Chief complaints
A 65-year-old Asian man presented to the emergency department due to anorexia, which lasted for three weeks, and fever for four days.
History of present illness
The patient developed anorexia symptom for three weeks accompanied by the jaundice of the skin and sclera, without nausea, vomiting, fever, abdominal pain, abdominal distension, or other uncomfortable symptoms. 4 days before admission, the patient developed fever without chills, the temperature could be as high as 40℃. He received anti-inflammatory, antipyretic, and fluid rehydration treatments in the outpatient clinic. The patient still complained of anorexia when he was admitted to the hospital, he still had a low-grade fever below 38℃ every afternoon, and he lost 5 kg in weight in the last month.
History of past illness
The patient suffered from type 2 diabetes and hypertension for more than ten years but denied a history of hepatitis and allergy.
Personal and family history
The patient also had a smoking history of 40 years, 20 cigarettes a day, a history of drinking 40 years, and 150ml liquor a day. The patient denied a family history of liver cancer and other tumors.
Physical and laboratory examinations
Only mild jaundice of the skin and sclera was found on physical examination. The patient's laboratory examinations showed his alpha-fetoprotein (AFP) rose to 98.75ng/ml. After admission, the patient underwent a hepatitis virus test, and the result suggested hepatitis B core antibody (HBcAb) positive, hepatitis B emission antibody (HBeAb) positive, hepatitis B surface antigen (HBsAg) positive, whose value are 10.82S/CO, 0.03S/CO and 76.56IU/ml respectively.
Imaging examinations
His abdominal enhanced MRI showed a mixed density high signal on T2 weighted imaging (T2WI), a high signal on diffusion weighted imaging (DWI), and a low signal on T1 weighted imaging (T1WI), which was unevenly strengthened at the edge of the lesion during the enhanced scanning arterial phase, and decreased during the portal and delayed phase. The FDG-PET/CT scan showed abnormally increased uptake in the liver, and sigmoid colon, whose standard uptake value maximum (SUVmax) was 19.7 and 9.6, respectively. Therefore, he underwent a colonoscopy to clarify the lesion's nature, which showed there was no colon cancer.
To identify whether the patient can tolerate the right hepatectomy, the patient also received the indocyanine green (ICG) excretion test and liver volume measurement in abdominal CT, which showed ICG clearance is 0.105/min, the 15-minute retention rate is 19.9%, the left liver volume is 626cm3, and the right liver volume without tumor is 786cm3.
Final diagnosis
Histological findings of the resected tumor showed poorly differentiated cancer with large necrosis areas, and syncytiotrophoblast and vascular tumor thrombus can be found. Immunohistochemical results showed AFP (-), CK7(partial+), hepatocyte(-), Ki-67(index80%), hCG (syncytiotrophoblast+), GATA3(+), HpL (syncytiotrophoblast+), P63(partial+), P40(partial+) and SALL-4(weak+), which highly supported the diagnosis of choriocarcinoma rather than hepatocellular carcinoma.
Treatment
Based on the patient's clinical manifestations and examination results, we believed that the patient was more likely to suffer primary hepatic carcinoma. And according to the patient's preoperative examination results, we thought that he could tolerate the right hepatectomy and performed the operation for him. After the procedure, he received treatment including nutritional support, acid suppression, liver protection, and anti-infection, and his preoperative symptoms disappeared entirely.
Given this surprising pathological result, he underwent FDG-PET/CT again about a month after surgery, which revealed multiple nodules with increased uptake in the liver, lungs, and upper abdominal wall of both sides. He also tested his serum hCG, and the results suggested hCG +DT rose to 8453.0 mIU/ml at the same time, and this number rose to 17174 mIU/ml a week later.
Then the liver surgeons and gynecologists of our hospital formulated the chemotherapy regimen for this patient, which is FAEV regimen including vincristine (VCR) 2mg, floxuridine (FUDR) 1375mg*1d+1250mg*4d, dactinomycin (KMS) 400ug*1d+300ug*4d and etoplatin (VP-16) 160mg*5d. He underwent the first chemotherapy course 37 days after surgery, and he denied any uncomfortable symptoms during the process.
Outcome and follow-up
On the third day after the end of chemotherapy, the patient's blood routine test showed third-degree myelosuppression, WBC 1.57×109/L, neutrophil (NEUT) 0.73×109/L, platelet (PLT) 86×109/L. Despite immediately applying recombinant human granulocyte stimulating factor, recombinant human interleukin-11, recombinant human thrombopoietin, and platelet transfusion, the patient's myelosuppression still developed rapidly, and his blood routine result was PLT 24×109/L, WBC 0.36×109/L, NEUT 0.01×109/L 5 days later, and high fever and the symptoms of shock appeared, so he was transferred to the intensive care unit (ICU) for further treatment. The patient received anti-shock, anti-infection, and liver protection treatments at ICU, but the patient's condition did not improve significantly, and he was still in severe liver failure. After a brief treatment in the ICU, the patient was transferred to a lower-level hospital to continue receiving limited symptomatic treatment and hospice care. He died of liver failure about 100 days after the operation.