Three-time resection of the rib metastasis from hepatocellular carcinoma after two hepatic resections--a case report

A 40s woman, who had undergone hepatic resection twice for hepatocellular carcinoma (HCC), was admitted to our hospital because of a tumor with pain on the right 9th rib. From the findings of chest computed tomography (CT), abdominal CT and bone scintigraphy, we diagnosed the rib metastasis of HCC without any other recurrences. Local resection of the right 9th rib was performed in July 2008. Histologically, the tumor of the rib was diagnosed as the metastasis of HCC. The patient's pain on the right rib was disappeared after the operation. After the rib resection, the recurrence of the remnant of the right 9th rib occurred in June 2009. Local resection of the rib was performed in July 2009. Afterward, the recurrence of the remnant of the right 9th rib occurred again in April 2010. Local resection of the tumor of the same rib was performed in May 2010. The patient is still alive five years after the first hepatectomy. For HCC patients whose intrahepatic lesion or other metastatic lesions are controllable and the metastatic bone lesion is solitary and easily resectable, a resection for bone metastasis from HCC is thus locally effective in patient's pain control.     

Hepatocellular carcinoma presenting with bone metastasis

Bone metastasis is an unusual complication of hepatocellular carcinoma. We report here 2 cases of patients with bone metastases of hepatocellular carcinoma at presentation. Patient No. 1 with liver cirrhosis and hepatocellular carcinoma was admitted with a bone metastasis in the rib. The patient was treated with hepatic arterial chemotherapy and rib resection. Patient No.2 was known to have an asymptomatic liver mass of uncertain histology for a year when he presented with back pain. Because of signs of spinal compression, laminectomy was performed, and the diagnosis of metastatic hepatocellular carcinoma was established. The presence of bone metastases in hepatocellular carcinoma at presentation is extremely rare. More frequently, bone lesions are observed after successful treatment of the primary liver tumor. Both surgery and radiotherapy are used as palliative treatment in bone metastases of hepatocellular carcinoma. The treatment of hepatocellular carcinoma presenting with bone metastasis by bone resection and intraarterial chemotherapy seems to be of limited impact on patient survival because of dissemination of micrometastases in other organs and the frequent presence of other comorbid conditions. However, effective palliation using this multimodality approach is feasible. Hepatocellular carcinoma should be considered in the differential diagnosis of bone metastases.     

Effectiveness of intra-arterial infusion chemotherapy for solitary bone metastasis from lung cancer with radiotherapy--a case report

There have been few reports on intra-arterial infusion chemotherapy for metastatic bone cancer because the bone metastasis is multiple in almost all cases. However, selective intra-arterial infusion chemotherapy is thought to be more effective than systemic chemotherapy for solitary bone metastasis. The patient was a 47-year-old man who had been diagnosed with solitary metastasis of the right knee joint from lung cancer on the basis of various imaging studies and biopsy. The metastatic bone cancer showed rapid growth with systemic inflammatory response, and the patient's general condition became progressively worse. Therefore, radiotherapy alone consisting of 3 Gy of fraction x 5 fractions/week was initiated, but the metastatic lesion was a progressive disease (PD) at the middle point of radiotherapy (24 Gy), and we had no choice but to alter the therapy. Angiography showed dense tumor staining, so intra-arterial infusion chemotherapy was contemplated. Subsequently 15 mg/body of CDDP was administered persistently 5 days a week through a catheter placed in the right femoral artery that had been introduced via the left femoral artery. After 8 courses of this therapy (total dose 600 mg), the metastatic bone cancer was remarkably reduced in size and showed nearly a complete response (CR) on CT scan. This result suggests that intra-arterial infusion chemotherapy is very effective if there is only one bone metastasis lesion.     

Intra-arterial injection of iodine-131-labeled lipiodol for treatment of hepatocellular carcinoma.

BACKGROUND/AIM: The therapeutic effect of intra-arterial injection of 131-iodine-labeled lipiodol for treatment of hepatocellular carcinoma in palliative or adjuvant settings has been promising. We report, the results of an open study of this therapy in cirrhotic patients with small hepatocellular carcinoma. PATIENTS AND METHOD: Forty patients with hepatocellular carcinoma were given intra-arterial injections of 131-iodine-labeled lipiodol. These injections were repeated if necessary every 3 months. Tumor response (WHO criteria) was determined on CT scans performed after each treatment and every 3 months during the follow-up. Side effects and the cause of death were recorded. Therapeutic response and survival were analyzed. RESULTS: The median number of treatment was 2 (1-4). There was one complete response, 18 partial responses (47.5% response rate); 19 had stable disease and 2 progressions. Overall survival rates (+/-CI 95%) at 1, 2 and 3 years were: 90+/-4.7%, 60.3+/-8%, and 39+/-8.3%, respectively. Median survival was 27 months; 25 patients have died (4-56 months), 8 of tumor progression with a multifocal spread in the liver. Tolerance was good except for 2 patients who develop a fatal drug-related pulmonary insufficiency. CONCLUSION: These data suggest that intra-arterial therapeutic injection of 131-iodine-labeled lipiodol for treatment of hepatocellular carcinoma can provide high rate response and long survival for individuals not eligible for surgery or local treatment.     

A case of spindle cell type hepatocellular carcinoma responding to hepatic intra-arterial infusion chemotherapy

We report herein a case of spindle cell type hepatocellular carcinoma responding to hepatic intra-arterial infusion chemotherapy. A 50-year-old woman was hospitalized for right epigastralgia. A computed tomography scan demonstrated cloudy liver tumor with a diameter of 12 cm in S5 and S8. Surgery was performed based on the diagnosis of liver tumor. However, because the tumor was also present in the left lobe, we did only a biopsy for a part of tumor. From the pathological findings, this was diagnosed as a spindle cell type hepatocellular carcinoma. After the operation, hepatic intra-arterial injection therapy of continuous infusion with 5-FU was conducted for two weeks. A small reduction in the tumor was seen with computed tomography after the completion of two courses.     

Complete necrotization of hepatocellular carcinoma by chemotherapy and subsequent intravascular coagulation: a case report.

A 45-year-old man with hepatocellular carcinoma who developed intravascular coagulation following complete tumor regression by chemotherapy is described. After 2 doses of 10 mg of Mitomycin C given into the hepatic artery at the time of selective angiography, and 16 intravenous doses of 5-fluorouracil and Mitomycin C, 2 doses per week, subjective symptoms and hepatomegaly disappeared. Alpha-fetoprotein became negative and a remarkable change in tumor size and vasculature was noted in the arteriogram. Three months after chemotherapy, the patient developed thrombocytopenia, intravascular hemolysis, and acute renal failure. Autopsy disclosed a 8 X 7 X 5 cm solitary, encapsulated hepatocellular carcinoma in the right lobe. The tumor was surrounded by a thick capsule and completely necrotized. Neither intrahepatic invasion nor extrahepatic metastasis was observed. In the kidney, generalized fibrin thrombi were seen in the afferent arterioles of glomeruli as accounted for by intravascular coagulation.     

Bone metastasis in hepatocellular carcinoma

Bone metastasis was observed in 16.1% or in 14 of 87 male autopsy cases of hepatocellular carcinoma. The primary tumor within the liver was located in the right lobe in all but one case. There were six patients who first presented with signs attributable to bone metastasis, and lung metastasis subsequently became evident in five of them. These 6 patients lived significantly longer as compared with 8 other patients with bone metastases and 73 patients without. The possible route by which hepatocellular carcinoma cells were carried to the bone is discussed.     

A case of hepatocellular carcinoma with bone metastasis which responded to oral administration of UFT

A 61-year-old male was referred to our hospital for evaluation of right upper arm pain. He was diagnosed as having primary hepatocellular carcinoma with bone metastasis by his high titer (111,683 ng/ml) of serum alpha-fetoprotein, computed tomography and abdominal angiography, and so UFT therapy, 400 mg daily, was instituted. After 2 months of this therapy, the titer of serum alpha-fetoprotein gradually decreased. Seven months later, the titer was 3,997 ng/ml and reduction of the hepatic tumor size was shown by computed tomography and ultrasonography. Furthermore, the right upper arm pain diminished and X-ray examination revealed remarkable improvement. During chemotherapy, there was no severe side effect apart from mild anemia and the patient is presently still alive. This case suggests the efficacy of UFT for the treatment of primary hepatocellular carcinoma.     

Solitary rib metastasis of nasopharyngeal carcinoma

We report a case of a 49-year-old man who developed solitary rib metastasis of nasopharyngeal cancer. Patient had been treated for primary carcinoma with radiation therapy and concomitant chemotherapy. The bone metastasis presented as bulky, solid, painful mass in the posterior arch of 10th rib, within nine months the end of treatment. Biopsy of the solitary lesion presented the same histological characteristics as those of primary lesion. Although there are reported in literature series of nasopharyngeal cancer metastasizing to bone, we did not find previously pubfished report of a nasopharyngeal carcinoma metastasizing only to a rib.     

A case of brain metastasis from hepatocellular carcinoma

Reported is the case of a patient who underwent surgical resection of a brain metastasis from a hepatocellular carcinoma. The 62-year-old male was admitted to hospital because of headaches and a left hemiparesis. Six years earlier he had undergone transcatheter arterial embolization for a hepatocellular carcinoma. Further, one year ago the lower lobe of his right lung had been resected because of a pulmonary metastasis from the same tumor. A neurological examination on admission revealed disorientation, dressing apraxia, and a left hemiparesis. A CT scan revealed two highly dense masses with peripheral low dense areas in the right temporoparietal region, which were heterogenously enhanced with a contrast medium. Right carotid angiogram showed tumor stains in the same region. Also, a magnetic resonance T1 weighted image showed highly intense masses, and a T2 weighted image showed low intensity masses with prominent brain edema. Thus, a right fronto-temporo-parietal craniotomy was performed, and the two masses were removed. Histological examination revealed hepatocellular carcinoma. The postoperative course was uneventful, and the left hemiparesis improved gradually, enabling the patient to walk without assistance. A brain metastasis from a hepatocellular carcinoma has been rarely reported in the literature since the survival period is very short due to rapid disease progression at the primary site, so that most reports have been based on postmortem examination. The MRI, CT, and the angiographic findings are included in this report.     

A case of hepatocellular carcinoma with bone metastasis responding to concurrent TS-1/low-dose cisplatin (CDDP) therapy and radiotherapy

A standard treatment for hepatocellular carcinoma with extrahepatic metastasis is not established and chemotherapy is ineffective. We experienced a case of hepatocellular carcinoma with bone metastasis that responded to concurrent TS-1/low-dose cisplatin (CDDP) therapy and radiotherapy. A 58-year-old male patient with left iliac bone metastasis after 2 hepatectomies was admitted to our hospital. The titer of serum AFP and PIVKA-II showed an extremely high levels, 12,350.5 ng/ml and 993 mAU/ml, respectively. The uptake area was found at the left iliac bone by scintigraphy with 99mTc-HMDP. Treatment with TS-1/low-dose CDDP therapy and radiotherapy (36 Gy) was started concurrently. The chemotherapy regimen comprised daily oral administration of 100 mg of TS-1 for 21 days and CDDP 10 mg/body infusion (day 1-5, 8-12). An additional 2 courses of TS-1/low-dose CDDP therapy were repeated. After that, severe pain diminished and the titer of serum showed AFP and PIVKA-II had improved to within normal ranges. The uptake at the left iliac bone was found to have decreased by scintigraphy. Adverse events were grade 1 nausea and leucopenia. TS-1/low-dose CDDP therapy seems to be applicable for the treatment of hepatocellular carcinoma with bone metastasis.     

Intra-arterial cellular immunochemotherapy for unresectable pancreatic cancer with liver metastasis

PURPOSE: To date, no treatment has had a significant impact on pancreatic cancer with liver metastasis. We performed locoregional cellular immunochemotherapy for unresectable pancreatic cancer with liver metastasis. SUBJECTS AND METHODS: A 71-year-old man was diagnosed for unresectable stage IVb pancreatic cancer. This patient was given intra-arterial infusion of gemcitabine (GEM) 400 mg/body and intravenous infusion GEM 600 mg/body, simultaneously. The day after GEM infusion, he was given intra-arterial autologous tumor cell activated T lymphocytes (AuTL). RESULTS: Tumor markers, such as CEA and CA19-9, had decreased a little. Primary tumor and metastatic liver tumor were reduced, but he died due to intra-abdominal dissemination within 5 months after diagnosis of unresectable pancreatic cancer. CONCLUSIONS: Reduced primary pancreatic tumor and metastatic liver tumor was obtained by locoregional cellular immunochemotherapy. But we could not control intra-abdominal dissemination. In conclusion, we suggest that intra-abdominal AuLT infusion in combination with intra-arterial AuLT infusion may be advisable to patients for unresectable pancreatic carcinoma with intra-abdominal dissemination.     

A case report of primary liver cancer with cerebral metastasis after hepatic resection

A 67-year-old male, who had a left hepatectomy for hepatocellular carcinoma, was readmitted to our hospital because of a left hemiparesis. A brain computed tomography scan and an r-carotid angiogram revealed a large mass involving the right parietal area, and thus a brain tumor removal was performed. A histological diagnosis of the removed brain tumor found it to be a metastatic, hepatocellular carcinoma. The patient died of pulmonary congestion due to lung metastasis, approximately 2 years and seven months after hepatectomy, and 1 year and three months after the removal of this metastatic brain tumor. In selected cases, the removal of a metastatic brain tumor seems to bring about improvements in the quality and duration of life.     

A case of hepatocellular carcinoma associated with multiple pulmonary tumor thrombi and rupture of its right adrenal metastasis

A 54-year-old man, who had the history of a blood transfusion 29 years ago, was admitted to our hospital because of dyspnea and abdominal fullness. Physical examination revealed jaundice and massive ascites and laboratory data suggested liver cirrhosis. The high level of AFP and a CT scan indicated the association of hepatocellular carcinoma and its metastasis to the right adrenal gland. On the 21st hospital day, he suddenly complained of severe pain in the right upper quadrant and the right flank, and fell into hemorrhagic shock. Blood transfusion was given, but he died on the 24th hospital day. Autopsy revealed liver cirrhosis, accompanied by hepatocellular carcinoma with the metastasis to the right adrenal gland and multiple pulmonary tumor thrombi. Massive hemorrhaging due to rupture of the right adrenal metastasis was seen in the retroperitoneal space.     

Association of breast cancer with meningioma: report of a case and review of the literature.

We report a case of meningioma subsequently developed in a patient with primary breast carcinoma. A 53-year-old woman received a left modified radical mastectomy because of stage IIA breast carcinoma. Histologically, the tumor was a predominantly intraductal carcinoma with negative lymph node metastasis. Estrogen receptor (ER) was negative but progesterone receptor (PR) of the left tumor was positive by immunohistochemistry. Four years later, cranial bone and/or brain metastasis was suspected from a routine follow-up bone scintigram. The patient showed no symptoms or signs at that time. Magnetic resonance imaging (MRI) and angiography revealed that the right parasagittal mass was suspicious of meningioma. A complete tumor removal was performed. On histological examination, this brain tumor was a transitional-type meningioma (meningotheliomatous and fibrous type) without malignant findings. ER was negative but PR was positive also in this tumor. She is currently well 6 years after the initial surgery. A review of the literature is presented with emphasis on the association between breast cancer and meningioma, which indicates a possible hormonal relationship. The knowledge of this association is important in the differential diagnosis of patients with breast cancer who develop central nervous manifestations.     

Case report--a patient who has survived more than 4 years with repeated resection for bilateral adrenal metastasis from hepatocellular carcinoma

We report a patient with bilateral adrenal metastasis from hepatocellular carcinoma (HCC) who has survived for a long period as a result of repeated resection. A 55-year-old male patient with C type hepatitis underwent transcatheter arterial chemo-embolization (TACE) for HCC in November 1997. There was no recurrence in the liver, but left adrenal metastasis was detected in January 1998, followed by right adrenal metastasis in November 1998. We performed surgical resection for bilateral adrenal metastasis in March 1999. The histological diagnosis was well approximately moderately differentiated hepatocellular carcinoma. A recurrence in the right adrenal gland was detected eight months later. As there was no distant metastasis, we performed re-operation in December 1999. Recurrence in the liver was detected in October 2000 and was treated by TACE. He has survived more than 4 years since the first detection of adrenal metastasis. We conclude that surgical treatment is useful for patients with adrenal metastasis who have no distant viable lesion.     

A Case of Hepatoblastoma in Adult

A rare case of hepatoblastoma in a 60-year-old man is reported.The first sign of his illness was metastasis found as a tumoron the left fifth rib. There were no laboratory or angiographicfindings that might differentiate hepatoblastoma from hepatocellularcarcinoma. In this case, the diagnosis was made by histologicalexamination at autopsy, which revealed mesenchymal tumor tissuesin addition to the epithelial ones. The incidence of hepatoblastomain people over 15 years old is 0.056% of that of hepatocellularcarcinoma in Japan.     

A case of renal cell carcinoma with lymph node metastasis keeping remission for five years by adjuvant immunotherapy with ubenimex

We report herein the long-term remission of a woman following postoperative ubenimex therapy. A 46-year-old woman with a tumor in the left kidney and a swollen para-aortic lymph node was referred to our department for surgery. Preoperative computed tomography revealed a stage IV renal cell carcinoma. Since her right kidney naturally ruptured after hospitalization, the patient underwent bilateral kidney and partial paraaortic lymph node dissection. Histopathological tests revealed that the tumor was T3, N2, M0, mixed type. As the residual lymph node was swollen at 4 months after the operation, treatment with ubenimex was started. Five years after the operation, no new lymph node metastases were recognized under continuous treatment with ubenimex. Single administration of ubenimex appears to be effective for cases of renal cell carcinoma with lymph node metastasis to maintain good patient QOL because of its few side effects.     

A case of hepatocellular carcinoma with right atrium tumor thrombus treated with combined doxorubicin and interferon-beta/intra-arterial injection chemotherapy and hepatectomy

A-58-year-old male was admitted to Osaka University Hospital for advanced hepatocellular carcinoma in July 2005. The main tumor was located in the posterior segment and hepatic vein tumor thrombus extended to the right cardiac atrium. He felt of pressure in his chest and a serum total bilirubin level was beyond normal range because of the tumor progress. We started a doxorubicin and interferon-beta combined chemotherapy. Although anti-tumor effect was NC, his symptom rather improved and a serum total bilirubin level went into the normal range. Consequently, we performed an extended posterior segmentectomy and tumor thrombectomy of IVC and right cardiac atrium. The patient survived for 13 months after the initial treatment, but he died of distant metastasis. It was suggested that the doxorubicin and interferon-beta combined chemotherapy might be the promising modality for advanced hepatocellular carcinoma as one of the multimodel treatment.     

Retroperitoneal metastasis of hepatocellular carcinoma - a case report

The patient was a 54-year-old man. He was an HBV carrier, and hepatocellular carcinoma (HCC) was detected for the first time in 2000. An operation was performed, but HCC recurred. After repeating the operation and transarterial chemo-embolization (TACE) for the recurrent HCC, a tumor was found in January 2009 on the ventral side of the right kidney, and we thought it was a retroperitoneal metastasis of HCC or peritoneal dissemination. He was enrolled in a trial of systemic chemotherapy, called "S-1 monotherapy for extrahepatic metastasis of HCC", but the tumor seemed progressive. Since he showed no other lesion, he was indicated for surgical resection. Intraoperatively, the tumor was localized between the duodenum and the right kidney, and was covered by the retroperitoneum. Pathological examination of the resected specimen revealed retroperitoneal metastasis of HCC. Intrahepatic recurrence was detected 6 months after the resection. Therefore, he underwent TACE, and he is currently (1 year after surgery) alive without any extrahepatic metastasis. We describe herein this case because retroperitoneal metastasis of HCC is very rare.