A 58-year-old Chinese man was admitted to our hospital because of pain in the right upper abdomen for 1 month, the pain disrupted sleep, with loss of appetite and fatigue, his local hospital test showed that the tumor marker was high, the level alpha-fetoprotein (AFP) was 172.9ng/ml, carcinoembryonic antigen (CEA) was 9.16ng/ml, Carbohydrate antigen 125 (CA 125) was 42.64 U/ml, Carbohydrate antigen 199 (CA 199) was 53.08 U/ml. Hepatitis B virus DNA quantitative was 5.35E + 05IU/ml. Hepatobiliary ultrasound indicated liver cirrhosis and fibrosis, liver masses could be seen. The patient’s past medical history included hepatitis B associated liver cirrhosis for 10 years, and antiviral therapy was not applied regularly. Personal history included smoking for more than 20 years, about 6–7 cigarettes a day, without history of alcoholism. Family history: his mother had Esophagogastric Junction Cancer, his sister had breast cancer, his brother had liver cirrhosis. Positive physical examination: liver palm and spider nevus could be seen. Tenderness in the right upper abdomen, the liver could be reached 1cm below the costal area. After he admitted to our hospital, chest computed tomography (CT) and abdominal magnetic resonance imaging (MRI) was performed to evaluated the tumor, the result showed left lung and multiple liver masses (Fig. 1), liver masses in segment Ⅶ-Ⅷ biopsy pathology showed a malignant tumor(Fig. 2), Immunohistochemical staining results were as follows: CKpan (weak +), Syn (+), CgA (+), CD56 (+), CD34 (-), CK19 (-), Arginase-1 (-), HepPar-1 (-), AFP (-), Vimentin (partly weak +), CK7 (-), CK20 (-), Villin (-), TTF-1 (-), CDX-2 (-), Ki-67 ( active zone about 70%+), MLH1 (+), MSH2 (+), MSH6 (+), PMS2 (+), PD-L1 (22C3)(CPS 1), These findings resulted in a diagnosis of a malignant tumor of small cell neuroendocrine carcinoma. The patient has received one cycle chemotherapy of etoposide and cisplatin, febrile neutropenia was discovered 2 weeks after chemotherapy, post the treatment of recombinant human granulocyte colony-stimulating factor (GSF), white blood cells are elevated to the normal range.
Combined with the previous history of hepatitis B associated liver cirrhosis, primary liver cancer cannot be excluded, then, mass in liver segment Ⅴpuncture biopsy was performed, which was consistent with hepatocellular carcinoma(Fig. 3), Immunohistochemistry results were as follows: GS(+), GPC3 (focal +), HSP70 (focal +), CD34 (+), CK19 (-), Arginase-1 (+), HepPar-1 (+), AFP (-), Ki-67 (active zone about 15%+), the patient was treated with sorafenib(0.4g Bid) in combination with Transcatheter arterial chemoembolization (TACE) and hepatic artery infusion chemotherapy (HIAC), partial remission (PR) was achieved 1 month later, TACE was performed once a month, twice of total, the adverse effect was slight. About 3 months later abdominal CT showed the liver masses were stable, but head magnetic resonance imaging (MRI) predicted a new brain metastasis in left parietal lobes without symptoms. The patient was treated with one cycle of Zimberelimab (240mg), the patient's treatment was interrupted due to the COVID-19. 3 months after the treatment, head MRI and abdominal CT showed that the tumor of head and liver was stable (Fig. 4–6), but retroperitoneal lymph node enlarged, and liver ultrasonic contrast showed the margin of liver Ⅴ segment mass enhanced, TACE was performed the third time to control the hepatocellular carcinoma, combined with sorafenib and four cycles of tirelizumab was given. Efficacy evaluation was stable, and the brain tumor was smaller without symptoms, no sever adverse was discovered by the time of writing, and the patient was in a good physical condition.