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.     

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。     

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.     

Hepatocellular Carcinoma With Tumor Thrombus Occupying the Right Atrium and Portal Vein: A Case Report and Literature Review

Hepatocellular carcinoma (HCC) patients with tumor thrombus extended through the major hepatic veins and inferior vena cava into the right atrium (RA) are rare, and most cases are considered as the advanced stage with a poor prognosis.We report a case of HCC with a tumor thrombus extending into the RA and a tumor thrombus in the portal vein. A literature search for case reports was performed on PubMed.Compared with the published literature, our case is one of the youngest patients, but with the most advanced HCC that invades both the hepatic inflow and outflow vasculature. For this patient, we resected the tumor thrombus in the RA with the use of cardiopulmonary bypass, and then removed the tumor thrombus in the portal vein and ligated the left branch of portal vein. Because of insufficient remnant liver volume, microwave ablation and transcatheter arterial chemoembolization were performed to control the growth of HCC. The patient survived 6 months after surgery.This case suggests that for patients with extension of HCC into the RA and portal vein, surgery is a useful therapeutic modality, even in case that liver tumor cannot be resected.     

Left ventricular opacification after peripheral venous injection of a modified albumin solution.

The usefulness of a modified albumin solution was assessed in 8 dogs after peripheral venous and inferior vena cava injections. The contrast agent is a mixed solution made of glucose, albumin and glycerin, with sonicated microbubble diameter of 5.0 +/- 2.3 microns. Multiple injections (8 ml each) of this contrast agent (total 80 injections) into peripheral vein and inferior cava were performed. The blood pressure from femoral artery was measured before, during and after injections. Two-dimensional echocardiograms were recorded in a modified long axis view on videotapes for play back analysis. The pulmonary transit time and left ventricular contrast persistent time was determined for each injection. The videodensity of the region of interest (ROI) at the center of right ventricle and left ventricle was measured. The background videodensity of both ventricles was evaluated. The videodensity over the ROI of both ventricles with peak contrast enhancement was measured in all frames for 3 consecutive cardiac cycles. The peak videodensity of right and left ventricle subtracting the background videodensity of each ventricles was further calculated respectively. The injections caused no change in blood pressure or heart rate. All injections produced right ventricular contrast echo. As much as 85% of peripheral venous and 82.5% of inferior vena cava injections resulted in left ventricular contrast which was 0.68 and 0.65 as bright as that produced in the right ventricle. Pulmonary transit time and left ventricle contrast persistent time of peripheral venous injection was 4.05 +/- 0.53 and 13.67 +/- 4.28 seconds respectively. No difference of these data (3.93 +/- 0.47 and 11.65 +/- 4.66 seconds) from those produced by inferior vena cava injections were noted.(ABSTRACT TRUNCATED AT 250 WORDS)     

Fractured Inferior Vena Cava Filter Strut Presenting with ST-Segment Elevation and Cardiac Tamponade

The fracture of an inferior vena cava filter strut and its migration to the heart is a rare sequela of implanted inferior vena cava filters. Perforation through the right ventricle into the pericardium with resultant cardiopulmonary compromise is even less frequent. We report the case of a 53-year-old man who presented with chest pain and hypotension consequent to cardiac tamponade. A fractured inferior vena cava filter strut had migrated and perforated his right ventricle. The fractured strut was successfully removed by means of cardiac surgery. Inferior vena cava filters should be placed when necessary to minimize the risk of pulmonary embolism, and regular radiologic monitoring should be performed; however, the eventual extraction of retrievable filters should be considered. In addition to discussing the patient''s case, we briefly review the relevant medical literature.     

Inferior Vena Cava Filter Migration to the Right Ventricle Causing Nonsustained Ventricular Tachycardia

Inferior vena cava filters are commonly used to prevent pulmonary embolism in patients who manifest deep vein thrombosis and recurrent pulmonary embolism despite anticoagulation, or in patients with contraindications to anticoagulation. We report the case of a 69-year-old man with a structurally normal heart who experienced migration of an inferior vena cava filter to the right ventricle, which caused the abrupt onset of recurrent episodes of nonsustained ventricular tachycardia unresponsive to intravenous antiarrhythmic medication. Cardiac imaging revealed the location of the filter within the right ventricle, and the device was removed, with subsequent resolution of the arrhythmia. We anticipate that the incidence of inferior vena cava filter migration might increase in the future because of recent changes in device construction. The sudden appearance of nonsustained ventricular tachycardia in a patient with an inferior vena cava filter might indicate the occurrence of this potentially life-threatening sequela and should lead to emergent cardiac imaging.Key words: Foreign-body migration, inferior vena cava filter, pulmonary embolism/prevention & control, tachycardia, ventricular/etiology/diagnosis, vena cava, inferior, vena cava filters/adverse effects/utilization, venous thrombosis, ventricular tachycardiaInferior vena cava (IVC) filters were first developed in 1972 and have come into increasingly common use as a prophylactic measure in patients with contraindications to anticoagulation. The overall incidence of adverse sequelae for IVC filters has been extremely low. Intracardiac migration, in particular, has been rare: slightly more than 100 cases have been reported in almost 40 years. Recently, device migration has increased, apparently because of the use of lighter and more flexible alloys to facilitate insertion of the filter. Presented here is a case of IVC filter migration across the tricuspid valve into the right ventricle (RV), heralded by the abrupt onset of frequent episodes of nonsustained ventricular tachycardia (VT) unresponsive to intravenous amiodarone. The tricuspid valve is notoriously arrhythmogenic, and the sudden development of complex ventricular ectopic beats should alert the clinician to the possibility of intracardiac device migration. As the use of these new filters increases in the near future, we suspect that this serious sequela will become more common.     

Secondary tumors of the right heart. Echocardiographic aspects. Apropos of 6 cases in the adult

Secondary cardiac tumours are rare but but are now more frequently diagnosed by echocardiography. We report 6 cases of intracardiac metastases affecting the right heart which were diagnosed by 2D echocardiography. In 3 cases, a very mobile, oval-shaped tumour was visualised within the right atrium prolapsing into the tricuspid orifice in diastole like a myxoma but associated in 2 cases with signs of invasion of the inferior vena cava. Two other non-mobile tumours were observed causing massive invasion of the right atrium and the last case was of an infiltrating tumour of the right ventricle resulting in pulmonary infundibular obstruction. In the light of our experience and a review of the literature, it is difficult to distinguish secondary tumours of the right atrium from myxomas especially when the tumours are mobile and when it is impossible to visualise a pedicle inserted on the interatrial septum or tumoral invasion of the inferior vena cava. At the ventricular level, the diagnostic signs differ according to whether there is tumoral invasion of the cavity or infiltration of the muscular wall. These cases illustrate the value of 2D echocardiography in the diagnosis of intracardiac metastases, sometimes even in the absence of clinical signs.     

Situs ambiguus and atrial isomerism. Angiographic analysis of associated congenital heart diseases

Forty-seven cases of situs ambiguus have been analyzed angiographically: 24 had right atrial isomerism and 23 left atrial isomerism. The following criteria were considered for identification: auricular morphology; inferior vena cava: azygos continuation or connection in median position to the atrial cavity; bronchial anatomy; anatomy of the pulmonary arteries and their relation to the bronchi. In the group with right atrial isomerism we observed levocardia in 15 cases, dextrocardia in 7 and mesocardia in 2. Bilateral superior vena cava was identified in 13 cases. Inferior vena cava drained in most cases (21) in the middle portion of the atrial cavity; it was on the same side of the abdominal aorta in 20 cases. Pulmonary venous drainage was visualized in 19 patients: in 8 cases it followed the usual pattern of the total anomalous drainage, supracardiac (7) or infracardiac (1); in 2 cases mixed forms were found; in 9 cases the pulmonary veins entered directly the common atrial cavity. Common atrium was seen in 80% of the cases; in the remaining a huge atrial septal defect was present. The atrioventricular connection was double inlet in the 16 cases of univentricular heart; in all of them, and in additional 7 biventricular hearts, the mode was via a common atrio-ventricular valve; only in one case the atria connected to the ventricles through two distinct atrioventricular valves. The univentricular hearts in most cases (22) were, angiographically, of indeterminate type. The interventricular relationship was normal (left ventricle posterior and to the left) in 6 of the 8 biventricular hearts.(ABSTRACT TRUNCATED AT 250 WORDS)     

Aggressive surgical resection for hepatocellular carcinoma with tumor thrombus extending to inferior vena cava and synchronous pulmonary metastasis

We describe a 66-year-old man having hepatocellular carcinoma with tumor thrombus extending into the inferior vena cava and synchronous pulmonary metastasis. He was referred to Chiba University Hospital on May, 2000, complaining of emaciation. Radiological findings showed a huge hepatocellular carcinoma in the entire right lobe and tumor thrombus extended into the intrapericardial inferior vena cava. He also had a solitary pulmonary metastasis in the left pulmonary lobe (stage IVB). Right hemihepatomy was performed under total hepatic vascular exclusion without cardiopulmonary bypass, and tumor thrombus was completely removed. Thoracoscopic wedge resection of pulmonary metastasis was also performed. The patient had an uneventful postoperative course. Histopathological examination revealed that the tumor was moderately differentiated hepatocellular carcinoma The patient is still alive after 26 months with pulmonary recurrence, but without hepatic recurrence. To our knowledge, there has been no reported case of resection for both hepatocellular carcinoma invading the inferior vena cava and synchronous pulmonary metastasis. In conclusion, aggressive surgical resection for advanced hepatocellular carcinoma concomitant with pulmonary resection may bring about better prognosis in highly selected patients.     

Echocardiographic study of an intravenous leiomyoma: case report and review of the literature

Intravenous leiomyoma is a rare tumor of smooth muscle with invasion to veined channels that affects women at reproductive age. The case of a 45-year-old woman is described, with history of oophorectomy and hysterectomy, in addition to abdominal surgery due to mesenteric tumor. Several months later, the patient developed syncope and dyspnea secondary to pulmonary embolism. Echocardiographic study reported a mass in right side of heart proceding from inferior vena cava. The patient underwent tumor surgical resection from left iliac vein and histologic study concluded intravascular leiomyomatosis.     

Surgical correction of isolated persistent left superior vena cava draining to left atrium in a neonate.

A one day old baby who presented with cyanosis was later shown to have an isolated persistent left superior vena cava draining into the left atrium with hypoplastic right superior vena cava. This extremely rare anomaly was diagnosed by cardiac catheterisation at one week. Surgical correction at two weeks, by anastomosis of the innominate vein to the right atrium and by ligation of the left superior vena cava at its junction with the left atrium, was successful. This patient is the youngest case in which successful surgical correction of this isolated anomaly has been reported.     

Surgical correction of isolated persistent left superior vena cava draining to left atrium in a neonate

A one day old baby who presented with cyanosis was later shown to have an isolated persistent left superior vena cava draining into the left atrium with hypoplastic right superior vena cava. This extremely rare anomaly was diagnosed by cardiac catheterisation at one week. Surgical correction at two weeks, by anastomosis of the innominate vein to the right atrium and by ligation of the left superior vena cava at its junction with the left atrium, was successful. This patient is the youngest case in which successful surgical correction of this isolated anomaly has been reported.     

Uterine hemangiopericytoma with cardiac involvement and pulmonary metastasis: A case report and literature review

Uterine hemangiopericytoma is extremely rare. This article describes a case of uterine hemangiopericytoma. The tumor involved the parauterine vein; extended into the inferior vena cava, right cardiac cavity, and pulmonary artery; and metastasized to the lungs. It was irregular in shape and exhibited the string-of-beads sign on echocardiography, and it was tightly attached to the right ventricular surface and pulmonary artery wall. The patient underwent tumor resection without adjuvant treatment. A pelvic nodule was found 3 months postoperatively and was considered a recurrent lesion.     

A rare association recognized before cardiac surgery: persistent left superior vena cava and secundum atrial septal defect

One of the most common congenital anomalies of systemic veins is persistent left superior vena cava. Association of persistent left superior vena cava with other congenital cardiac diseases is common and frequently encountered during diagnostic studies. Contrast echocardiography has an important role in the diagnosis. Owing to the fact that cardiopulmonary by-pass procedure may be problematic in patients with persistent left superior vena cava, this anomaly should be detected before cardiac surgery and required measures should be taken. Our case is an association of persistent left superior vena cava detected in a patient to be operated for secundum atrial septal defect. We report the case owing to its low frequency and to emphasize the importance of detection before cardiac surgery.     

Transesophageal echocardiography in the detection of inferior vena cava and cardiac metastasis in hepatocellular carcinoma

Antemortem diagnosis of inferior vena cava (IVC) and cardiac metastasis of hepatocellular carcinoma (HCC) is difficult but important before consideration of curative resection. There are only a few cases of cardiac metastasis of HCC which have been diagnosed antemortem by echocardiography. Accordingly, 18 consecutive patients with HCC who were potential candidates for curative resection were studied by transthoracic (TTE) and transesophageal echocardiography (TEE). One (6%) and two (11%) patients had cardiac and IVC metastasis of HCC, respectively, which was detected by two-dimensional TTE. In contrast, by using TEE, four patients (22%) showed tumor invasion of the IVC, of whom two (11%) had tumor mass extending into the right atrium (RA). There was no significant difference in age, serum level of alpha-fetoprotein, and percentage of right liver lobar involvement between those with and without cardiac metastasis. Patients without cardiac metastasis detected on TTE or TEE had significantly longer mean duration of survival (5.0 ±2.1 vs. 2.1 ± 1.0 months; p < 0.05). In summary, TEE may be more useful than TTE in the detection of cardiac metastasis of HCC, which occurred in 22% of patients whose primary tumor was considered to be surgically resectable in our series. This can be safely performed in patients with HCC and can provide optimal visualization of the IVC and RA. The high prevalence of subclinical cardiac metastasis in HCC mandates the use of TEE in all patients with HCC prior to surgical intervention.     

Clinical features and imaging diagnosis of biliary cystadenocarcinoma of the liver

Biliary cystadenocarcinoma of the liver is a relatively rare disease. Herein, we reported a case of biliary cystadenocarcinoma with a review of the literature. A 71-year-old female was admitted with the chief complaint of epigastralgia. The imaging studies revealed a biliary cystadenocarcinoma in the left hepatic lobe with suspicion of direct invasion to the left and middle hepatic veins and inferior vena cava. However, there was no direct invasion of the tumor to these veins in operation findings, and an extended left hepatic resection was performed without resection of inferior vena cava. The tumor was histologically diagnosed as biliary cystadenocarcinoma of the liver. Diagnosis of biliary cystadenocarcinoma is usually difficult preoperatively, however, a diagnosis was possible with the use of imaging studies. It was suggested that this tumor originated from a benign cystadenoma because of the existence of a transitional zone between normal cells and atypical cells in the cystic wall. Systematic hepatectomy was recommended as the initial treatment in consideration of the features of cystadenocarcinoma.     

The Role of Myocardial Contrast Echocardiography to Assess the Origin of a Mass in Right Cardiac Cavities

We report the case of a patient with hepatocellular carcinoma who was admitted to our hospital with fatigue and edema of lower extremities. Transthoracic echocardiographic examination revealed a mobile echogenic cavoatrial mass that infiltrated the inferior vena cava and extended along the vessel protruding into the right cardiac cavities. The differential diagnosis included a tumor mass originating from the liver and subsequently infiltrating the inferior vena cava and extending into the right cardiac cavities or a large thrombus formed on the tumor mass that infiltrated the inferior vena cava.     

Intravenous leiomyomatosis extending into the right ventricular cavity: one-stage radical operation using cardiopulmonary bypass--a case report

The authors describe a 47-year-old woman with intravenous leiomyomatosis (IVL) extending into the right ventricular cavity. This rare entity is a neoplasm originating from smooth muscle of the uterus, with vermiform extensions into the inferior vena cava. The patient underwent a one-stage operation under simultaneous sternotomy and laparotomy, and radical excision of the tumor was successfully achieved with use of normothermic cardiopulmonary bypass. Although this tumor is histologically benign, it sometimes extends into the cardiac cavity and causes sudden death due to incarceration into the atrioventricular orifice. Moreover, recurrence or lung metastasis of IVL has been reported. The authors recommend a one stage-radical resection of the tumor or a two-staged operation within a short interval. In the literature, 24 surgical cases of the intravenous leiomyomatosis with intracardiac extension have been reported. The diagnosis and surgical treatment of this tumor are reviewed and discussed.     

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.