A successful surgical treatment for solitary pulmonary and adrenal metastases after hepatic resection to hepatocellular carcinoma--a case report

We report a 65-year-old man who received a successful surgical treatment for both pulmonary and adrenal metastases after curative resection to hepatocellular carcinoma (HCC). He received a partial hepatic resection for HCC of the right hepatic lobe. Thirty-eight months after the first hepatic resection, a metastatic lesion of the right pulmonary lobe was detected by computed tomography (CT). He was orally administered of UFT (600 mg/day). After 6 months of the chemotherapy, a metastatic lesion of lung became decreased in size. However, a metastatic lesion of the right adrenal gland was detected by abdominal CT scan. Fifty six months after the first operation, we performed right adrenalectomy. A further 4 months later, we performed partial resection of the right pulmonary lobe. Eight months after the pulmonary resection, intrahepatic recurrence was detected and he received transcatheter arterial embolization (TAE) twice. Eighty one months after the first operation, he died of liver failure due to tumor progression. Surgical resection for metastases from HCC resulted in long-term survival even if there were extrahepatic metastases in two different sites.     

Successful treatment of multiple pulmonary and peritoneal recurrence of hepatocellular carcinoma with bronchial artery infusion therapy and PEIT followed by surgery--a case report

A case of hepatocellular carcinoma, successfully treated with multimodal loco-regional treatments, is reported. An 80-year-old male presented with multiple pulmonary and peritoneal metastases 4 months after right heimihepatectomy for ruptured HCC. Bronchial artery infusion of mitomycin C induced pulmonary tumor regression and stabilization. Peritoneal tumor was treated by arterial infusion of SMANCS, followed by percutaneous injection of absolute ethanol, which ended in surgical removal in 28-postoperative month due to abscess formation. He had been well until right adrenal and left pulmonary metastases appeared. Resection of both metastases was carried out in 39-post hepatectomy month. Recurrent left pulmonary metastasis was treated with two sessions of bronchial artery infusion with no effect this time. Video-assisted partial resection of the left lung was performed in 54 post-hepatectomy month. But his AFP level kept rising. Eventually pulmonary metastasis recurred and tumor thrombus reached the left atrium 58 months after hepatectomy. He wanted no more treatment. He died of cerebral infarction caused by tumor thrombus. He enjoyed a good QOL for five years through multimodal loco-regional treatments.     

A case of advanced hepatocellular carcinoma with lung and bone metastases effectively treated by orally administered UFT

A 52-year-old male underwent hepatic subsegmentectomy for hepatocellular carcinoma (HCC). Five months later, a recurrent tumor was found in the liver and transcatheter arterial embolization (TAE) was performed. However, recurrent tumors were growing rapidly with multiple lung and bone metastases. The titer of serum AFP was elevated to 896,095 ng/ml and the titer of serum PIVKA-II was elevated to 1294.5 AU/ml. The patient was treated by oral administration of UFT (600 mg/day). Two weeks later, his general condition was improved, and several months later, the liver tumor, multiple lung metastases and multiple bone metastases had almost disappeared. The titers of serum AFP and PIVKA-II were reduced to the normal range. He has maintained a good state of health for about four years now. This case suggests the clinical usefulness of UFT for advanced HCC.     

A case of successful surgical resection followed by S-1 administration for hepatocellular carcinoma with lung metastases and a tumor thrombus into right atrium

A case of a 68-year-old man with hepatocellular carcinoma (HCC) is presented. He underwent partial liver resection for three times and transcatheter arterial chemoembolization (TACE) for three times. Follow-up CT revealed a recurrent hepatic surface mass with malignant extended into the inferior vena cava (IVC) and right atrium (RA). CT scan also revealed multiple metastatic nodules in bilateral lungs. The tumor thrombus into the RA and the hepatic surface mass were successfully treated with surgical resection. Pathological specimen allowed the diagnosis of poorly-differentiated HCC. Adjuvant chemotherapy with S-1 resulted in complete remission of lung metastases. Tumor markers showed a significant improvement after S-1 administration. This case report suggests that a surgical resection followed by S-1 administration would be effective for a patient with lung metastases and a tumor thrombus into IVC or RA.     

Surgical Treatment of Adrenal Metastasis Following hepatectomy for Hepatocellular Carcinoma

In three patients who underwent hepatectomy for solitary hepatocellularcarcinoma (HCC), adrenal metastases, on the right sides of twopatients and the left side of the third were subsequently detectedby ultrasonography (US) and/or computed tomography (CT), andsuccessfully resected after an average interval of 16 monthsfrom hepatectomy. There were no metastatic lesions in the lung,lymph node or bone. Two patients, however, who were found tohave metastasis in the right adrenal also had multiple smallrecurrent foci in the residual liver. The latter were controlledby arterial embolization therapy and the patients are aliveat 12 and three months post-adrenalectomy. In the other patient,with left adrenal metastasis, the serum alpha fetoprotein levelof 3,000 ng/ml returned to normal and he is doing well threeand a half years after adrenalectomy. Since there is no effectivetherapy for metastatic adrenal HCC after hepatectomy, surgerywould appear to be indicated, should no other distant metastasisbe recognized clinically.     

A case of inoperable gastric small cell carcinoma effectively treated by chemotherapy and radiotherapy

We herein report a case of advanced gastric small cell carcinoma treated by chemotherapy and radiotherapy. A 69-year-old man was admitted to our hospital presenting with appetite loss and body weight loss. He was diagnosed to have an inoperable gastric small cell carcinoma with severe lymph node metastases and left adrenal gland metastasis. Chemotherapy with TS-1/paclitaxel, cisplatin/irinotecan and cisplatin/etoposide was sequentially performed. Primary and metastatic foci had obviously diminished. Eighteen months after the initial therapy, he had dysarthrosis and multiple brain metastases were found. Metastatic foci were decreased and his symptom was improved by successful radiotherapy. We conclude that chemotherapy and radiotherapy are effective for primary and metastatic lesions of gastric small cell carcinoma.     

Multimodal treatment for adrenal metastases from hepatocellular carcinoma (HCC)

The patients with hepatocellular carcinoma (HCC) with adrenal metastases are often accompanied with the metastasis from other sites, and their prognosis is poor. After 1999, we examined the prognosis and efficacy of the seven patients with drenal metastases from HCC. Four patients were surgically treated, and three of them received radiation therapy (RT). All of the 7 patients were men and the mean age was 72 years old (range: 53-77 years old). The mean interval from the initial treatment of hepatocellular carcinoma to the adrenal metastases was 46 months (1-95 months). If there was a good control observed in the intrahepatic lesion with no metastases besides adrenal glands, we selected a surgical resection of the metastatic adrenal glands. The mean overall survival time after the surgical treatment of the adrenal metastases was 23 months (7-54 months), and we considered it as a good prognosis. The mean progression free survival of the adrenal metastases was 15 months (5-30 months). Besides on such a good clinical outcome, we conclude that aggressive multimodal therapy including surgical resection of metastatic foci may be recommended if the patients with hepatocellular carcinoma have no other metastatic sites other than the adrenal gland and liver lesions are well-controlled.     

A surgical case of solitary lymph node metastatic recurrence of hepatocellular carcinoma after hepatectomy

The patient was a male in the sixties who received interferon therapy against hepatitis C. At first, the patient was pointed to having an increased alpha fetoprotein (AFP) level of 1104 ng/ml. Partial hepatectomy was performed against hepatocellular carcinoma (HCC) (segment 3, 44 mm in diameter) and diagnosed by further exams. The serum AFP level decreased to a normal range after hepatectomy for the time being. A rapid elevation of serum AFP level (11,293 ng/ml) was observed nine months after the surgery. No evidence of recurrence in the intra- and extra hepatic organs such as adrenal gland, lung, bone, and brain except for intra abdominal solitary lymph node metastasis was observed. Then the metastatic lymph node was removed surgically. After the removal of the lymph node, the serum AFP level decreased within a normal limit immediately. This patient currently survives without the disease for 30 months after the initial operation, and for 19 months after a resection of the meatastatic lymph node.     

A long survival case of sigmoid colon cancer patient with initially unresectable hepatic metastases

The prognosis of a colorectal cancer patient with unresectable hepatic metastases is extremely poor. To improve the prognosis, when the hepatic metastases were initially unresectable, we performed second-look hepatectomy (s-l hepatectomy) after neoadjuvant hepatic arterial 5-FU infusion plus UFT (HAI-PMC). Here, we report the case of a sigmoid colon cancer patient with initially unresectable hepatic metastases showing a prolonged survival (6.5 years) by second-look operation after HAI-PMC. A 57-year-old woman was diagnosed with sigmoid colon cancer with unresectable liver metastases. Sigmoidectomy and hepatic arterial catheterization were performed in the initial operation, and HAI-PMC was performed 6 months after. Metastatic foci of the liver had shrunk (90.9%), but solitary metastatic lung cancer was detected during HAI. As no other metastatic lesion was observed, partial resection of the liver and lung was performed as a second-look operation, 6 months after the initial operation. The woman continued venous infusion chemotherapy as an outpatient, and she survived for 6.5 years after the initial operation. This result suggests that strategic multidisciplinary treatment utilizing s-l hepatectomy after neoadjuvant chemotherapy can lead to better prognosis for colorectal cancer patients with hepatic metastases.     

Adrenalectomy for solitary adrenal metastasis from colorectal carcinoma

A 60-year-old man underwent anterior resection for advanced rectal carcinoma. Seven years and 2 months later, right lower pneumonectomy was performed for a metastatic lung tumor. Two years and 2 months thereafter, left adrenalectomy was performed for solitary adrenal metastasis. The patient remained disease-free for 10 months postoperatively, until multiple lung metastases appeared. The patient is alive and well, under mild chemotherapy with oral doxifluridine, 3 years and 5 months after left adrenalectomy. We conclude that patients with solitary adrenal metastasis may benefit from surgical resection and that resection could be considered as a therapy for solitary adrenal metastasis from colorectal carcinoma.     

Complete disappearance of metastatic lung tumors and mediastinal lymphnode in a case of hepatocellular carcinoma treated by low-dose 5-fluorouracil/cisplatin therapy

We report a case of complete disappearance of multiple lung metastases and mediastinal lymphnode metastasis by intravenous administration of 5-fluorouracil/cisplatin (FP) after operation for primary hepatocellular carcinoma (HCC). A 54-year-old male was diagnosed with HCC associated with alcoholic liver cirrhosis. He also had a single lung metastasis at the time of diagnosis. After hepatic resection for HCC, the metastatic tumor progressed and became multiple lesions with mediastinal lymphnode involvements. Low-dose FP therapy was performed. Then, 250 mg/m(2)/day of 5-fluorouracil was given intravenously for 5 days weekly by continuous infusion and 10 mg/m(2)/day of cisplatin by intravenous infusion. Both lung metastases and mediastinal lymphnode metastasis were decreasing after six cycles of this therapy. Because of alcoholism and liver damage, chemotherapy could not be continued. But all metastatic lesions were completely disappeared ten months after this therapy. Bone marrow suppression (grade 4) was observed during the chemotherapy but resolved by interruption of treatment. Low-dose FP therapy may well be useful for patients suffering from advanced HCC with distant metastasis.     

Complete response of a massive hepatocellular carcinoma with lung metastasis to UFT (DPD inhibitory fluoroprymidines: DIF)

A 77-year-old man was referred to our hospital because a periodic examination for hepatitis C cirrhosis and diabetes mellitus at a nearby clinic had revealed an elevated AFP level. Abdominal ultrasound and CT scan revealed a giant tumor in the right hepatic lobe, and a diagnosis of hepatocellular carcinoma was made with a biopsy. A pulmonary CT scan also revealed a diffuse granular shadow in the right lung field, leading to a diagnosis of multiple pulmonary metastases from the hepatocellular carcinoma. Arterial infusion chemotherapy was performed, but was ineffective. Thus, the administration of 600 mg/day of UFT was initiated. Both the AFP and PIVKA-2 levels, which had been increasing, returned to normal 3 months later. Ultrasound and CT scan showed that the hepatocellular carcinoma and lung metastatic foci had disappeared completely. The administration of UFT therefore appears promising for the treatment of hepatocelluar carcinoma and can be used safely, even with patients in poor general condition.     

Prognosis after resection of residual masses following chemotherapy for metastatic nonseminomatous testicular cancer: a multivariate analysis.

Following chemotherapy for metastatic nonseminomatous testicular cancer, 86 patients with normal serum markers AFP and HCG underwent resection of residual tumour masses (63 laparotomy, 11 thoracotomy, 12 both). Prognostic factors for relapse and survival were analysed with Kaplan-Meier curves and Cox regression analysis. Putative prognostic factors included age, the primary histology, prechemotherapy level of the tumour markers AFP and HCG, the extent of disease (lymph nodes, lung and hepatic metastases) before and after chemotherapy, the histology of the resected material and the completeness of the surgical procedure. Eleven patients relapsed during follow-up (median 47 months), accounting for a 5 year relapse free percentage of 87.4%. Adverse prognostic factors were (1) prechemotherapy level of HCG (> or = 10,000 IU l-1; (2) incomplete resection; and (3) the extent of disease, especially of lung metastases (prechemotherapy number < or = 3,4-19, > or = 20; or size after chemotherapy > 1 cm; or presence of any residual lung metastasis after chemotherapy without residual abdominal metastases). The histology found at resection was not associated with the risk of relapse, which might be explained by the effectiveness of postresection chemotherapy, which in the majority of these patients was a salvage regimen rather than two further cycles of the initial cytostatics. A good and a poor risk group were formed, based on HCG level and completeness of resection. The effect of salvage chemotherapy after resection of viable cancer cells needs further investigation.     

Multiple hepatocellular carcinomas successfully treated by combined therapies

We report a case of advanced multiple hepatocellular carcinomas (HCC), successfully treated by combination therapies of transarterial chemoembolization (TAE), operation and radiofrequency ablation therapy (RFA). A 59 year-old man was detected with an increased serum alpha-fetoprotein (AFP) level and an ultrasonography (US) revealed three nodules of HCC at the right lobe in August 1998. He was successfully treated with a combination therapy of TAE and percutaneous ethanol injection therapy (PEIT) at the beginning. However, HCC had recurred quite often. TAE had been repeated for twelve times before right trisegmentectomy was performed in November 2002. Thirteen months after the operation, CT revealed a new lesion at subsegment 3, which was treated by RFA. Furthermore, a metastatic single lesion had appeared at the left lung, which was resected. He has still been well for 82 months since the first detection of HCC.     

A Successfully Resected Case of Recurrent Lung and Liver Metastases of Rectal Cancer Treated with XELIRI + Bevacizumab Therapy

It has been reported that many colorectal cancer (CRC) patients with synchronous or metachronous liver metastases underwent surgery subsequent to neoadjuvant combination chemotherapy with folinic acid, fluorouracil, and oxaliplatin (FOLFOX), folinic acid, fluorouracil, and irinotecan (FOLFIRI), or capecitabine and oxaliplatin (XELOX). However, there are very few reports of the use of capecitabine and irinotecan (XELIRI). We herein report a successfully resected case of recurrent lung and liver metastases of rectal cancer treated with combination chemotherapy with XELIRI + bevacizumab (BV) therapy. A 63-year-old male developed recurrence of a solitary nodule in the right lower lobe of the lung and multiple liver metastases after low anterior resection for rectal cancer 1 year previously. Partial resection of the right lower lobe of the lung was performed and treatment with XELIRI + BV was initiated. A computed tomography scan revealed a reduction in tumor size without any new lesions after four cycles of XELIRI + BV therapy. Partial hepatectomy of S1, S5, and S7 was safely performed. The patient is now undergoing adjuvant chemotherapy and has been free from recurrence for 18 months following surgery. There are only few studies with relatively low patient numbers reporting on the outcome after resection of both pulmonary and hepatic metastases of CRC. We therefore report a patient who underwent sequential resection of pulmonary and hepatic metastases with XELIRI + BV therapy.Key words: Colorectal cancer, Liver metastasis, XELIRI     

Completion pneumonectomy for lung metastases

OBJECTIVE: Completion pneumonectomy (CP) for malignant disease is generally accepted but controversial for lung metastases. The data available show a high perioperative morbidity and mortality with a poor long-term prognosis. We analysed the postoperative outcome and long-term results of our patients undergoing CP. PATIENTS AND METHODS: Between January 1986 and May 2003, nine patients underwent completion pneumonectomy for lung metastases. This represents 10% (9/86) of all CPs performed and 1.7% (9/525) of all pneumonectomies. RESULTS: One to three metastasectomies in the form of wedge resection (16), segment resection (5) and lobectomies (3) were performed prior to CP. The mean time interval between the operation of the primary tumour and the first metastasectomy was 38 months, the first and second metastasectomy 12 months, the second and third metastasectomy 14 months, and the third metastasectomy and CP 25 months. Six patients had an extended completion pneumonectomy. Operative morbidity and mortality was 0%. One patient is still alive and recurrence-free 9 months after CP. Two patients have recurrent pulmonary contralateral metastases under chemotherapy and six patients died of metastatic disease. Actual survival is 33%, recurrence-free survival (RFS) is 11%. The 3-year survival is 34%. CONCLUSION: Since there was no morbidity and mortality in our series, CP for lung metastases seems to be justified but the long-term survival is limited by the occurrence of contralateral or extrapulmonary metastatic disease. Multiple resections of metastases have a positive influence on survival, but the last step of resection in the form of CP does not seem to improve long-term survival.     

Angiosarcoma with malignant peripheral nerve sheath tumour developing in a patient with klippel-trénaunay-weber syndrome

Purpose: We discuss the coexistence of Klippel-Trénaunay-Weber syndrome with various malignancies, the possible histogenetic pathways and therapeutic implications.Patient: We report on a 46-year-old man presenting with increasing pain and swelling of his right lower leg after fracturing his fibula. Since birth he was known as having the uncommon syndrome of Klippel-Trénaunay-Weber of his right lower leg.Methods: Our patient underwent an above-knee amputation for biopsy-proven malignant vascular tumour, first thought to be a composite hemangio-endothelioma and/or angiosarcoma with lung metastases.Results: In the amputated extremity, a vascular malformation was found with tumour showing various components with foci of angiosarcoma adjacent to diffuse neurofibroma and areas with high-grade malignant peripheral nerve sheath tumour. Amputation and palliative chemotherapy were indicated, but he died of pulmonary and cerebral metastases 2 months postoperatively.Discussion: This case describes an angiosarcoma with malignant peripheral nerve sheath tumour developing in a patient with Klippel-Trénaunay-Weber syndrome. A case never described before in literature and probably, as in our case, difficult to diagnose at first biopsy.     

Treatment of a Case of Asynchronous Bilateral Renal Cell Carcinomas with Inferior Vena Caval Thrombus and Hepatic Metastases

A 56-year-old man underwent a right radical nephrectomy withremoval of a vena caval thrombus and resection of hepatic metastasesfor right renal cell carcinoma. Twenty-one months after thefirst operation, a left renal cell carcinoma was detected whichwas treated with left radical nephrectomy and followed by hemodialysis.The patient then enjoyed an active life for 14 months but died18 months after his second operation due to lung metastasis.Bilateral radical nephrectomy and hepatic resection may be justifiedsince there is no strongly effective adjuvant therapy for suchadvanced cases.     

Local recurrence and metastatic disease in a typical N1 carcinoid bronchial tumour

Typical carcinoid bronchial tumour is a well-known disease that, for years, was considered benign. Currently, it is classified within the group of neuro-endocrine lung tumours. It is a low-grade malignancy tumour with a capability of local and distant recurrence. Complete resection with mediastinal lymphadenectomy is the treatment-of-choice. There are, usually, long-term survivors, even in cases of recurrence or mediastinal node invasion. These patients could benefit from removal of recurrent or metastatic disease. We present, here, a case of a 19-years-old female diagnosed as having N1-bronchial typical carcinoid tumour. She underwent radical surgery, but with mediastinal recurrence and hepatic metastases. A new radical lung resection was performed, end a liver transplant was the therapy-of-choice for the metastatic lesion.     

Extended right hemihepatectomy as a salvage operation for recurrent bile duct cancer 3 years after pancreatoduodenectomy

Salvage surgery for recurrent bile duct cancer is generally impractical due to local invasion of surrounding major vascular structures or distant metastases. We describe a case of a relapsed tumor in the right hepatic duct 3 years after pancreatoduodenectomy for middle to distal bile duct cancer. The recurrent tumor, measuring 25 x 12 x 12 mm, was mostly confined within the right hepatic duct. It displayed an intraductal superficial extension rather than transmural invasive growth to the hepatic hilum. An extended right hemihepatectomy was successfully performed with a histologically negative margin. The patient is currently doing well without any signs of local recurrence or distant metastasis 8 months after the second operation. Precise pathological examination revealed that the lesion had originated from multicentric foci in the right hepatic duct, not as a result of anastomotic recurrence. These results raised the consideration of a potentially more indolent subgroup of bile duct cancer. This is a detailed report of a successfully resected recurrent bile duct cancer, for which the patient underwent major hepatectomy as a salvage procedure after pancreatoduodenectomy for the primary tumor. An aggressive surgical approach will be a rational treatment of choice for recurrent disease when metachronous multicentric tumor development in the bile duct is suspected and curative resection can be safely performed.