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.     

A case of successful second look operation for hepatocellular carcinoma with right atrial tumor thrombus

We report a case of advanced hepatocellular carcinoma (HCC) with right atrial tumor thrombus treated by interferon (IFN)-combinated chemotherapies and second look operation. A case was a 56-year-old man who had right upper abdominal and back pain. The abdominal CT revealed an early enhanced lesion in the posterior segment of the liver with right atrial tumor thrombus. The patient underwent 2 courses of IFN-β/adriamycin combination therapy and followed by surgical resection. Due to severe congestive live, we only surgically resected tumor thrombi at right atrium, inferior vena cava, and right hepatic vein. Additionally, we closed posterior branch and right hepatic vein to prevent from a tumor progression. Following 16 months of IFN/5-FU and IFN/S-1 therapy, we performed a right posterior sectionectomy of the liver. Twelve months after the second operation, liver tumor relapsed and we performed transcatheter arterial chemoembolizatin, followed by IFN-combinateted chemotherapies. Thereafter, we continued chemotherapy for 14 months. The tumor progressed into the bile duct, and he died after 3 years and 8 months from the initial treatment. The case suggests that some patients with HCC with major vascular invasion and tumor thrombus can gain a long-term survival by multifocal treatment including surgery and chemotherapy.     

A case of multiple lung metastases of hepatocellular carcinoma after resection of liver and tumor thrombi in the inferior vena cava responding to chemotherapy using 5-FU, mitoxantrone and CDDP

A 58-year-old man, who had a history of chronic type B hepatitis, was diagnosed as hepatocellular carcinoma with tumor thrombi in the inferior vena cava. He underwent resection of central bisegments and tumor thrombi, while postoperative chest CT demonstrated multiple lung metastases. Following 2 courses of chemotherapy using 5-FU, mitoxantrone, and CDDP (FMP therapy), multiple lung nodules disappeared and alpha-fetoprotein returned to the normal level. FMP therapy thus proved effective for a case of distant metastases of hepatocellular carcinoma.     

Clinical and radiologic features of hepatocellular carcinoma originating in the caudate lobe

Five patients with hepatocellular carcinoma in the caudate lobe were evaluated. Computed tomography (CT) scan and/or angiography clearly demonstrated multiple intrahepatic metastases in four (80%), and tumor thrombi in the portal vein in two (40%), and in the inferior vena cava in one. Even though there was no recognizable lung metastasis, metastases were found in the orbita in one patient, and in the ribs and thoracic vertebrae in two patients. Four patients died after a mean period of 5.5 months from the initial diagnosis. The mechanism for early invasion into the vessels and multiple intrahepatic metastases of hepatocellular carcinoma arising from the caudate lobe is discussed.     

A case of an elderly patient having advanced hepatocellular carcinoma with tumor thrombus in the inferior vena cava treated with chemo-radio-therapy--intraarterial infusion of weekly high dose 5-FU (WHF)

The patient was an 81-year-old man, diagnosed with advanced huge hepatocellular carcinoma (HCC) with tumor thrombus extending into the inferior vena cava (Vv3), for which resection was judged impossible. The radio therapy (51 Gy) for tumor thrombus was carried out, and he received a weekly hepatic arterial infusion therapy (weekly high-dose 5-fluorouracil (5-FU)) for these legions. After 8 cycles, the CT scan revealed a minor response of the tumor (SD), and,the tumor marker reduced. After 10 months, these legions had markedly regressed (PR), the tumor thrombus in the inferior vena cava was not detectable. There were no severe side effects. Ten months since the start of chemo-radio therapy, the positron emission tomography (PET) revealed a metastatic tumor of the femoral bone in recurrence. In conclusion, some elderly patients of advanced HCC with tumor thrombus may obtain a long term survival through this treatment.     

肾癌伴腔静脉癌栓的手术治疗

目的:探讨手术治疗肾癌合并腔静脉癌栓患者的预后。方法:回顾分析2003年12月～2009年12月我院12例经手术及病理证实的肾癌合并腔静脉癌栓患者的资料,其中男性10例,女性2 例,中位年龄62（42～76）岁。肾静脉癌栓6 例,左侧2 例,右侧4 例; 下腔静脉癌栓Ⅱ级（肝下型）3 例,Ⅲ级（肝内型）3 例。12例患者术前均经CT或MRI 检查明确诊断肾癌合并腔静脉癌栓。结果:12例患者接受肾癌根治术的同时行静脉癌栓切除,术后9 例患者得到随访,随访时间6～72个月,无瘤生存1～3 年4例,生存5 年以上的4 例,1 例术后6 个月死于肿瘤复发。结论:CT和MRI 对肾癌伴下腔静脉癌栓诊断率较高,可准确判断癌栓位置,对无淋巴结和远处转移者,在行肾癌根治术的同时行下腔静脉癌栓取出术是治疗肾癌合并静脉瘤栓积极有效的治疗方法。      

A successful treatment of conversion chemotherapy by mFOLFOX6 plus cetuximab for initially unresectable synchronous colorectal liver metastases

A 63-year-old woman with a synchronous huge colorectal liver metastasis was referred to our institution.The lesion was technically diagnosed unresectable because the estimated future remnant liver volume was insufficient due to the invasion of the three hepatic veins and hepatic hilum.She underwent 7 courses of mFOLFOX6 and 14 administrations of cetuximab as conversion chemotherapy.Periodic abdominal CT scans revealed the tumor becoming PR, and she was free of cancer invasion to the left hepatic vein.After the remainder of chemotherapy lasting 4 weeks, right trisectionectomy and combined partial resection of the inferior vena cava and primary closure was performed.The postoperative course was uneventful and the patient was discharged at 20 days after the operation.She underwent chemotherapy postoperatively, and then underwent laparoscopic sigmoidectomy.A conversion chemotherapy using cetuximab may contribute to ward rapidly reducing tumor size and improving the resectability of initially unresectable huge colorectal liver metastases, thus leading to prolonged survival.     

Effectiveness of radiation therapy to the venous thrombosis between the inferior vena cava and right ventricle

In the management of hepatocellular carcinoma (HCC), a tumor thrombus occurrence between the hepatic vein and right ventricle is life threatening. We studied the effectiveness of radiation therapy to the venous thrombosis between the inferior vena cava and right ventricle. CASE 1: A 66-year-old man who suffered from no hepatic viral infection had hepatectomy of the huge HCC (over 20 cm) and recurrence at the post dperated liver and lung. After transarterial embolization, he suffered from dispnea and was found with tumor thrombus from the left hepatic vein to right atrium. Radiation therapy to the tumor thrombus was done and dispnea disappeared. He died by pneumonia at 5 months after the radiation. CASE 2: A 74-year-old woman who had hepatecomy and RFA for multiple HCC. For the recurrence of HCC, TAE and RFA were performed. After the tumor thrombus in the inferior vena cava, mammarian cancer was found and radiation therapy was performed. She died after 4 months from lung edema, but no growth of tumor thrombus was found. CASE 3: A 79-year-old man who had TAE, hepatectomy, RFA and MCT for multiple hepatoma. After these treatments, tumor thrombus at the right ventricle was found. Although he suffered from portal tumor thrombosis, lung metastases, bone metastases and colon cancer after the radiation therapy, he is still alive at the 19 month of treatments. Radiation therapy is safe and effective for venous tumor thrombosis of HCC.     

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.     

体外循环技术在肿瘤外科治疗中的应用

目的:探讨体外循环在肿瘤外科治疗应用中的可行性和适应症,总结经验教训。方法:本院2010年~2015年体外循环下肿瘤手术12例,年龄26~72 岁 男性8例,女性4例。肾癌6例,其中单纯伴下腔静脉瘤栓2例,同时合并右心房瘤栓4例,1例合并冠心病同时行CABG术（术中死亡）;肝癌合并下腔静脉、右心房瘤栓1例;气管肿瘤2例;卵巢肉瘤合并下腔静脉、右心房瘤栓1例;肺癌侵犯左心房1例,侵犯右心房1例。浅低温心脏不停跳体外循环下（9例）或心脏停跳体外循环（3例）; 腔静脉,主动脉插管10例,阻断瘤栓远端下腔静脉,据瘤栓部位切开下腔静脉、右心房,剥离切除瘤栓;股动,静脉转流2例,建立气管通路后停止转流;原发肿瘤依据具体情况同期处理（旷置1例,余行切除）。结果:体外循环转流时间(56.17+63.72)min;原发肿瘤根治切除率91.67%。术中死亡一例,其余均存活出院。随访4例肾癌2个月、1例肺癌病人1个月,均存活无肿瘤复发及转移。结论:体外循环如严格控制适应症,有利于提高手术切除率,改善晚期肿瘤病人生活质量及延长生存时间;并可有效预防肺栓塞等严重并发症。     

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.     

A complete response to one-shot hepatic arterial infusion of epirubicin in a patient with highly advanced hepatocellular carcinoma

A 61-year-old male was admitted for advanced hepatocellular carcinoma (HCC) with multiple lung metastases and tumor thrombus in the portal vein and superior vena cava. At first, we planned to perform transcatheter arterial embolization (TAE) to avoid the rupture of the liver tumor. But, due to the severe liver dysfunction, ie Child-Pugh C and 36% ICG R15, hepatic arterial infusion (HAI) of epirubicin 40 mg was performed. After that, the patient was followed at the outpatient ward and his general condition has gradually improved without a special treatment. At the present, one year and ten month after HAI, the serum alpha-fetoprotein (AFP) is almost within normal limits and CT scans show that HCC with multiple lung metastases, and tumor thrombus in the portal vein and superior vena cava almost disappeared. Although, spontaneous regression of HCC was a rare phenomenon, it might have played a major role in the good anticancer efficacy of this patient as well as high anti-cancer agent sensitivity of his liver tumor.     

Aggressive surgical treatment prolonged survival of a patient with synchronous hepatocellular carcinoma with tumor thrombus in the inferior vena cava and sigmoid colon cancer

A 71-year-old man was admitted to our institution having a HCC with tumor thrombus extending to the inferior vena cava. He simultaneously had a sigmoid colon cancer. S8 segmentectomy combined with a removal of tumor thrombus in the IVC and sigmoidectomy was performed. He had an uneventful postoperative course. He had a recurrence to the lung 46 months after the surgery, and underwent a pulmonary partial resection. Hepatic recurrence was found in 59 months after the initial surgery. Transcatheter arterial chemoembolization was performed for the treatment. The patient died of esophageal variceal rupture 78 months after the surgery. Although this case was a highly advanced hepatocellular carcinoma with tumor thrombus in the inferior vena cava and synchronous sigmoid colon cancer, a surgical treatment and multidisciplinary therapy may contribute to a long-term survival.     

肾癌腔静脉癌栓的诊断与治疗

背景与目的：肾癌可侵犯肾静脉,形成癌栓延伸至腔静脉,甚至右心房。肾癌腔静脉癌栓临床处理困难,但是在根治性肾切除时取尽癌栓,患者可获得长期生存。本文报告我们处理肾癌腔静脉癌栓的体会。方法：回顾性分析1995年5月～2003年10月经手术治疗的14例肾癌腔静脉癌栓患者的临床资料,包括术前诊断、手术方法和患者的预后。结果：B超发现腔静脉癌栓9例,漏诊5例;CT诊断癌栓12例,漏诊2例;8例MR1检查均发现腔静脉癌栓并对癌栓范围显示清楚。14例中肝下腔静脉癌栓12例、肝内膈下和膈上腔静脉癌栓各1例,术后随访时间6～37个月,13例无瘤生存,1例(ⅢC患者)于术后23个月因癌死亡。结论：B超和CT是诊断肾癌腔静脉癌栓常用方法,MR1判断癌栓范围较B超和CT准确。对没有淋巴和远处转移的肾癌腔静脉癌栓患者外科治疗能获良好的远期效果。     

Non-surgical treatment of hepatocellular carcinoma with tumor thrombus in the right atrium

A 65-year-old Japanese man who had been suffering from severe and progressive dyspnea for more than 2 months underwent an extended right hepatectomy for hepatocellular carcinoma (HCC) in August 2001. Radiological examination, performed in August 2003, revealed the mass in the left lobe of the liver extended into the left hepatic vein, the inferior vena cava and the right atrium. Those clinical manifestations were supposedly attributed to HCC tumor thrombus in the right atrium. The decision to carry out the palliative operation for the tumor thrombus was not made because of poor prognosis in light of hemodynamic compromise indicating a reasonable liver function. A sequential course of treatments for the tumor thrombus was performed including transcatheter chemotherapy, transarterial chemoembolization and radiation therapy. Although a radiological response rate was 27% in diameter of the tumor thrombus, the clinical manifestations, such as dyspnea or edema, completely disappeared during the treatment. No surgical standard or interventional regimen for HCC tumor thrombus in the right atrium has been established. However, we here demonstrated the possibility for the treatment of the tumor thrombus with intensive combination therapies.     

Combined liver and inferior vena cava resection for hepatic malignancy

OBJECTIVE: The experience from a single center, in combined liver and inferior vena cava (IVC) resection for liver tumors, is presented. METHODS: Twelve patients underwent a combined liver resection with IVC replacement. The median age was 45 years (range 35-67 years). Resections were carried out for hepatocellular carcinoma (n = 4), colorectal metastases (n = 6), and cholangiocarcinoma (n = 2). Liver resections included eight right lobectomies and four left trisegmentectomies. The IVC was reconstructed with ringed Gore-Tex tube graft. RESULTS: No perioperative deaths were reported. The median operative blood transfusion requirement was 2 units (range 0-12 units) and the median operative time was 5 hr. Median hospital stay was 10 days (range 8-25 days). Three patients had evidence of postoperative liver failure, resolved with supportive management. Two patients developed bile leaks, resolved conservatively. With a median follow up of 24 months, all vascular reconstructions were patent and no evidence of graft infection was documented. CONCLUSIONS: Aggressive surgical management of liver tumors, offer the only hope for cure or palliation. We suggest that liver resection with vena cava replacement may be performed safely, with acceptable morbidity, by specialized surgical teams.     

Complete remission of multiple recurrent hepatocellular carcinomas by oral administration of enteric-coated tegafur/uracil in a patient with huge hepatocellular carcinoma extending to the inferior vena cava after hepatic resection: analysis of mRNA expression of fluoropyrimidine metabolism enzymes in the primary tumor

We herein report the complete remission of multiple recurrent hepatocellular carcinomas (HCCs) by the oral administration of tegafur/uracil (UFT) alone. A 56-year-old Japanese man with two huge HCCs was admitted and underwent hepatic resection. Intraoperative ultrasonography revealed that the tumor thrombus extended to the inferior vena cava (IVC) with a small tumor in the left hepatic lobe. Right trisectionectomy of the liver, removal of the tumor thrombus in the IVC, and partial resection of the left lobe were performed. Microscopic examination revealed that the larger tumor was moderately to poorly differentiated HCC and the smaller tumor was well-differentiated HCC. The small tumor in the left lobe was diagnosed as an intrahepatic metastasis of the larger tumor. Two months after the surgery, computed tomography (CT) revealed multiple HCC recurrences in the remnant liver, but complete remission was achieved by the administration of UFT alone. To clarify the reason for the good response of the recurrent HCC to UFT, the mRNA expression level of several fluoropyrimidine metabolism enzymes was measured in resected specimens. A lower expression of thymidine phosphorylase (TP) might explain the good response to UFT. The patient is alive without intra- or extrahepatic recurrence more than 6 years after the hepatic resection.     

Temporary placement of inferior vena cava filter prior to transcatheter arterial embolization (TAE) for hepatocellular carcinoma with IVC tumor thrombus--prevention of pulmonary tumor emboli after TAE]

A 66-year-old-man with a right huge hepatocellular carcinoma (HCC) extending into both the right portal vein and the right atrium underwent transcatheter arterial embolization (TAE) via the right hepatic artery. Prior to the TAE, a temporary inferior vena cava (IVC) filter was placed suprarenally for prevention of pulmonary tumor emboli. When we replaced the temporary IVC filter with a new one 7 days after the TAE, the filter which was pulled out of the IVC captured a fragment of the tumor thrombus. A histopathological specimen demonstrated only ghost cells. The patient has been followed at our outpatient clinic without any tumor thrombus or pulmonary infarction for 13 months after this procedure.     

Renal cell carcinoma invading the hepatic veins.

BACKGROUND: Hepatic vein invasion by renal cell carcinoma with inferior vena cava tumor thrombus is relatively uncommon. The Budd-Chiari syndrome that results from obstruction of the suprahepatic venous drainage by the tumor could evolve toward liver fibrosis and death. Early diagnosis and surgical treatment of this condition is of prime importance. Complete mobilization of the liver and rotation of the inferior vena cava enhances exposure of the ostium of the hepatic veins. This maneuver allows for the complete removal of tumor from the hepatic veins and decompression of the liver. METHODS: Between May 1997 and April 2000, four patients with renal cell carcinoma and inferior vena cava thrombus with hepatic vein invasion underwent surgery at the study institution. Three of the patients had Budd-Chiari syndrome. Surgical techniques were developed to handle these difficult tumors safely. RESULTS: Three patients presented with the Budd-Chiari syndrome, one of whom was found to have severe liver failure before surgery. The fourth patient presented with a hepatic vein tumor thrombus. A caval atrial thrombus and hepatic vein thrombus in one patient were removed successfully without opening the chest. Three patients required cardiopulmonary bypass. Hypothermic arrest was required in one patient. At the time of last follow-up, 2 patients were alive at 14 months and 30 months after surgery, respectively, without recurrence. One patient died 6 months after surgery due to metastatic renal carcinoma and 1 patient who had prior severe liver failure died of multiple organ failure 2 weeks after undergoing surgery. None of the four patients required reoperation. CONCLUSIONS: Prompt surgical treatment should be performed to avoid hepatic failure and disease progression. The surgical technique described in the current study allowed for removal of the tumor from the hepatic veins and the authors believe it can be used with cardiopulmonary bypass to enhance visibility of the hepatic veins.     

A case of hepatocellular carcinoma with tumor thrombus in the right atrium successfully treated by arterial administration of lipiodol-SMANCS

In February, 1996, a 73-year-old male with liver dysfunction was admitted to our hospital for further examination and treatment of liver tumor. The liver tumor was revealed by imaging examination, which was mainly in the S4-S8 of liver with a thrombus growing from the right anterior branch to the right branch of the portal vein, and from the right hepatic vein to the inferior vena cava and right atrium. The serum AFP and PIVKA-II levels were elevated to 3.610 ng/ml and 54 AU/ml, respectively. The patient was diagnosed as having hepatocellular carcinoma, and was treated by arterial administration of anticancer drugs (epirubicin hydrochloride, mitomycin C and carboplatin) and TAE. Though the main tumor (S4-S8 of liver) was reduced by TAE, the portal and atrial tumor thrombus did not respond. One month after TAE (20 May, 1996), the first arterial administration of Lipiodol-SMANCS was given, followed by 4 successive procedures with an interval of about 1.5 months (total dose 15 mg), resulting in remarkable tumor thrombus shrinkage and reduction of AFP levels to 80 ng/ml. This case shows that arterial administration of SMANCS may be one of the effective treatments for hepatocellular carcinoma, even with tumor thrombus of hepatic vein, IVC and right atrium.