AFP (1,710.0 ng/ml, normal range 0-10 ng/ml), AFP-L3% (19.35%, normal range 0-10%), and PIVKA-II (261.3 ng/ml, normal range 0-40 ng/ml). Abdomen-enhanced CT displayed marked tumor shrinkage, with the maximum tumor diameter reducing to 6.9 cm, and the diameter of the two largest lesions decreasing to 12.3 cm, demonstrating a reduction exceeding 30% compared to the initial assessment ( Figures 1C, D ). According to the Response Evaluation Criteria in AFP (+), HepPar-1 partial (+), Ki-67 index 60% ( Figures 5B-D ). An upper abdomen CT conducted 3 days postoperatively revealed the postoperative appearance of the right lobe of the liver, with no significant fluid accumulation in the abdominal cavity or around the liver ( Figures 1E, F ). One month postoperatively, tumor-related markers indicated AFP (21.9 ng/ml, normal range 0-10 ng/ml), AFP-L3% (16.84%, normal range 0%-10%), and PIVKA-II (50.7 ng/ml, normal range 0-40 ng/ml), with no apparent abnormalities on upper abdomen enhanced CT ( Figures 1G, H ). Over the subsequent 11-month follow-up period, tumor markers remained within normal limits ( Figures 6A-C ), and no tumor recurrence was observed in the imaging examination after the surgery ( Figures 1G-J ).
case_images: During the TACE procedure, the imaging showed staining of the right liver tumors.
case_images: fimmu-15-1358602-g002.jpg
case_images: PMC11165049_01_fimmu-15-1358602-g002.jpg
case_images: f2
case_images: Subsequent imaging revealed satisfactory deposition of the iodized oil ( Figure 2 ).
case_images: Preoperative CT three-dimensional reconstruction model. The black arrow indicates the tumor, the red arrow indicates the portal vein, the yellow arrow indicates the inferior vena cava, and the green arrow indicates the abdominal aorta.
case_images: fimmu-15-1358602-g003.jpg
case_images: PMC11165049_01_fimmu-15-1358602-g003.jpg
case_images: f3
case_images: Before the procedure, a comprehensive CT three-dimensional reconstruction model ( Figure 3 ) was perfected, and on 4 May 2023, a laparoscopic hepatic partial resection was performed.
case_images: Specimen of tumor resection. Resection specimen of the tumor: there were a total of three tumors, with volumes of 6.9 cm x 6.2 cm x 6 cm, 5 cm x 4 cm x 3.8 cm, and 2.2 cm x 1.8 cm x 1.8 cm, respectively.
case_images: fimmu-15-1358602-g004.jpg
case_images: PMC11165049_01_fimmu-15-1358602-g004.jpg
case_images: f4
case_images: Postoperative pathological examination revealed poorly differentiated HCC, and extensive necrosis (approximately 70%) was observed within the tumors, with three nodular tumors measuring 6.8 cm x 6.2 cm x 6 cm, 5 cm x 4 cm x 3.8 cm, and 2.2 cm x 1.8 cm x 1.8 cm ( Figure 4 ).
case_images: Pathological and immunohistochemical images. Histological staining of the tumor sections (HE x100) revealed poorly differentiated hepatocellular carcinoma accompanied by extensive degeneration and necrosis. The tumor cells exhibited significant atypia, including the presence of giant cells, without satellite nodules, definite neural invasion, or intravascular tumor thrombi. Nodular cirrhosis was observed around the liver section, with partial hepatocyte cholestasis and fatty degeneration (A). AFP demonstrated a positive reaction (B x100). HepPar-1 exhibited partial positive reaction (C x100). Ki-67 positivity index was 60% (D x100).
case_images: fimmu-15-1358602-g005.jpg
case_images: PMC11165049_01_fimmu-15-1358602-g005.jpg
case_images: f5
case_images: No tumor tissue was found at the resection margins; nodular cirrhosis was observed surrounding the margins ( Figure 5A ). AFP (+), HepPar-1 partial (+), Ki-67 index 60% ( Figures 5B-D ). An upper abdomen CT conducted 3 days postoperatively revealed the postoperative appearance of the right lobe of the liver, with no significant fluid accumulation in the abdominal cavity or around the liver ( Figures 1E, F ).
case_images: The graphical depiction of the dynamic shifts in AFP (A), AFP-L3% (B), and PIVKA-II (C) throughout the therapeutic course, along with the treatment timeline (D).
case_images: fimmu-15-1358602-g006.jpg
case_images: PMC11165049_01_fimmu-15-1358602-g006.jpg
case_images: f6
case_images: Over the subsequent 11-month follow-up period, tumor markers remained within normal limits ( Figures 6A-C ), and no tumor recurrence was observed in the imaging examination after the surgery ( Figures 1G-J ). Relevant data and the treatment timeline are depicted in  Figure 6 .