Less aggressive features of colorectal cancer with liver metastases showing macroscopic intrabiliary extension

We have previously reported the frequent occurrence of bile duct invasion by liver metastases from colorectal cancer. We found that patients with macroscopic intrabiliary cancer growth survive longer after hepatectomy than those without this feature. In the present study, we analyzed the clinicopathological features of primary colorectal cancer showing macroscopic intrabiliary extension of liver metastases. We reviewed 217 patients who underwent initial hepatic resection for colorectal liver metastasis between 1992 and 1998, and analyzed the corresponding primary colorectal cancers clinicopathologically. Microscopic bile duct invasion was found in 89 of 217 cases (40.6%) and, of these cases, 23 (10.6%) had macroscopic intrabiliary extension. Histological sections of the corresponding primary colorectal cancer were available in eight (group A) of these 23 cases. These were compared with 20 cases, selected randomly, of colorectal cancer that did not show bile duct invasion and were diagnosed as liver metastases. These patients underwent hepatectomy during the same period as group A and were used as a control (group B). The histology of the primary tumors revealed well-differentiated adenocarcinoma in 100% of group A and in 25% of group B. The average maximum diameter of the primary tumor was 5.32 cm in group A and 3.61 cm in group B. Venous invasion was detected in 25% of group A and in 90% of group B (P < 0.01), while the incidences of lymphatic vessel invasion and lymph node metastases were similar between the groups. These data suggest that macroscopic intrabiliary extension could be a good indicator of a unique subgroup of colorectal cancers showing less aggressive features even though they develop liver metastases. Careful histological evaluation is important even for metastatic tumors.     

A case of rectal metastatic tumor in the soft tissue of the hand.

Hand metastases occur infrequently, and metastatic tumors in the soft tissue of the hand caused by rectal cancer are extremely rare. We report a case here. The patient was a 76-year old man. He underwent Miles operation for rectal cancer located in the lower portion of the rectum. Histopathologically, the resected specimen showed well-differentiated adenocarcinoma. Six years postoperatively, a tumor involving the soft tissue of the palma was found in his left hand. The tumor was resected, and pathological examination showed a well-differentiated adenocarcinoma similar to the primary rectal carcinoma. Immunohistochemical examination demonstrated that this hand tumor had metastasized from rectal cancer. Fifteen cases of colorectal metastatic tumors in the hand have been documented, of which three were soft-tissue metastases. This report describes the fourth case.     

Intraductal papillary neoplasm arising from peribiliary glands connecting with the inferior branch of the bile duct of the anterior segment of the liver

Intraductal papillary neoplasms of the bile duct are generally thought to arise from neoplastic papillary proliferation of epithelial cells lining the bile duct. We herein report a case with findings that strongly suggested that the biliary cystic tumor might have derived from a peribiliary gland. A 69-year-old female was found to have a cystic lesion with intracystic protrusions at the anterior segment of the right hepatic lobe and underwent hepatic anterior segment resection. Fluoroscopy of the resected specimen injected with contrast medium into the cyst revealed a connection between the cystic lesion and the bile ducts. The cyst was multilocular in appearance. On microscopic examination, the cyst was located within the portal tract of the inferior branch of the anterior segment and connected with the inferior branch of the bile duct. The wall of the hepatic cyst lacked an ovarian-like stroma. The tumor was composed of papillary and glandular components, and the tumor cells were similar to gastric foveolar and pyloric gland epithelia and regarded as adenoma. These tumor cells were positive for MUC 5AC, MUC6, and HIK1083. The tumor was finally diagnosed as an intraductal papillary neoplasm of the bile duct (adenoma, gastric type) arising from a peribiliary gland.     

肝脏第IX段临床应用解剖及恶性肿瘤的介入栓塞化疗

目的探讨肝脏第IX段临床应用解剖及其占位性病变的介入治疗。方法对50例肝脏进行解剖观察;对6例肝脏第IX段占位性病变进行介入栓塞化疗。结果肝脏第IX段动脉主要来源于肝右动脉,部分来自肝中动脉或肝左动脉;门静脉主要来自门静脉右前叶上段支,小部分来自门静脉左支横部;胆管汇入右肝管;静脉血由数支细小静脉经第3肝门直接汇入肝后下腔静脉,部分汇入肝右静脉。第IX段肝脏肿瘤通过血管介入治疗后,肿瘤显著缩小;其中4例合并黄疸患者肝功能明显缓解。结论肝脏第IX段是一个结构上较为独立的区域,有其特殊的管道系统和引流系统,位置深隐,单独或联合手术切除较困难;通过介入技术可以对该区段进行相应的治疗。利用微导管采用超选技术,可以对肝脏第IX段的病变进行精确的治疗,微创、副作用小、可重复操作,能够弥补外科手术的局限性,达到甚至超过外科手术的治疗效果。     

Histologic diagnosis of hepatic tumors

Many types of tumors, benign and malignant, primary and metastatic, can occur in the liver. Diagnostic criteria for two relatively common and two uncommon primary malignant liver tumors are presented. Hepatocellular carcinoma, the most common primary malignant hepatic tumor, is recognized when the tumor cells show features of liver cell differentiation, such as a trabecular growth pattern, intercellular bile canaliculi, eosinophilic granular cytoplasm, bile production or other hepatic synthetic products. Intrahepatic cholangiocarcinoma shows glandular differentiation, similar to other adenocarcinomas. It often cannot be distinguished from metastatic adenocarcinoma, and the diagnosis requires the exclusion of an extrahepatic primary site. Undifferentiated (embryonal) sarcoma is a rare primary liver tumor of children and young adults. It shows undifferentiated stellate and spindle cells in a myxoid matrix. Hepatic angiosarcoma is a malignant endothelial cell proliferation, beginning in the hepatic sinusoids, eventually filling the vascular structures, and often progressing to tumorous vascular masses. The histologic diagnosis of all types of liver tumors requires the application of strict morphologic criteria to light microscopic observations. Diagnoses that do not conform to such criteria are often inaccurate.     

Hepatic angiomyolipoma with a giant hemangioma

Hepatic angiomyolipoma is a rare hepatic mesenchymal tumor. We report a case of hepatic angiomyolipoma that was successfully resected along with a giant hemangioma. A 53-year-old Japanese woman was admitted to our hospital for further evaluation of a liver tumor in segment 4. The tumor was detected on positron emission tomography during a health check-up. Abdominal ultrasonography revealed a well-defined mass of mixed echogenicity, 1.5 cm in diameter, in segment 4, and a giant hemangioma of mixed echogenicity, 7 cm in diameter, in segment 7. On enhanced computed tomography, the tumor in segment 4 showed hyperattenuation in the early phase and hypoattenuation in the delayed phase. On magnetic resonance imaging, the tumor in segment 4 showed hypointensity on T1-weighted images, hyperintensity on T2-weighted images, and hyperintensity on diffusion-weighted images. On angiography, the tumor in segment 4 appeared as a circumscribed hypervascular mass in the early phase and a slightly hypovascular mass in the delayed phase. The imaging findings suggested a primary hepatocellular carcinoma. The patient consented to resection of the tumor in segment 4 along with the giant hemangioma in segment 7. These tumors were resected with tumor-free surgical margins by partial resection of segments 4 and 7 of the liver. The cut surface of the resected specimen of segment 4 showed a yellowish tumor consisting of mature adipose tissue. The histopathological diagnoses of the resected specimens were angiomyolipoma in segment 4 and cavernous hemangioma in segment 7. The tumor in segment 4 consisted of mature lipocytes with angiomatous and small lymphocytic components, but no mitotic figures. The tumor showed immunoreactivity to smooth muscle antigen and homatropine methylbromide 45 and no immunoreactivity to AE/E3. The postoperative course was uneventful, and the patient remains well 1 year after the operation.     

Primary malignant gastrointestinal stromal tumor of the liver

We report the case of a malignant, primary, hepatic gastrointestinal stromal tumor (GIST) that was resected from the liver of a 79-year-old woman. To our knowledge, this is the first primary, hepatic GIST on record. The tumor expressed CD117 (c-Kit protein) and vimentin and had the ultrastructural features of GISTs. Sixteen months after partial hepatectomy and resection of the tumor, a hilar lymph node metastasis was found. The metastatic tumor had the same morphologic features as the primary tumor, but in addition it contained numerous multinucleated giant cells. This case shows that GIST can occur as a primary liver tumor, and accordingly, we point out that not all hepatic tumors with a GIST phenotype should be automatically considered to be metastases from a primary gastrointestinal site.     

Case of rectal malignant melanoma showing immunohistochemical variability in a tumor.

We report on a patient with rectal malignant melanoma. The patient was a 40-year-old man who complained of anal bleeding. His grandmother had died of pancreatic cancer and his mother had been operated for rectal cancer. Physical examination revealed a hard mass at the 12 o'clock position, 2 cm from the anal verge. A colonoscopic examination revealed an irregular surface mass, approximately 4.0 cm in size, located on the anterior wall of the lower rectum. A biopsy of the rectal tumor showed the proliferation of epithelioid cells with pleomorphic features. Immunohistochemical analysis was performed. S-100 protein, CD-56, and KIT expression were positive, but HMB-45 expression was negative. Abdominopelvic computed tomography (CT) revealed multiple liver and lymph node metastases. With the diagnosis of neuroendocrine carcinoma of the rectum, abdominoperineal resection was performed. After the operation, the serum lactate dehydrogenase level had rapidly increased. An abdominal CT showed progressive liver metastases. Thirteen days after the surgery, abdominal angiography was performed, which showed multiple hypervascular tumor stains in the liver. The reservoir was implanted transcutaneously with the aid of angiography and the catheter was fixed to the proper hepatic artery. Neoadjuvant chemotherapy using cisplatin and irinotecan via the subcutaneous reservoir port was performed and a partial response was obtained. However, the final pathological diagnosis of the surgically resected specimen was malignant amelanotic melanoma of the rectum. Immunohistochemical expression differed between rectal biopsy specimens and surgically resected specimens. HMB-45 expression was positive and KIT expression was negative in the resected specimen. As preoperative pathological diagnosis showed rare rectal tumor, we measured the chemosensitivity of the rectal tumor using the collagen gel droplet-embedded culture drug sensitivity test (CD-DST) to determine the most appropriate chemotherapy regimen for the patient. However, there were no anticancer drugs tested by CD-DST for malignant melanoma. With informed consent, the patient received two cycles of immunochemotherapy consisting of dacabazine, nimustine hydrochloride, vincristine sulfate, and interferon -beta. Although the patient was treated with immunochemotherapy for metastatic liver tumor, he died because of progression of metastases.     

Marked infiltration of eosinophils in necrotizing granulomas in the resected hepatic bed after cholecystectomy resulting from gallbladder cancer and metastatic liver cancer is associated with peculiar peripheral eosinophilia

It is known that after transurethral resection of the prostate (TUR-P) or a bladder tumor (TUR-BT), necrotizing granuloma formation associated with massive eosinophil accumulation can be detected at the site of the scar, revealing marked eosinophilia. This condition is called post-TUR prostatitis or cystitis. In the present study, we noticed a similar phenomenon in five patients who underwent cholecystectomy, of whom four had gallbladder adenocarcinoma and one had metastatic liver cancer originating from the rectum. We detected necrotizing granulomas with massive eosinophil accumulation, associated with marked eosinophilia. To induce these phenomena, the interval between the first operation (i.e., cholecystectomy) and the second operation (i.e., resection of the hepatic bed and extrahepatic bile duct) is very important. If the interval was 1 week, no granuloma formation was detected. On the other hand, if it was more than 2 weeks, the resected hepatic bed contained necrotizing granulomas with substantial eosinophil accumulation combined with an increase in peripheral eosinophilia (up to 34% in one case). Secondary resection was necessary to induce eosinophilia after cholecystectomy. In this sense, malignancies possessed a relationship with delayed eosinophilia. In the granulomas, some foreign body-type multinucleated giant cells were positive for both anti-interleukin (IL)-5 and CD68 antibodies. In sharp contrast, no eosinophilia was detected after cholecystectomy, with or without hepatic resection consequent to severe adhesion. Clinicians as well as pathologists should keep in mind that these peculiar phenomena of eosinophil accumulation surrounding the necrotizing granulomas and peripheral eosinophilia after cholecystectomy could occur.     

Well-differentiated adenocarcinoma, gastric foveolar type, of the extrahepatic bile ducts: A previously unrecognized and distinctive morphologic variant of bile duct carcinoma

Two examples of a rare but distinctive morphologic variant of extremely well-differentiated adenocarcinoma of the extrahepatic bile ducts are reported. One tumor arose in the common bile duct of a 51-year-old man; the other arose in the common hepatic duct of a 27-year-old man. Both tumors were composed predominantly (>95%) of gastric foveolar-type epithelium. Because of their bland nuclear features, low mitotic index, and focal polypoid and lobular architecture, they were initially confused with adenomas. Foci of less-differentiated adenocarcinoma and perineural invasion present in the deep portions of the tumors facilitated recognition. The neoplastic cells and extracellular mucin were periodic acid-Schiff- and alcian blue-positive. By immunohistochemistry, the tumor cells expressed cytokeratins 8 and 20 as well as cathepsin D, as reported in normal foveolar cells. Likewise, p53 overexpression was documented immunohistochemically in both adenocarcinomas, which also stained with the Ki-67 antibody. Despite the well-differentiated nature of the neoplasms and their deceptively benign microscopic appearance, one patient developed recurrence and liver metastasis 5 years after surgery. The other patient is disease-free 2 years following a segmental resection of the common hepatic duct, cystic duct, and gallbladder. The cell phenotype of these tumors can be explained by the ability of the bile duct epithelium to differentiate along gastric cell lines.     

Anatomie und Pathologie des intrahepatischen und extrahepatischen Gallengangskarzinoms

Adenocarcinomas of the intra- and extrahepatic bile ducts are rare tumors that begin with malignant transformation of the bile duct epithelia. Intrahepatic cholangiocarcinomas derive from the small bile ducts located proximally to the right and left hepatic ducts. Extrahepatic bile duct carcinomas originate in the right or left hepatic duct, the cystic duct, or the choledochal duct. Tumors located at the bifurcation are called Klatskin tumors. The intrahepatic cholangiocarcinomas are classified according to the TNM classification of liver tumors, while the extrahepatic bile duct tumors have their own TNM classification. Several factors, accompanied by a chronic inflammatory reaction, have been discussed in the etiopathogenesis of these tumors: schistosomiasis, ulcerative colitis with primary sclerosing cholangitis, and inborn bile duct cysts of the liver as a consequence of a disturbance of the ductal plate formation. Over 95% of bile duct tumors are adenocarcinomas. In the nomenclature of precursor lesions a two-grade classification of dysplasia (low-grade versus high-grade) has been found to be more reproducible.     

Cholangiocarcinoma arising in bile duct adenoma with focal area of bile duct hamartoma

A 59-year-old male with history of sigmoid colon cancer had a high serum-CEA level and was referred for the evaluation of metastatic liver disease. Ultrasonography and computerized tomography showed two tumours in the liver. Macroscopically, these were in segment 4 (S4) and 2 (S2). Histologically, the tumour in S4 showed a number of bile ductules with variable amounts of stroma, an appearance compatible with bile duct adenoma (BDA). There were markedly atypical ductules of various sizes, the epithelium of which had coarsely granular/hyperchromatic large nuclei, in some areas of the lesion. These atypical ductules showed invasive growth into the liver parenchyma. Some cystically dilated ductules with bile plugs resembling bile duct hamartoma (BDH) were also seen. The other tumour in S2, was a metastatic adenocarcinoma from sigmoid colon and showed strongly positive staining for CEA. Since the lesion in S4 of our case is solitary and most of histological features are similar to those of BDA with markedly atypical bile ductules, we consider that this may be the first case of cholangiocarcinoma associated with BDA with focal area of BDH. It is possible that the adenoma-carcinoma sequence occurs in biliary tumours.     

An unusual cause of multiple hepatic cysts

A metastatic hepatic process, generally arising from a primary tumor of the gastrointestinal tract, is a common cause of multinodular and/or multicystic liver. If the primary tumor remains unknown in spite of complete and exhaustive explorations, it might be useful to re-evaluate the benign nature of previously resected tumors. We report the case of a 37 year-old woman who presented a multicystic metastatic liver related to a nasal cylindrical cell carcinoma resected 4 years earlier and diagnosed initially "inverted papilloma". Cylindrical cell carcinoma also called "transitional carcinoma" or "schneiderian carcinoma" is rare with only a few cases reported in the literature. Metastases occur generally in the lungs and no previous reported cases mention secondary hepatic location.     

An approach to fine-needle aspiration biopsy diagnosis of hepatic masses

After reviewing collection techniques and the cytology of normal and reactive hepatocytes, a systematic approach to the evaluation of fine-needle aspiration biopsy smears of hepatic mass lesions is presented. One of the main problems facing the cytopathologist is the differentiation of cirrhosis from well-differentiated hepatocellular carcinoma. Smears from patients with cirrhosis often contain clusters of bile duct epithelial cells and chronic inflammatory cells, while properly sampled hepatocellular carcinoma smears should contain no bile duct epithelial cells and few inflammatory cells. Key criteria which favor the diagnosis of hepatocellular carcinoma over cirrhosis are: increased nuclear to cytoplasmic ratio, trabecular pattern, and atypical naked hepatocytic nuclei. Key criteria which favor the diagnosis of primary hepatocellular carcinoma over metastatic disease include polygonal cells with centrally placed nuclei, cells separated by sinusoidal capillaries, and bile. This systematic approach to the evaluation of hepatic fine-needle aspiration biopsies must be used with the realization that other uncommon mass lesions of the liver do exist (focal nodular hyperplasia, adenoma, hepatoblastoma, bile duct carcinoma, vascular tumors, mesenchymal tumors, and lymphomas).     

Intraduktale Chemotherapie eines Gallengangskarzinoms mit 5-Fluorouracil

Summary The prognosis of bile duct cancer is still poor. Curative surgical therapy is possible in only 10%–20% of cases. Palliative effects of chemotherapy and radiation are small. Newer palliative techniques like iridium 192 wire radiation or hepatic artery infusion of chemotherapeutic agents seem to be more effective.Another new form of palliative local chemotherapy, intrabiliary application of 5-fluorouracil, is described. A 67-year-old woman with an adenocarcinoma of the left and common hepatic ducts received symptomatic therapy by an external biliaray drainage for 20 months. In the following 3 weeks the amount of drained bile diminished and finally stopped, while icterus occurred. Catheter cholangiography showed a right catheter position, the known obstruction of the common hepatic duct and the left bile duct, and a diffuse right-sided peripheral bile duct occlusion, regarded as multifocal tumor spreading. Intraductal application of 5-fluorouracil via the PTCD tube, 125–375 mg twice a week, effected a rising bile secretion after a few days, to a final volume of 1,000 ml/day. An X-ray control 34 days after start of the therapy showed a nearly complete reopening of the formerly occluded peripheral bile duct system and a filiform reopening of the common hepatic duct with sufficient flowing off into the common bile duct and the duodenum. Certain side effects of this therapy were not noticed. After successful reopening of malignant bile tract occlusion, other palliative therapeutic techniques like internal bile drainage or iridium 192 wire radiation can be applied.

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Abkürzungsvrzeichnis CEA Carcinoembryonales Antigen - ERP Endoskopisch retrograde Pancreaticographie - Gamma-GT Gamma-Glutamyltransferase - GOT Glutamat-Oxalazetat-Transferase - GPT Glutamat-Pyrovat-Transaminase - LDH Lactatdehydrogenase - PTC Percutane transhepatische Cholangiographie - PTCD Percutane transhepatische Cholangiodrainage - TPZ Thromboplastinzeit     

Immunohistochemical detection of bcl-2 protein in normal and pathological human liver.

The bcl-2 protein, which prolongs cell survival by blocking apoptosis, is expressed by progenitor cells in several self-renewing tissues and by tumoral cells in some extrahepatic neoplasms. Because the liver is a slow self-renewing tissue, an immunohistochemical study of the cellular distribution of the bcl-2 protein was performed in normal liver (12 cases), nontumoral hepatic lesions (33 cases), and benign or malignant liver tumors (46 cases). In normal liver, bcl-2 was expressed by bile ductules and small bile duct epithelium, but not by hepatocytes or large bile duct epithelium. In cirrhosis and focal nodular hyperplasia, epithelial cells of the ductular proliferation were bcl-2-positive. Eight of 11 cholangiocarcinomas stained positively for bcl-2, whereas all 15 hepatocellular carcinomas were bcl-2-negative. bcl-2 was also expressed in 6 of 14 metastatic adenocarcinomas. These findings suggest that the ductular cells and small bile duct epithelial cells might have a prolonged survival and might be hepatic progenitor cells. In addition, the bcl-2 protein appears to be a marker of cholangiocarcinoma but not of hepatocellular carcinoma and could help in distinguishing between these two primary liver tumors.     

Tissue polypeptide antigen--a marker antigen differentiating cholangiolar tumors from other hepatic tumors

Twenty-two cases of primary hepatic tumors consisting of 11 hepatocellular carcinomas, 6 cholangiocarcinomas, 3 mixed hepatocellular and cholangiocellular carcinomas, and 2 biliary cystadenocarcinomas together with 8 cases of metastatic adenocarcinoma from various sites were studied by immunoperoxidase technic to demonstrate tissue polypeptide antigen. All of the tumors presumably derived from the epithelial lining of the bile duct, including cholangiocarcinoma, cholangiocarcinomatous portion of the mixed hepatocellular and cholangiocellular carcinoma, and biliary cystadenocarcinoma showed strong positive reaction. The hepatocellular carcinoma and the metastatic adenocarcinoma exhibited negative to weakly positive reactions. These results indicate that TPA can be of use in differentiating bile duct carcinomas from hepatocellular carcinoma and, to a lesser extent, from hepatic metastases of various adenocarcinomas.     

利用微血管铸型技术研究肝外胆管动脉的分布特征

目的　统计分析肝外胆管的血供来源和分布以及在十二指肠上段胆管的吻合动脉链之间的多环形血管网,为胆管外科手术提供临床解剖学理论依据。 方法　以丙烯酸树脂为动脉填充剂灌注6例肝外胆管动脉制备铸型标本,使用photoshop测量法测量微小血管内径,观测和分析肝外胆管的血供来源和分布情况。 结果　肝固有动脉左、右支在肝总管上方存在弓型交通支,十二指肠上段胆管左右边缘的吻合动脉链间有丰富的横向动脉,吻合动脉链的供血约53%来自下方,来自上方的约占46%,1%来自中段肝固有动脉。通过对每条横向动脉中部的内径和两侧起始部的内径测量,发现肝总管中段和上段的横向动脉较粗,中部的平均内径分别为（0.26±0.02）mm和（0.24±0.04）mm,与两侧的内径比也比较大,上段比值最大,为1.09,中段其次,为1,下段中部的平均内径为（0.14±0.03）mm;与两侧的内径比值为0.74。 结论　肝外胆管上、下方的血供来源比例相对均衡;肝外胆管手术应尽可能于动脉吻合相对较少的胆总管十二指肠上段和血管相对较细小肝总管下部做纵行小切口,以降低肝外胆管血供的损伤;肝总管段的血供丰富,支持现行原位肝移植离断部位在胆囊管汇合处上方的主张。     

A method for segmental gross examination of the liver

Segmental localization of hepatic tumours by the pathologists is often approximate. However this information is essential to analyze the impact of preoperative treatments. We describe a new technique for gross examination of the liver, based on hepatic segmental anatomy. After segment I has been resected, sagittal sectioning along the umbilical scissure splits the liver into the left and right lobes. On the left lobe, parenchymal sectioning along the plane of the left hepatic vein separates segment II from segment III. On the right lobe, parenchymal sectioning along the median hepatic vein separates segment IV from the right liver. The right liver is then separated into its four segments once the parenchyma has been cut along the plane of the right hepatic vein and the right portal axis, respectively. We used this technique to examine 387 explanted livers, 214 of wich contained tumors. In 49 cases, pathologic location of the lesions concorded with radiological findings in 92% of cases.     

Hepatic resection of metastatic tumor from serous cystadenocarcinoma of the ovary

Metastatic carcinomas are the largest group of malignant tumors of the liver. But parenchymal liver metastasis from cystic ovarian adenocarcinoma is very rare. We report a case in which the resection of metastatic liver neoplasm from ovarian serous cystadenocarcinoma was done 7 yr after initial treatment. A 48-yr-old oriental housewife complained of easy fatigability and right lower quadrant discomfort. The hepatic mass was detected by ultrasonographic examination. Serum albumin, bilirubin, and aspartate aminotransferase/alanine aminotransferase were normal. Alkaline phosphatase level was slightly increased at 146 IU/L. A tumor marker study showed alpha-fetoprotein 0.97 IU/mL, carcinoembryonic antigen 0.965 ng/mL, cancer antigen 125 1,267 ng/mL and CA 19-9 106.1 ng/mL. The operation involved cholecystectomy and segmentectomy VI and VII of the liver. The patient recovered from the surgery without any complication. On the 10th postoperative day, the patient received a single-regimen chemotherapy with paclitaxel (Taxol, 155 mg/m(2) BSA) and was discharged. She has been carefully followed-up without any evidence of recurrence after completion of the remaining 5 cycles of chemo-therapy, at intervals of three weeks.