A 60-year-old man was presented to the hospital with complaints of right upper abdominal distension and pain with fatigue for half a month. Abdominal enhanced CT revealed a large space-occupying lesion in the right lobe of the liver with multiple foci, measuring approximately 11.9 cm in maximum diameter, suggestive of mixed hepatocellular carcinoma. Additionally, tumor thrombus was observed in the right branch and main portal vein, along with multiple enlarged lymph nodes in the retroperitoneum and mesentery. Decompensated stage signs of liver cirrhosis were evident, including portal hypertension, splenomegaly, esophageal and gastric varices, as well as ascites. Later liver biopsy was confirmed moderately differentiated hepatocellular carcinoma. Immunohistochemical (IHC) staining demonstrated cancer cells: Glypican-3 (+), Hepatocyte (+), CD34 (sinus (+)), CEA (-), CK7 (-), CK20 (partial (+)), AFP (+), CK19 (-), CKp (+), Arg-1 (-), GS (partial (+)), HSP70 (+), Ki67 positive cells (60%+), and tumor markers tests were abnormal, AFP: 53.3ng/mL(0-7ng/mL), CA125: 286U/mL(0-35U/mL), NSE:82.4ng/mL (0-20.46ng/mL), CY211:4.97ng/mL(0-3.3ng/mL). The electronic gastroduodenoscopy indicated mild esophageal varices, hemorrhagic gastritis, and chronic inflammation of the gastric antrum mucosa with acute inflammatory activity (neutrophil+). The electronic colonoscopy unveiled no abnormalities in the ileum and colorectal. Moreover, the patient’s Karnofsky score, 60 points, ECOG score, 2 points, VAS score, 7 points, and NRS score, 4 points. He had a history of hepatitis B virus for over 20 years and was taking entecavir capsules (0.5 mg, po, qd) for anti-HBV therapy. The five tests conducted for HBV revealed the following results: HBsAg > 130IU/mL, Anti-HBs:10.6mIU/mL, HBeAg:213 S/CO, and high-sensitivity quantitative analysis of HBV DNA indicated viral replication (GHBV-DNA = 3.37E + 6). Additionally, liver fibrosis biomarkers were assessed as follows: PC-III:54ng/mL, LN:215ng/mL, IV-C:259ng/mL, HA:125ng/mL. The patient’s liver function was classified as Child-Pugh C; however, their heart, lung and kidney functions were essentially normal in nature. Importantly to note is that the patient explicitly denied any medical history pertaining to hypertension, diabetes or coronary heart disease. Following extensive and rigorous discussion by the MDT, it was collectively determined that the patient would undergo FOLFOX (oxaliplatin + leucovorin calcium + 5-fluorouracil) hepatic arterial infusion chemotherapy (HAIC) in combination with lenvatinib and sintilimab regimen. Oxaliplatin 85mg/m2, d1, ivgtt; leucovorin calcium 400mg/m2, d1, ivgtt; 5-fluorouracil 400mg/m2, 0–2 h, d1, iv, 1200mg/m2/d, d1-d2, ivgtt; lenvatinib 8 mg, po, qd; sintilimab 200 mg, ivgtt, with 21 days as a treatment cycle. Considering the patient’s impaired hepatic function and utilization of peritoneal puncture drainage owing to extensive ascites, only a combination of targeted therapy (lenvatinib, 8 mg, po, qd) and immunotherapy (sintilimab, 200 mg, ivgtt) was administered during the second treatment cycle. After undergoing two cycles of treatment, the patient experienced sudden and excruciating pain in the perianal and left inguinal regions. Physical examination revealed that an approximately 2 × 1 cm excrescence could be seen at the anal opening, along with redness, swelling, heat and pain in the perianal, scrotum as well as left inguinal region. Additionally, fistulas measuring approximately 5 × 4 cm and 4 × 3 cm were observed in the left perianal and left inguinal regions (Fig. 5A-B), accompanied by exudation of bloody fluid and yellow purulent secretion. Ultrasound examination (Fig. 6) demonstrated mixed echoes measuring about 4.4 × 1.1 cm in the left perianal region, exhibiting an irregular shape with indistinct boundaries. Additionally, interconnected mixed echoes measuring approximately 1.9 × 0.5 cm were detected in the deep fat layer, indicating perianal abscess along with localized sinus formation. The patient’s vital signs showed T36.5 °C, P74beats/min, R19beats/min, BP111/64mmHg. His white blood cell count was 5.58 × 109/L (with 81% neutrophils), and platelet count was 50 × 109/L (Fig. 7A). Liver function tests (Fig. 7B): TBil: 99.6µmol/L, DBil: 62µmol/L, IBil: 37.6µmol/L, ALT: 25U/L, AST: 66U/L; Blood biochemistry (Fig. 7C): ALB: 15.5 g/L, A/G: 0.41, GLU: 3.03mmol/L; Infection indicators (Fig. 7D): PCT: 2.34ng/mL, IL-6: 236pg/mL; Serum ammonia (NH3) (Fig. 7E): 39.2µmol/L; Coagulation function examination (Fig. 7F): PT: 20.1s; APTT: 47.6s, FIB: 1.66 g/L; INR: 1.8; Dimer: 4.19 µg/mL. The initial diagnosis was as follows: (1) hepatic malignancy; (2) perianal abscess; (3) necrotizing fasciitis; (4) hepatitis B virus infection; (5) decompensated liver cirrhosis; (6) portal hypertension; (7) splenomegaly; (8) gastric fundus esophageal varices; (9) hepatic encephalopathy; (10) hypoproteinemia; 11. thrombocytopenia; 12. coagulation dysfunction; 13. ascites.

Local changes of infected lesions in the patient hepatocellular carcinoma. (A, B) Fistulas measuring approximately 5 × 4 cm and 4 × 3 cm were observed in the left perianal and inguinal areas, respectively. (C, D) The ulcers in the left perianal and inguinal areas exhibited complete healing, leaving behind two visible scars

Ultrasonographic findings of the hepatocellular carcinoma patient. (A) Heterogeneous echoes with irregular morphology and indistinct margins were observed in the left perianal region measuring approximately 4.4 × 1.1 cm. (B) Mixed echoes were identified within the deep adipose layer measuring around 1.9 × 0.5 cm

Laboratory examination results for the hepatocellular carcinoma patient. (A) Complete blood count; (B) Liver function tests; (C) Blood biochemical examination; (D) Infection indicators; (E) Serum ammonia; (F) Coagulation function examination

The wound secretion was subjected to bacterial and fungal culture, which confirmed the presence of Klebsiella pneumoniae infection. Drug sensitivity testing revealed susceptibility to third generation cephalosporins, ciprofloxacin, gentamicin, and imipenem. Consequently, ceftazidime was administered as an appropriate anti-infection treatment. The patient presented with an enlarged perianal and scrotal inflammation, along with an expanded left perianal and left inguinal fistula, accompanied by a substantial discharge of yellow malodorous pus on June 21, 2022. As a result of unsatisfactory conservative treatment, surgery involving incision and drainage of the perianal abscess was conducted under general anesthesia. Following meticulous debridement and dressing changes, remarkable reduction in perianal inflammation was observed after 12 days post-operation, leading to removal of the inguinal abscess drainage tube. The third cycle of sintilimab immunotherapy was administered on postoperative day 13, which was continued for two subsequent cycles, without experiencing any recurrence of NF. By August 16, 2022, the incision had completely healed (Fig. 5C-D). Follow-up until October 20, 2022, the patient died due to complications of liver failure and hepatorenal syndrome.