Management of adrenal metastasis of hepatocellular carcinoma by asynchronous resection of bilateral adrenal glands

We report on a 65-year-old man who received asynchronous bilateral adrenalectomy for adrenal metastasis of hepatocellular carcinoma. Fifteen months after curative resection of right hepatic lobe for hepatocellular carcinoma, a metastatic lesion of the left adrenal gland was detected and left adrenalectomy was performed. Ten months after the second operation, a metastatic lesion in the right adrenal gland, associated with tumor thrombus in the inferior vena cava, was revealed. Transcatheter arterial embolization of the arteries feeding the metastatic tumor was performed, but its effects were incomplete. As there was the tumor thrombus in the inferior vena cava and no other intrahepatic recurrence or extrahepatic metastasis was found, resection of the right adrenal gland with tumor thrombus, without the employment of veno-venous bypass, was performed, followed by postoperative hormonal supplementation. Changes in the patient's alpha-fetoprotein level were clinically useful for the detection of the metastatic lesions and the evaluation of therapeutic effects. Metastasis to adrenal gland from hepatocellular carcinoma should be actively managed, and the appropriate surgical treatment selected, if intrahepatic recurrence and/or other extrahepatic metastasis are controlled. To achieve higher curability and better outcome in patients with bilateral adrenal metastasis of hepatocellular carcinoma, bilateral total adrenalectomy is indicated, accompanied by effective postoperative hormonal supplementation. (Received Apr. 15, 1998; accepted July 24, 1998)     

Recurrent hepatocellular carcinoma presenting with superior vena cava syndrome

A 45-year-old male received wedge resection for his small hepatocellular carcinoma in April 1989 and extended right lobectomy for tumor recurrence 8 months later. Unfortunately, recurrent hepatic tumor with lung metastases were found 18 months after the second operation. Both the hepatic and pulmonary recurrent tumors were resected and transcatheter arterial embolization was added for the residual hepatic tumors. He remained symptom free for another 18 months. However, mediastinal lymphadenopathy, superior vena cava thrombus with superior vena cava syndrome, cardiac and brain metastases developed subsequently. He died of increased intracranial pressure. It is rare for hepatocellular carcinoma to have mediastinal metastases, superior vena cava thrombus and superior vena cava syndrome.     

Treatment of colorectal liver metastasis with biliary and portal vein tumor thrombi by hepatopancreatoduodenectomy

We present a case of a large colorectal liver metastasis with portal vein and biliary tumor thrombi and duodenal and jejunal direct invasion that required hepatopancreatoduodenectomy. A 38-year-old woman presented to her local hospital with right back pain and jaundice. She had undergone transverse colectomy and limited liver resection for transverse colon cancer with a synchronous liver metastasis in September 1991, and low anterior resection for rectal carcinoma in January 1996. She was diagnosed as having colorectal liver metastasis and was referred to our hospital for possible surgery. Radiologic and endoscopic examinations revealed a large liver tumor occupying the right lobe, biliary dilation in the left lateral section, and a portal vein tumor thrombus. Invasion of the inferior vena cava and the right renal vein were also suspected. Intraoperative findings revealed a large liver tumor that occupied the right lobe and invaded the duodenum and jejunum. The tumor was resected successfully by right trisectionectomy, caudate lobectomy, pancreatoduodenectomy, partial resection of the jejunum, and combined portal vein resection and reconstruction. The inferior vena cava, right kidney, and renal vein could be detached from the tumor. The patient has enjoyed an active life without recurrence for 2 years since the operation.     

An approach to intrapericardial inferior vena cava through the abdominal cavity, without median sternotomy, for total hepatic vascular exclusion.

In surgical resection for hepatocellular carcinoma with tumor thrombus extending into the inferior vena cava and other malignancies involving the retrohepatic inferior vena cava, the usefulness of total hepatic vascular exclusion has been reported by several authors. Total hepatic vascular exclusion usually consists of clamping at three points; at the infrahepatic inferior vena cava, at the suprahepatic inferior vena cava, and in Pringles' maneuver. Tumor thrombus extending into the inferior vena cava at the intrapericardial level below the right atrium can be resected without the use of cardio-pulmonary bypass. The inferior vena cava at the intrapericardial level has been reported to be usually approached by median sternotomy such as Chevron incision. We herein demonstrate an approach to the intrapericardial inferior vena cava through the abdominal cavity without median sternotomy.     

Total vascular hepatic exclusion for tumor resection: a new approach to the intrathoracic inferior vena cava through the abdominal cavity by cutting the diaphragm vertically without cutting the pericardium

For the resection of advanced liver tumors in which the tumor thrombus extends into the intrathoracic inferior vena cava (IVC) above the diaphragm, surgeons need very skillful techniques and much experience. However, after detachment of the line of fusion of the pericardium to the diaphragm (LFPD), the intrathoracic IVC can be exposed easily. We herein present this novel surgical method, an approach to the intrathoracic IVC through the abdominal cavity. A 66 year-old man was referred to our hospital because of high-grade fever. Computed tomography revealed a large tumor of the left hepatic lobe with tumor thrombus extending into the intrathoracic IVC through the left hepatic vein. Laboratory data showed elevated levels of alpha-fetoprotein (AFP) (726 ng/ml) and protein induced by vitamin K absence (114 AU/ml). The patient was diagnosed with hepatocellular carcinoma (HCC) of the left hepatic lobe with tumor thrombus extending into the IVC. He underwent left hepatectomy with partial resection of the IVC and intravascular tumor thrombectomy under total hepatic vascular exclusion (THVE) without the use of cardiopulmonary bypass (CPB). Before THVE, we approached the IVC through the abdominal cavity with vertical dissection of the diaphragm after detachment of the LFPD without cutting the pericardium or performing median sternotomy. This procedure could be very beneficial and helpful for many liver surgeons.     

Long-term surviving patient with inferior vena cava tumor thrombus and extrahepatic metastasis after spontaneous ruptured hepatocellular carcinoma

We present a case of long-term survival in a patient with inferior vena cava tumor thrombus (IVCTT) and extrahepatic metastasis after resection for spontaneous ruptured hepatocellular carcinoma (HCC). The patient was a 73-year-old Japanese man previously diagnosed with chronic hepatitis B. He was referred to our emergency room and diagnosed with spontaneous ruptured HCC. The patient was immediately treated with transcatheter arterial embolization, and we then performed second-stage hepatic resection 50 days later. Although des-gamma-carboxy prothrombin was reduced to a normal level after hepatectomy, it gradually increased and computed tomography showed a disseminated tumor in the diaphragm near S2 of the liver with IVCTT and right atrium tumor thrombus. Recurrent HCC was treated with monthly transcatheter arterial infusion chemotherapy (TAI) and conformal radiotherapy (RT) of 40 Gy. After TAI and RT procedures, the disseminated tumor and IVCTT completely disappeared. Four years after TAI and RT procedures, the tumors were well controlled with no local recurrence. About 6−7 years after spontaneous ruptured HCC, lung metastasis and spleen metastasis were detected and resected, respectively. The patient is still alive and doing well over 7 years after spontaneous ruptured HCC.     

Hepatocellular carcinoma with a tumour thrombus extending to the tricuspid valve: report of a successful en bloc resection

This paper reports the use of cardiopulmonary bypass with mild hypothermia for the successful en bloc resection of a hepatocellular carcinoma in a cirrhotic liver with a tumor thrombus extending into inferior vena cava (IVC) and to the right atrium (RA), often prolapsing the tricuspid valve. The patient was a 77-year-old woman with antibodies against hepatitis C virus (HCV) and a serum alpha-fetoprotein (AFP) concentration of 13,566ng/mL. Imaging showed a large tumor in the left lobe of the liver extending into the RA, which often was prolapsed the tricuspid valve to produce mitral valve regurgitation. To prevent intraoperative pulmonary thromboembolism, both cardiac arrest and hepatic vascular occlusion with mild hypothermia were applied. The RA and IVC tumor thrombus and left liver were resected in en bloc. The cardiac arrest and hepatic vascular exclusion times were 56 and 15 min, respectively. The operation took 11 h, and the total blood loss was 1,078mL. The resected specimen weighed 1,000g and the tumor measured 8.0 x 7.8cm.     

Does a surgery for hepatocellular carcinoma with tumor thrombus highly occupying in the right atrium have significance? A case report and review of the literature

Hepatocellular carcinoma (HCC) advancing to the right atrium (RA) through the hepatic vein has generally been regarded as a terminal lesion of carcinoma. However, because tumor thrombus (TT) in the RA may cause sudden death by heart failure or pulmonary embolism, it is a pathologic condition that needs emergency extraction. Our case was a 55-year-old male. The HCC had a main lesion in the anterior region of the hepatic right lobe, accompanying TT highly occupying the region from the middle hepatic vein and inferior vena cava to the RA. For this tumor, we conducted an extended right anterior segmentectomy and extraction of the TT in the RA under an extracorporeal circulation. He was discharged on the 28th day after surgery, and at present, when 12 months have passed since the surgery, survives without any sign of its recurrence. There have been eight HCC cases including our case, reported regarding the simultaneous resections of a main tumor and TT under cardiopulmonary bypass. Because two patients among this group of eight survived for more than two years, resection is recommended even for advanced HCC highly infiltrating to the RA.     

Combined resection of the inferior vena cava for hepato-biliary and pancreatic malignancies

Seven cases of hepato-biliary and pancreatic malignancies that underwent partial resection of the inferior vena cava) were reviewed. Histological findings of inferior venca cava involvement were direct invasion in 5 cases, tumor thrombus in 1 case, and adhesion in 1 case. Correct preoperative diagnosis of inferior vena cava involvement was made in only 2 cases. A retrospective study on enhanced CT revealed that irregular deformity of the inferior vena cava had suggested inferior vena cava involvement. Total occlusion of the inferior vena cava was employed temporarily for inferior vena cava resection in 3 cases. A saphenous vein graft was used for reconstruction in 2 cases. Complications due to inferior vena cava resection are, as yet, unknown. One patient is alive, without recurrence, 24 months after the operation. One case underwent re-resection of liver metastasis, and is alive 17 months after the operation. Although advanced hepato-biliary and pancreatic malignancies involving inferior vena cava have been regarded as having a poor prognosis, an aggressive surgical approach may be applicable in some cases.     

Cholangiocellular carcinoma in a patient who has survived for 6 years after extended left hepatic lobectomy and caudate lobe resection with pancreatoduodenectomy

We describe a case of cholangiocellular carcinoma in a 66-year-old woman. A well-defined, hypoechoic tumor, 9 cm in greatest diameter, was detected in the left lobe of the liver by ultrasonography in December 1988. Celiac angiography showed a faintly stained tumor at the same location, with interruption of the left portal vein. Computed tomography revealed invasion of the inferior vena cava and lymph node enlargement around the head of the pancreas. In January 1989, the patient underwent extended left hepatic lobectomy with caudate lobe resection, pancreatoduodenectomy, partial resection of the inferior vena cava, and lymph node dissection around the hepatoduodenal ligament and the common hepatic artery. Postoperative histopathological examination revealed a moderately differentiated tubular adenocarcinoma. Cancer cells had invaded only the portal region, unlike the features of most cholangiocellular carcinomas. There was no evidence of lymph node metastasis in the dissected specimens. Six years after operation, there have been no signs of recurrence, and the patient is still alive and well.     

Treatment for hepatocellular carcinoma associated with tumor embolus in the inferior vena cava

Hepatic resection and removal of the tumor embolus was performed in six patients with hepatocellular carcinoma associated with tumor embolus in the inferior vena cava, without distant metastasis. Hepatic resection was performed in five patients under total hepatic vascular exclusion (THVE) with veno-venous bypass, using a centrifugal force pump and in one patient, under simple THVE without the bypass. In one patient, partial resection of segment VIII was performed, in one, a central bi-segmentectomy, and in four, right hepatic lobectomies were performed. Surgery was safely performed in all the 5 patients under THVE using the centrifugal force pump. One patient who underwent partial hepatic resection under the simple THVE, suffered cardiac arrest during surgery, but resuscitation was successful. Three patients died of reccurence within 1 year. The other three patients survived for 10 months, 2 years and 10 months, and 3 years and 10 months, respectively, after surgery. There were recurrences in the first two, patients, in both, treated by transcatheter arterial embolization, and to date, the third patient is disease-free. Hepatic resection was safely performed in patients with hepatocellular carcinoma associated with tumor embolus in the inferior vena cava, under conditions of THVE using the centrifugal force pump. Prolonged survival can be anticipated, with favorable liver function, in those patients in whom most of the lesion is resected.     

19例原发性肝癌心脏转移患者超声特征表现和预后分析

目的 总结肝细胞癌(HCC)心脏转移的超声表现特征,并分析其预后。方法 2013年1月～2019年5月我院收治的19例HCC心脏转移患者,回顾分析患者心脏超声表现,总结其特征,并随访其预后。结果 16例(84%)在肝癌相邻的肝静脉内可见实性回声,并延续至下腔静脉和右心房,3例(16%)肝癌相邻下腔静脉内可见实性回声,并延续至右心房;13例(68%)为混合回声,6例(32%)为低回声;15例(79%)边界清晰,16例(84%)形态不规则;19例(100%)右心房癌栓内未见血流信号;12例(63%)右心房癌栓随心动周期活动,活动规律与心动周期无关,7例(37%)右心房癌栓随心动周期活动不明显;3例(16%)累及右室流入道;本组患者发现右心房肿瘤转移后生存时间为25～412天,其中2例患者出现急性肺栓塞。结论 肝静脉-下腔静脉-右心房或下腔静脉-右心房连续性癌栓是本病最重要的超声表现,本病患者生存时间短,可并发急性肺栓塞而死亡。     

Recurrent hepatocellular carcinoma with tumor thrombus in right atrium - report of a successful liver resection with tumor thrombectomy using total hepatic vascular exclusion without concomitant cardiopulmonary bypass

For resection of advanced hepatocellular carcinoma (HCC) in which tumor thrombus (TT) extends into inferior vena cava (IVC) or right atrium (RA) surgery is challenging and requires skillful techniques. Here, we report a case of recurrent HCC with TT extending to the RA, who underwent successful resection with tumor thrombectomy without concomitant cardiopulmonary bypass. A 71-year-old man, who had been followed- up for hepatitis C by a local hospital, was diagnosed as having HCC in segment 6 for which he had undergone segmentectomy of segment 6 in May 2009. During follow-up, he developed severe leg edema and ascites with investigations revealing recurrent HCC in segment 7 with TT extending to the right atrium via IVC. After transarterial embolization the patient underwent extended resection of the segment 7 with tumor thrombectomy of the IVC and the right atrium and partial resection of the IVC wall using total hepatic vascular exclusion, without concomitant cardiopulmonary bypass. Total ischemic time was 23 minutes, operation time was 6 hours and blood loss was 2,474mL. The postoperative course was uneventful. Histopathology was recurrent hepatocellular carcinoma with hepatic venous invasion. We report the case of resected recurrent HCC with TT extending to right atrium without concomitant cardiopulmonary bypass.     

Growth of hepatocellular carcinoma into the right atrium. Report of five cases

Five patients had hepatocellular carcinoma growing into the right atrium. Clinically, all patients had edema in the legs, venous dilatation in the abdominal wall, ascites, and dyspnea. Paroxysmal aggravation of dyspnea and its alleviation by a left decubitus position were noted in three patients. Three patients developed shock after a change in posture. A gallop rhythm in the cardiac murmur was detected in two. Pathologically, all livers had hepatocellular carcinoma and macronodular cirrhosis. At autopsy, a tumor thrombus was found that completely occluded the right hepatic vein and extended into the inferior vena cava and right atrium, partially occluding the inferior vena cava. Antemortem diagnosis of right atrial tumor thrombi in patients with primary hepatocellular carcinoma is difficult, but the condition should be suspected when dyspnea, abnormal cardiac sounds, and shock develop.     

立体定向放射治疗原发性肝癌伴下腔静脉癌栓的疗效评价

目的评价立体定向放疗治疗肝细胞癌伴下腔静脉癌栓的疗效。方法在66例肝细胞癌伴下腔静脉癌栓患者中,36例接受立体定向放射治疗,30例未接受放射治疗。结果 36例接受伽玛刀治疗的癌栓患者,12例（33.3%）癌栓完全缓解,10例（27.8%）部分缓解,13例（36.1%）稳定,1例（2.8%）进展。癌栓治疗有效率为61.1%,1年生存率为27.8%,中位生存期为9.8个月;未放疗的30例患者1年生存率为11.5%,中位生存期为3.5个月。多因素分析显示,放疗组病人生存情况与肝内病灶单多发有关。Child-Pugh分级是影响预后的主要因素。结论立体定向放射治疗可明显延长肝细胞癌伴有下腔静脉癌栓患者的生存期。     

Inferior vena caval tumor thrombus extending into the right atrium in a patient with pancreatic cancer

Venous thromboembolism is a common complication in patients with cancer and an important cause of morbidity and mortality. Idiopathic thrombosis, migratory or recurrent thrombophlebitis may be the first manifestation of an occult malignancy. While deep venous thrombosis and pulmonary embolism are the most common thrombotic conditions in patients with malignant disease, tumor thrombus may be seen in inferior vena cava, mainly in patients with renal cell carcinoma, hepatocellular carcinoma, testicular tumors or adrenal carcinoma. Although pancreatic cancer is one of the cancers that are most strongly associated with thrombotic complications along with cancers of ovary and brain, there has been no report about presence of thrombus in the inferior vena cava in pancreatic cancer. We report a female patient with pancreatic cancer associated with tumor thrombus extending from the inferior vena cava to the right atrium     

Inferior Vena Caval and Right Atrial Thrombosis Complicating an Amebic Hepatic Abscess

We describe a 50-yr-old black laborer who presented with right lower chest pain, weight loss, and pedal edema. Ultrasonography and computed tomograms showed a large abscess cavity in the right lobe of the liver which extended very close to the inferior vena cava. The lumen of the adjacent inferior vena cava was partially occluded by thrombus, which could be traced up into the cavity of the right atrium. The hepatic veins were normally patent. Sterile blood-stained pus was aspirated from the abscess. Antibodies against Entamoeba histolytica were present in high titer in the patient's serum. Although propagation of hepatocellular carcinoma into the inferior vena cava and even up into the right atrium is well recognized, inferior vena caval thrombosis extending up into the right atrium has not hitherto been reported as a complication of amebic hepatic abscess.     

Hepatocellular carcinoma with inferior vena cava and right atrial tumor thrombus: A case report

This is a case report of a 45‐year‐old patient admitted with the symptom of bilateral leg swelling. Ultrasonography revealed a hyperechoic mass in the right lobe of the liver, which invaded the right hepatic vein (RHV) and extended into the inferior vena cava (IVC) and right atrium (RA). Based on the high alpha‐fetoprotein (AFP) level and the ultrasonography findings, the patient was diagnosed as having hepatocellular carcinoma (HCC) with a RHV, IVC, and RA tumor thrombus and secondary Budd–Chiari syndrome (BCS). HCC with a tumor thrombus extending into the IVC and RA has rarely been observed, and as a cause of secondary BCS, this type of HCC has been even more rarely reported.     

Inferior vena cavectomy for renal cell carcinoma with intracaval tumor thrombus

Excision of the inferior vena cava for renal cell carcinoma with intracaval tumor thrombus is infrequently performed. Herein the authors report a 60-year old woman with a right renal cell carcinoma and massive occluding tumor thrombus of the inferior vena cava. Following a negative metastatic workup, this patient underwent surgery to remove the tumor and thrombus. Thrombectomy occurred via excision of the affected portion of inferior vena cava and proximal left renal vein. Reconstruction of the vena cava was not undertaken. The patient did not suffer any morbidity during recovery in hospital. Her renal function was normal upon discharge. All resection margins were negative for tumor. This experience is compared to those reported in the literature. Postoperative morbidity may be minimized by careful patient selection. Suitable patients should have a right-sided tumor with an occlusive subhepatic vena caval tumor thrombus.     

Budd-Chiari syndrome as the primary manifestation of a fibrolamellar hepatocellular carcinoma.

An 18-year-old female patient was admitted with ascites, right upper abdominal tenderness and peripheral edema. Angiography showed complete occlusion of the vena cava inferior up to the level of the right atrium. By open heart surgery, masses of thrombotic material were pulled out of the v. cava inferior/vv. iliacae which histologically contained tumor cell populations consistent with a hepatocellular carcinoma. Celiacography showed a highly vascularized tumor in the right hepatic lobe. Histologically, it proved to be fibrolamellar subtype hepatocellular carcinoma.