Management considerations for purported spontaneous regression of hepatocellular carcinoma: a case report

Spontaneous regression of metastatic hepatocellular carcinoma following 3 weeks of lenvatinib

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality and is associated with a poor prognosis. Rarely, there is spontaneous regression of the tumour. We present a case of a middle-aged male with presumed metastatic HCC who experienced enduring regression following 3 weeks of lenvatinib, which was discontinued due to side effects. While this could represent an unusually successful response to therapy, spontaneous tumour regression or an alternative diagnosis should be considered. We discuss possible mechanisms that might explain this unusual case and advocate for tissue confirmation in select cases, where there is diagnostic doubt or when the disease pattern does not clearly follow the recognised natural history. Therefore, if regression occurs-whether spontaneous or in response to treatment-it can be better understood and subsequent therapies recommended.

Spontaneous regression of hepatocellular carcinoma: A mini-review

Spontaneous tumor regression is an extremely rare phenomenon in the oncology field. However, there are several case reports resulted in the regression of hepatocellular carcinoma (HCC) and the accumulation of clinical information and analyses of the mechanism can contribute to the development of a novel therapy. For this purpose, we have carefully reviewed 23 cases of spontaneously regressed HCC published in recent 5 years and our case. The information regarding the tumor size, tumor marker, treatments, etc., have been summarized. The mechanism of spontaneous regression has been discussed to date and presumed to be due to many factors, including hypoxia and immunological reactions. In this careful review of the 24 cases based on the clinical information, hypoxia, systemic inflammation, and both upon spontaneous regression were seen in 3, 8, and 4 cases, respectively among the 15 cases for which the information regarding the proposed mechanisms are available. Recent development of immunotherapeutic approaches in oncology shows promising results, therefore, accumulation of additional cases and analysis of mechanisms underlying the spontaneous regression of HCC are essential and could lead to the development of a new generation of immunotherapies including antibodies directed against immune reactions.

Complete necrosis of hepatocellular carcinoma after preoperative portal vein embolization: a case report

Background

Hepatocellular carcinoma has a poor prognosis; few patients can undergo surgical curative treatment according to Barcelona Clinic Liver Cancer guidelines. Progress in surgical techniques has led to operations for more patients outside these guidelines. Our case shows a patient with intermediate stage hepatocellular carcinoma presenting a good outcome after curative treatment.

Case presentation

We report the case of an 80-year-old Moroccan man, who was positive for hepatitis c virus, presenting an intermediate stage hepatocellular carcinoma (three lesions between 20 and 60 mm). He presented a complete tumor necrosis after portal vein embolization and achieved 24-month disease-free survival after surgery.

Conclusions

Perioperative care in liver surgery and multidisciplinary discussion can help to extend indications for liver resection for hepatocellular carcinoma outside European Association for the Study of the Liver/American Association for the Study of Liver Diseases recommendations and offer a curative approach to selected patients with intermediate and advanced stage hepatocellular carcinoma.

Spontaneous neoplastic remission of hepatocellular carcinoma

We report on a case of a 57-year-old male who underwent a curative resection for hepatocellular carcinoma (HCC) with histological confirmation of a spontaneously necrotized tumor. Initial serum AFP level was 4,778 ng/mL. A 3.7 cm hyperechoic mass in segment 6 of the liver was observed on ultrasonography and dynamic contrast-enhanced liver MRI showed a 3.7 × 3.1 cm sized HCC. He was scheduled to undergo curative surgical resection under the clinical diagnosis of an early stage HCC (Barcelona Clinic Liver Cancer stage A). Without treatment, the serum AFP level declined rapidly to 50 ng/mL over five weeks. He underwent curative wedge resection of segment 6 of the liver. Histology revealed complete necrosis of the mass rimmed by inflamed fibrous capsule on a background of HBV-related cirrhosis with infiltration of lymphoplasma cells. Exact pathophysiology underlying this event is unknown. Among the proposed mechanisms of spontaneous neoplastic remission of HCC, circulatory disturbance and activation of host immune response offer the most scientific explanation for the complete histologic necrosis of HCC in the resected mass seen in our patient.

Hepatocellular Carcinoma with Cervical Spine and Pelvic Bone Metastases Presenting as Unknown Primary Neoplasm

The occurrence of hepatocellular carcinoma (HCC) is closely associated with viral hepatitis or alcoholic hepatitis. Although active surveillance is ongoing in Korea, advanced or metastatic HCC is found at initial presentation in many patients. Metastatic HCC presents with a hypervascular intrahepatic tumor and extrahepatic lesions such as lung or lymph node metastases. Cases of HCC presenting as carcinoma of unknown primary have been rarely reported. The authors experienced a case of metastatic HCC in a patient who presented with a metastatic bone lesion but no primary intrahepatic tumor. This case suggests that HCC should be considered as a differential diagnosis when evaluating the primary origin of metastatic carcinoma.

Complete spontaneous necrosis of hepatocellular carcinoma confirmed on resection: A case report

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Spontaneous necrosis of hepatocellular carcinoma without any pretreatment or angiography is extremely rare.

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Spontaneous necrosis of HCC was highly suspected given the history of alcoholic hepatitis, based on the elevation of AFP and the CT findings.

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The mechanisms of spontaneous regression are still unclear.

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Recurrence after regression or viable malignant cells in resected specimen are reported.

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The ideal management strategy for this disease is surgical intervention if the liver function is acceptable.

Introduction

Complete spontaneous necrosis of hepatocellular carcinoma (HCC) without any pretreatment or angiography is rare. We present a rare case of spontaneous complete necrosis of HCC, as confirmed after hepatectomy.

Presentation of case

The patient, a 74-year-old man with a history of alcoholic hepatitis, was referred to our hospital for confirmation of suspected HCC. In March 2015, abdominal ultrasonography detected a low echoic mass in segment 8 (S8) of the liver. Contrast-enhanced computed tomography (CT) imaging revealed interval growth of this tumor and showed that the tumor was well enhanced in the arterial phase and washed out in the portal and delayed phases. The serum alpha-fetoprotein level was elevated at 30.8 ng/mL and the percentage of the L3 isoform was 25.5%. Two months later, CT imaging showed that the tumor was of low density and had decreased in size; no contrast enhancement of the tumor was seen. Spontaneous necrosis of the HCC was considered; however, as we could not exclude viable malignant cells in the tumor, we performed S8 segmentectomy of the liver. The resected tumor specimen had a thick fibrous capsule. Histopathological findings showed only granulation and necrotic tissue accompanied by bleeding and hemosiderosis. No viable tumor cells were observed. The serum alpha-fetoprotein level returned to the normal range one month after surgery.

Discussion

If spontaneous regression has occurred, there is a possibility of HCC recurrence and of remnant viable tumor cells.

Conclusion

We present a rare case of complete spontaneous necrosis of HCC and strongly recommended surgical intervention.

The natural immunity to evolutionary atavistic endotoxin for human cancer

We propose a new theory of the immunological control of cancer corresponding to the hypothesis that the specific natural immunity to evolutionary atavistic endotoxin has a potential role in human cancer prevention. The results of our studies have shown that IgMNAE, i.e. endogenous or spontaneous IgM class antibodies to enterobacterial lipopolysaccharide molecules (lipid A), control the immune mechanisms responsible for the internal medium stability not only against the damaging impact of the carcinogenic factors, but also against the malignant transformation of its own degenerated cells. Among people who in 1979 and 1982 had IgMNAE in their blood serum, after 15-30years fell ill with cancer 10%, versus 15% among people who had no IgMNAE (p<0.05). Therefore, it is possible to maintain that the stimulation of IgMNAE synthesis would help in the destruction and elimination of damaged somatic cells or prevent their mechanisms from the formation of invasiveness, metastatic and other properties of their parasitism. In the mechanism of the natural immunity to endotoxin it is possible to see the formation of the respective evolutionary protective reactions which protect the damaged cells from acquiring resistance to damaging factors and thus from becoming an independent new parasitic population. Thereby the presented theory of the immunological control of cancer has a causal connection with our evolutionary resistance theory of the origin of cancer. Collectively, these data suggest that activation of natural immunity to endotoxin and production of vaccines against evolutionary atavistic endotoxin or gram-negative bacterial endotoxin can be helpful when applied in cancer prophylaxis for persons with a low level of natural immunity to endotoxin and perhaps in creating immunotherapeutic methods for stopping the endogenous parasitism of tumour cells by binding IgMNAE to atavistic endotoxin in cancer patients.

Spontaneous massive necrosis of hepatocellular carcinoma with narrowing and occlusion of the arteries and portal veins

We herein present the case of a 77-year-old man who had fever and right hypochondriac pain. He visited his doctor and underwent contrast computed tomography (CT), and he was suspected to have a liver abscess. He received an antibiotic treatment and his symptoms soon disappeared, but the tumor did not get smaller and its density on contrast CT image got stronger. He underwent biopsy and moderately differentiated hepatocellular carcinoma (HCC) was found. Extended left hepatic and caudate lobectomy was performed. Histological examination showed moderately differentiated HCC with narrowing and occlusion both in the arteries and portal veins associated with mild chronic inflammation. The mechanisms of spontaneous regression of HCC, such as immunological reactions and tumor hypoxia, have been proposed. In our case, histological examination showed the same findings. However, the mechanism is complex, and therefore further investigations are essential to elucidate it.