43933115

A 54-year-old man was referred to our hospital because of accidental finding of

elevated AFP level of 2700 during his regular HBV-related checkup at local hospital
two weeks ago. He is a HBV carrier for 30+ years and has history of alcohol drinking.
Patient had mild general weakness, deceased physical status and appetite, right flank
soreness and unintentional weight loss of 4kg within past 6 months. He had no night
sweating, fever, jaundice nor abdominal discomforts. Examination findings showed
no evidence of ascites, splenomegaly nor enlarged liver.
Hepatitis B virus surface antigen (HBs Ag) was seropositive, and hepatitis B virus DNA
was 8.42*10^6 IU/mL. Serum alpha-fetoprotein (AFP) was elevated (>2,700 ng/mL).
Serum of carbohydrate antigen 19.9 (CA-19.9) was slightly elevated (CA-19.9 48.1)
Further workup revealed one mass in S6 of liver, isodense in portal phase but
washout appearance in later phase, and surrounding IHD mild dilatation on
Multiphasic Computed Tomography (CT) of the abdomen. The patient was diagnosed
with HCC (Barcelona clinic liver cancer [BCLC] stage B, child class B, performance
status 0).
Pre-op surveys were in acceptable ranges, so open hepatectomy with lymph node
dissection was carried out for the purpose of treatment and staging. Operation
findings showed a 3*2cm tumor over S6/7 of liver with IHDs invasion and tumor
thrombus from posterior branch of right IHD to bifurcation. Surface of liver S5/6/7
segmentectomy, bile duct thrombectomy and open cholecystectomy were
performed. Pathology report showed metastatic carcinoma in lymph node 12 and
posterior IVC and severe fibrosis of liver tissue (Ishak fibrosis stage 5), Neoplastic
cells were moderately differentiated. According to AJCC 7th, patient was staged
pT2N1, stage IVA. The patient was immediately started on antivirus therapy with
Tenofovir and immunotherapy with sorafenib began one month after operation.
Follow up CT 3 months after the operation showed progressive metastatic
lymphadenopathy, two new soft tissue mass in the aortocaval region, size measured
1.7cm and 3.0cm, along with ascites and CHD, IHD dilation. Due to disease
progression, patient started to receive pembrolizumab in conjunction with sorafenib.