Transcatheter Arterial Embolization for Spontaneous Rupture of Hepatocellular Carcinoma

For the last 6 yr, we had 47 cases of spontaneous rupture of hepatocellular carcinoma causing hemorrhage into the peritoneal cavity. Thirty-three cases were treated by supportive care and 14 cases by emergency transcatheter arterial embolization. Fourteen cases underwent emergency transcatheter arterial embolization and abdominal pain developed in 71.4%, shock in 50.0% and bloody ascites in all cases and the hematocrit of bloody ascites ranged between 1.0% and 40%. On hepatic angiogram, the mean tumor extent rate was 47.9% and the extravasation of the contrast material was noted in 35.7%. The mean survival time of 14 cases that underwent emergency transcatheter arterial embolization was 98.5 days and 13.0 days in 33 cases with supportive care. The former was significantly longer than the latter.     

Spontaneous Rupture of the Spleen Secondary to Metastatic Hepatocellular Carcinoma: A Report of a Case and Review of the Literature

An extremely rare case of splenic rupture at the site of metastasis of hepatocellular carcinoma is reported. A 62-yr-old woman with hepatocellular carcinoma and its suspected metastasis to the spleen died of intraperitoneal hemorrhage. Autopsy disclosed a laceration of the spleen as the definitive cause of the hemorrhage. There were multiple nodules of metastatic hepatocellular carcinoma in the spleen, some of which were exposed at the lacerated portion of the splenic capsule. This may be the first report of a case of spontaneous rupture of the spleen secondary to metastatic hepatocellular carcinoma. Splenic rupture can he one of the causes of hemoperitoneum in patients with hepatocellular carcinoma.     

Spontaneous Regression of Hepatocellular Carcinoma

Spontaneous regression of cancer is a rare phenomenon seldom described in patients with hepatocellular carcinoma. A case of spontaneous regression of liepatocellular carcinoma is reported and compared with the reports published in the English literature. A 52-yr-old man presented with biopsy-proven hepatocellular carcinoma, which was considered to he unresectable at initial laparotomy. The tumor subsequently regressed without specific treatment, as assessed radiologically and by normalization of a previously elevated α-feto protein level. At repeat laparotomy 14 months after initial diagnosis, intraoperative ultrasound failed to disclose a hepatic mass, and multiple biopsies showed no evidence of malignancy. To date, only nine case reports of apparently spontaneous regression of hepatocellular carcinoma have been published in the English literature. Clinical characteristics discriminating these patients from less fortunate patients with hepatocellular carcinoma could not be identified. The mechanisms underlying this intriguing phenomenon remain unknown.     

Spontaneous Regression of Hepatocellular Carcinoma

We report a 65-yr-old man with hepatitis B virus-related liver cirrhosis and biopsy-proven hepatocellular carcinoma who has undergone spontaneous regression. The tumor became impalpable, and was no longer detectable by ultrasonography and computed axial tomography, 5 and 30 months later. The alpha-fetoprotein level also decreased to normal range. The clinical course is silent, and the patient is alive and well 37 months after the initial diagnosis.     

Sorafenib for Treatment of Hepatocellular Carcinoma: A Systematic Review

Background  

Sorafenib, a drug that inhibits Raf serine/threonine kinases mediating cell proliferation and receptor tyrosine kinases involved in angiogenesis, is approved for treatment of advanced hepatocellular carcinoma.     

Utilization of Hepatocellular Carcinoma Surveillance Among American Patients: A Systematic Review

BACKGROUND

Although surveillance for hepatocellular carcinoma (HCC) is recommended in high-risk patients, several studies have suggested it is being underutilized in clinical practice. The aim of our study was to quantify utilization rates for HCC surveillance among patients with cirrhosis and summarize patterns of association between utilization rates and patient socio-demographic characteristics.

DATA SOURCES

We performed a systematic literature review using the Medline database from January 1990 through March 2011 and a manual search of national meeting abstracts from 2008?C2010.

METHODS

Two investigators independently extracted data on patient populations, study methods, and results using standardized forms. A pooled surveillance rate with 95% confidence intervals was calculated. Pre-specified subgroup analysis was performed to find correlates of surveillance utilization.

RESULTS

We identified nine studies that met inclusion criteria. The pooled surveillance rate was 18.4% (95%CI 17.8%?C19.0%). Surveillance rates were significantly higher among patients followed in subspecialty gastroenterology clinics compared to those followed in primary care clinics (51.7% vs. 16.9%, p?CONCLUSIONS Utilization rates for HCC surveillance are low, although they are significantly higher among patients followed in subspecialty clinics. Current studies fail to determine why HCC surveillance is not being performed. Future efforts should focus on identifying appropriate intervention targets to increase surveillance rates and reduce socio-demographic disparities.     

Persistently Rising Alpha-fetoprotein in the Diagnosis of Hepatocellular Carcinoma: A Review

Hepatocellular carcinoma (HCC), one of the most common malignant tumors worldwide, is known for its grim prognosis, with untreated life expectancy being only a matter of months after the diagnosis. The difficulty in making a diagnosis early is one of the main contributing factors to the poor prognosis. Alpha-fetoprotein (AFP) had long been used as a surveillance tool, but suboptimal specificity and sensitivity has prompted liver societies to abandon the recommendation for its universal use, even in combination with ultrasonography. Most studies have shown no obvious correlation between serum AFP level and HCC tumor size, stage, or survival post-diagnosis. However, some studies concluded that a gradual rise or persistent elevation in AFP were positive predictors for tumor development. Other studies reported a fall in AFP followed by a rise in patients with HCC as well as persistently rising AFP levels without development of HCC on follow up. Our calculation of the sensitivity and specificity of persistently rising AFP for HCC were both low, at 60% and 35.8%, respectively, indicating that the presence of persistently rising AFP per se did not offer diagnostic benefit. In addition, our calculated mean slopes of persistently rising AFP levels in HCC and non-HCC patients were numerically very different, but the difference was not statistically significant. We conclude that the published data do not support a role for rising AFP levels per se in the diagnosis of HCC.     

CASE REPORT: Spontaneous Gas-Forming Liver Abscess Caused by Salmonella Within Hepatocellular Carcinoma: A Case Report and Review of the Literature

In conclusion, pyogenic liver abscess in hepatocellular carcinoma is unusual. Most of the reported cases occurred after a treatment such as transcatheter arterial embolization or percutaneous ultrasound-guided ethanol injection. Salomonella very rarely causes pyogenic liver abscesses. Only 14 cases have been reported in the English literature since 1911. Salmonella liver abscess occurring within a primary neoplasm is even rarer. There were only two such cases described in patients with hepatocellular carcinoma before. The present case is the third one, but it may be the first case of obvious spontaneous gas-forming liver abscess caused by Salmonella within hepatocellular carcinoma.     

Two Cases of Intraabdominal Bleeding Caused by Hepatocellular Carcinoma Rupture Soon after the Initiation of Chemotherapy with Lenvatinib

We herein report two patients with hepatocellular carcinoma (HCC) who exhibited intraabdominal bleeding caused by tumor rupture soon after lenvatinib initiation. A hypervascular nodule was present in the lateral segment manifesting extrahepatic protrusion in an 81-year-old-man and in the caudate lobe, which was completely occupied by the tumor, in an 83-year-old-man. Both patients were given lenvatinib, and epigastralgia occurred suddenly three and five days later. Computed tomography revealed high-attenuation areas suggesting bleeding around the left and caudate lobes. Considering the strong antiangiogenic effects by lenvatinib, transcatheter arterial embolization should be performed before lenvatinib initiation in patients with subcapsular HCC.     

Rupture of Hepatocellular Carcinoma as a Result of Blunt Abdominal Trauma

Spontaneous rupture of hepatocellular carcinoma occurs frequently in populations in which this tumor is common, but rarely in populations with a low incidence of the tumor. Rupture caused by blunt abdominal trauma has previously been reported in a single patient only. We describe three southern African black men who presented with an acute hemoperitoneum after blunt trauma to the abdomen, and in whom a moderate-size hepatocellular carcinoma was found at laparotomy to have ruptured. In two of the patients, it was possible to resect the tumor. This resectability rate is unusual in blacks with hepatocellular carcinoma, because the tumor is characteristically far advanced at the time of presentation and is rarely amenable to resection.     

Superficial Esophageal Carcinoma: A Clinicopathological Review of 59 Cases

During the period from 1975 to 1989, a total of 59 patients with superficial esophageal carcinoma (SEC) were operated on in our Surgical Clinic. Forty patients of the 59 (68%) had been treated during the previous 5 yr. Although 22 patients (37%) complained of slight esophageal symptoms, 12 patients had only symptoms unrelated to esophageal disease, and 25 patients were asymptomatic. In the latter patients, the lesion was found by chance at the time of screening or follow-up examination of upper gastrointestinal tract disease. Endoscopy was very useful for the diagnosis of SEC, and Lugol's solution staining technique was an effective adjunctive means. The lesions in about half of the patients were initially diagnosed by endoscopy in our series. Radiologic diagnosis of the lesions confined to the mucosal epithelium or lamina propria was particularly difficult. Lymph node metastasis was not observed in patients with intraepithelial or mucosal carcinoma. However, the metastasis was demonstrated in 18 of 38 patients (47%) with submucosal invasion. The 5-yr survival rate of patients with SEC was 73%, which was significantly superior to that of patients with advanced esophageal carcinoma (26%). Since the prognosis for the patients with submucosal invasion and lymph node metastasis was poor, we should be enthusiastic about extended lymph node dissection in the surgical treatment for patients in whom submucosal invasion is suspected.     

Muscular Metastasis of Hepatocellular Carcinoma: Case Report and Literature Review

There are few case reports of hepatocellular carcinoma (HCC) metastasis to the skeletal muscle. A 78-year-old man developed a mass in the right shoulder. Washout of contrast medium during contrast-enhanced ultrasonography (CEUS) in both the primary HCC and the metastatic site was detected. Several nodules were scattered throughout the liver on an autopsy. In addition, the moderately differentiated HCC had metastasized to the right teres major muscle. Rare muscular metastasis should be considered if a hepatic tumor is moderately or poorly differentiated HCC. Early washout during CEUS is consistent with a pathological diagnosis of moderately or poorly differentiated HCC.     

Successful Transcatheter Arterial Embolization for Hemothorax from a Spontaneous Rupture of Hepatocellular Carcinoma Metastasis to the Chest Wall in an Elderly Patient

An 87-year-old man with hepatocellular carcinoma (HCC) presented with right-sided chest pain. Computed tomography revealed right bloody pleural effusion and an extravasation from an arterially enhanced mass in the right seventh posterior intercostal space. These findings indicated hemothorax from a rupture of HCC metastasis to the chest wall. Angiography of the intercostal arteries confirmed a hypervascular tumor, and transcatheter arterial embolization resulted in hemostasis. He was discharged with palliative care and remains alive after 9 months. Although hemothorax represents an unusual, life-threatening complication of HCC, our case suggests that transcatheter treatment can achieve hemostasis and a favorable survival even in elderly patients.     

Cloacogenic Carcinoma: A Study of Six Cases and Review of Literature

A clinicopathological study of six cases of cloacogenic carcinoma and review of the literature was undertaken. These tumors arise from transitional epithelium of the pectinate line. The tumors are often deceptive in the beginning and may often resemble small abscesses, fissures, or fistulas. Often they appear outside the mucosa and skin. Histologically, they are well, moderately, or poorly differentiated. Local excision is adequate for small noninfiltrating tumors. Pelvic radiation, combined with surgery for lesions greater than 2 cm with local extension and/or pelvic nodes, controls the pelvic disease. Well and moderately differentiated tumors have a better prognosis than squamous cell carcinoma. Overall survival rate is approximately 50%. Cure rate depends on the size of the lesion, differentiation of tumor, depth of invasion, duration of the symptoms, nodal involvement, lymphatic or vascular invasion, and contiguous organ invasion. Cloacogenic carcinoma is a better term than other names used in the literature for this tumor.     

Spontaneous Regression of a Large Hepatocellular Carcinoma with Multiple Lung Metastases

A 75-year-old Japanese man with chronic hepatitis C was found to have a large liver tumor and multiple nodules in the bilateral lungs. We diagnosed the tumor as hepatocellular carcinoma (HCC) with multiple lung metastases based on imaging studies and high titers of HCC tumor markers. Remarkably, without any anticancer treatment or medication, including herbal preparations, the liver tumor decreased in size, and the tumor makers diminished. Moreover, after 1 year, the multiple nodules in the bilateral lungs had disappeared. Fifteen months after the first medical examination, transcatheter arterial chemoembolization (TACE) was performed for the residual HCC. Because local relapse was observed on follow-up computed tomography, a second TACE was performed 13 months after the first one. At 4 years after the second TACE (7 years after the initial medical examination), there was no recurrence of primary or metastatic lesions. Spontaneous regression of HCC is very rare, and its mechanism remains unclear. Understanding the underlying mechanism of this rare phenomenon may offer some hope of finding new therapies, even in advanced metastatic cases.