Hepatocellular carcinoma metastasis in the pituitary gland: case report and review of the literature

Symptomatic pituitary metastases are uncommon and have been reported mainly in autopsy series. Although all types of malignancies can metastasize to the pituitary gland, a review of the literature has indicated that lung and breast carcinomas are the most frequent primary tumors while hepatocellular carcinoma metastasis has only recently been described.A 59-year-old man with abdominal pain and fever was admitted to our hospital. Hepatosplenomegaly was present without signs of ascites. Laboratory tests showed only abnormal hepatic biochemistry while the radiological studies revealed a solid mass occupying the left hepatic lobe. The patient underwent excision of the left hepatic lobe and was closely followed-up. Six months later he readmitted with headache and visual disturbances. MRI revealed a solid mass in the sella region pressing the optic chiasma. Transsphenoidal excision of the pituitary mass was followed and the histological examination of the tumor was compatible with hepatocellular carcinoma.Symptomatic pituitary metastases are uncommon and may be difficult to differentiate from pituitary adenomas. The present case emphasizes on the capricious nature of hepatocellular carcinoma and on the importance of the individualized therapeutic approach.     

An atypical extrahepatic metastasis of the distal phalanx from hepatocellular carcinoma

A 49-year-old woman presented with severe swelling and pain of the left little finger, which had exacerbated rapidly, in October 2006. The patient had a history of hepatocellular carcinoma and metastatic lung cancer. She had undergone partial hepatectomy for the hepatocellular carcinoma in September 2001 and pulmonary resection for metastatic lung cancer in November 2005. Roentgenogram of the hand on admission showed complete destruction of the distal phalanx of the left little finger. The final pathological result of the tissue obtained by disarticulation was an extrahepatic metastasis of hepatocellular carcinoma. Extrahepatic metastasis from primary hepatocellular carcinoma to the hand is very rare and only four cases have been reported in the literature. All the patients with extrahepatic metastases from the primary hepatocellular carcinoma to the hand had poor prognoses, but the patient presented in this article exhibited an unusual clinical course. The patient is still alive 1 year after the diagnosis of extrahepatic bone metastasis of the distal phalanx.     

A case of brain metastasis from hepatocellular carcinoma

Reported is the case of a patient who underwent surgical resection of a brain metastasis from a hepatocellular carcinoma. The 62-year-old male was admitted to hospital because of headaches and a left hemiparesis. Six years earlier he had undergone transcatheter arterial embolization for a hepatocellular carcinoma. Further, one year ago the lower lobe of his right lung had been resected because of a pulmonary metastasis from the same tumor. A neurological examination on admission revealed disorientation, dressing apraxia, and a left hemiparesis. A CT scan revealed two highly dense masses with peripheral low dense areas in the right temporoparietal region, which were heterogenously enhanced with a contrast medium. Right carotid angiogram showed tumor stains in the same region. Also, a magnetic resonance T1 weighted image showed highly intense masses, and a T2 weighted image showed low intensity masses with prominent brain edema. Thus, a right fronto-temporo-parietal craniotomy was performed, and the two masses were removed. Histological examination revealed hepatocellular carcinoma. The postoperative course was uneventful, and the left hemiparesis improved gradually, enabling the patient to walk without assistance. A brain metastasis from a hepatocellular carcinoma has been rarely reported in the literature since the survival period is very short due to rapid disease progression at the primary site, so that most reports have been based on postmortem examination. The MRI, CT, and the angiographic findings are included in this report.     

Unusual presentation of metastatic hepatocellular carcinoma in the nasal septum: a case report and review of the literature

Hepatocellular carcinoma with sinonasal metastasis is extremely rare. We report a case of a 49-year-old man who had a history of synchronous hepatocellular carcinoma and verrucous carcinoma of tongue. A painless and non-bleeding mass was found in the left nasal septum 16 months after hepatocellular carcinoma was diagnosed. On computed tomography, the mass was enhanced with contrast. It was resected and proved to be metastatic hepatocellular carcinoma. The patient was treated with radiotherapy to the nasal area and then with chemotherapy. He was still alive, 15 months after the appearance of the nasal metastasis.     

A case of hepatocellular carcinoma with bone metastasis responding to concurrent TS-1/low-dose cisplatin (CDDP) therapy and radiotherapy

A standard treatment for hepatocellular carcinoma with extrahepatic metastasis is not established and chemotherapy is ineffective. We experienced a case of hepatocellular carcinoma with bone metastasis that responded to concurrent TS-1/low-dose cisplatin (CDDP) therapy and radiotherapy. A 58-year-old male patient with left iliac bone metastasis after 2 hepatectomies was admitted to our hospital. The titer of serum AFP and PIVKA-II showed an extremely high levels, 12,350.5 ng/ml and 993 mAU/ml, respectively. The uptake area was found at the left iliac bone by scintigraphy with 99mTc-HMDP. Treatment with TS-1/low-dose CDDP therapy and radiotherapy (36 Gy) was started concurrently. The chemotherapy regimen comprised daily oral administration of 100 mg of TS-1 for 21 days and CDDP 10 mg/body infusion (day 1-5, 8-12). An additional 2 courses of TS-1/low-dose CDDP therapy were repeated. After that, severe pain diminished and the titer of serum showed AFP and PIVKA-II had improved to within normal ranges. The uptake at the left iliac bone was found to have decreased by scintigraphy. Adverse events were grade 1 nausea and leucopenia. TS-1/low-dose CDDP therapy seems to be applicable for the treatment of hepatocellular carcinoma with bone metastasis.     

Case report--a patient who has survived more than 4 years with repeated resection for bilateral adrenal metastasis from hepatocellular carcinoma

We report a patient with bilateral adrenal metastasis from hepatocellular carcinoma (HCC) who has survived for a long period as a result of repeated resection. A 55-year-old male patient with C type hepatitis underwent transcatheter arterial chemo-embolization (TACE) for HCC in November 1997. There was no recurrence in the liver, but left adrenal metastasis was detected in January 1998, followed by right adrenal metastasis in November 1998. We performed surgical resection for bilateral adrenal metastasis in March 1999. The histological diagnosis was well approximately moderately differentiated hepatocellular carcinoma. A recurrence in the right adrenal gland was detected eight months later. As there was no distant metastasis, we performed re-operation in December 1999. Recurrence in the liver was detected in October 2000 and was treated by TACE. He has survived more than 4 years since the first detection of adrenal metastasis. We conclude that surgical treatment is useful for patients with adrenal metastasis who have no distant viable lesion.     

A case of HBs antigen negative hepatocellular carcinoma without liver cirrhosis in a young woman

A 27-year-old woman, post parturition, was admitted to hospital because of epigastric pain. Ultrasonography and abdominal computerized tomography revealed a giant mass in the left lobe of the liver. Celiac angiography showed a hypervascular mass with irregular vascularity. Serum HBs antigen proved negative. A left hepatic lobectomy was performed in March, 1985. Histology of the tumor revealed the trabecular type of a hepatocellular carcinoma with Edmondson grade 2 atypism, whereas the non-cancerous region of the liver showed chronic inactive hepatitis. This case is presented, because of the rarity of a hepatocellular carcinoma developing in such a young patient. In addition, reported cases of a hepatocellular carcinoma in the young in Japan are reviewed.     

Solitary Metastasis from Papillary Thyroid Carcinoma in Cirrhotic Liver with Hepatocellular Carcinoma

We report a surgical case of hepatocellular carcinoma and solitaryliver metastasis from papillary thyroid carcinoma in differentlobes of the liver. The former, located in the right anteriorsuperior segment, and the latter, in the left caudate lobe,were resected simultaneously. The hepatocellular carcinoma wasa micro(thin)-trabecular, pseudoglandular type of Edmondson'sgrade. II. The liver metastasis was a papillary carcinoma offollicular variant from the thyroid. This is the first reportof hepatocellular carcinoma accompanying a solitary liver metastasisfrom papillary thyroid carcinoma without metastasis in otherorgans.     

A case report of primary liver cancer with cerebral metastasis after hepatic resection

A 67-year-old male, who had a left hepatectomy for hepatocellular carcinoma, was readmitted to our hospital because of a left hemiparesis. A brain computed tomography scan and an r-carotid angiogram revealed a large mass involving the right parietal area, and thus a brain tumor removal was performed. A histological diagnosis of the removed brain tumor found it to be a metastatic, hepatocellular carcinoma. The patient died of pulmonary congestion due to lung metastasis, approximately 2 years and seven months after hepatectomy, and 1 year and three months after the removal of this metastatic brain tumor. In selected cases, the removal of a metastatic brain tumor seems to bring about improvements in the quality and duration of life.     

Intracranial Metastasis in a Patient with Hepatocellular Carcinoma and Gastric Cancer

A 76-year-old man was referred to our hospital with visual disturbance, weakness of the left upper and lower limbs, and gait disturbance. He had previously received transarterial chemoembolization for hepatocellular carcinoma (HCC) 3 and 10 years ago. When he had received radiofrequency ablation for HCC recurrence 2 years ago, total gastrectomy was also performed for his gastric cancer. Subsequently, sorafenib had been administrated for concomitant lung metastatic tumors. On admission, MRI revealed an intra-axial tumor with perifocal edema. The level of carcinoembryonic antigen, but not alpha-fetoprotein, markedly increased. The tumor was successfully removed by craniotomy and pathological examination revealed that it was composed of adenocarcinoma, which was consistent with the primary gastric cancer. After surgery, his neurological disturbances rapidly resolved. Additional gamma-knife treatment was also performed for another small brain metastasis detected after craniotomy. Subsequently, sorafenib administration was discontinued and S-1 was administered postoperatively. Successful treatment of intracranial metastasis of gastric cancer is important and meaningful, even in patients with multiple primary malignancies.Key words: Multiple primary malignancy, Hepatocellular carcinoma, Gastric cancer, Double cancer, Intracranial metastasis, Surgical resection     

Retrograde metastasis of hepatocellular carcinoma with an interesting lesion of the stomach--a case report

A 48-year-old man with hepatocellular carcinoma (HCC) showing tumor emboli in the portal vein and a typical retrograde metastasis via the portal vessels, is reported. Metastatic lesions were localized only in the veins of the lesser omentum, stomach, lower esophagus, pancreas, left hemidiaphragm and left adrenal gland, due to the hemodynamic alteration of the portal blood flow caused by liver cirrhosis and HCC. No metastatic lesion was found in the lung, Kidney, bone or intestine. As gastric metastasis Borrmann I, II, III and submusal tumor types were reported, but the present case revealed hard fold-like lesions, as it were, hard white varices.     

Skull metastasis from hepatocellular carcinoma with chronic hepatitis B

A 56-year-old male visited our hospital for evaluation of an occipital mass. Contrast computed tomography showed hypervascular enhancement with osteolytic change in the skull and a huge enhanced mass in the liver. Magnetic resonance imaging showed bone metastasis in the thoracic vertebrae. Assays for hepatitis B surface antigen and hepatitis B core antibody were positive and his liver condition was Child-Pugh grade A. Our diagnosis was hepatocellular carcinoma (HCC) with skull and vertebrae metastases on chronic hepatitis B. He was treated with radiation therapy for bone metastases and transcatheter arterial chemoembolization for HCC. But he developed acute respiratory failure because of aspiration pneumonia, congestion and oedema with haemorrhage of the lungs and died. Dissection showed HCC with multiple bone metastases. The liver tumor was categorized as well-differentiated HCC, Edmondson classification I, trabecular type and pseudoglandular type. In the liver mild infiltration of lymphocytes was seen in Glisson's capsules which were significantly enlarged with well preserved limiting plates. Piecemeal necrosis was not obvious. No fibrosis was noted. An 8 cm × 7 cm × 3 cm metastatic lesion had formed in the left occipitotemporal part of the cranial bone. The lesion was osteolytic and showed invasion into the dura mater. Neither the subdural cavity nor the brain showed involvement from the metastatic tumor. However, skull metastasis from HCC is very rare and it affects the patient's prognosis and the quality of life. Therefore, it is very important to make an early diagnosis and carry out proper management of skull metastasis from HCC.     

Solitary adrenal metastasis from hepatocellular carcinoma: a case report of simultaneous successful resections

The case is presented of a 64-year-old male with a left adrenal mass and multiple liver lesions. Preoperative image work-ups included ultrasonography, computed tomography, selective liver and adrenal angiographies, and magnetic resonance imaging. Serial serum alpha-fetoprotein monitoring and the adrenal hormone profile were within the normal ranges. A left adrenalectomy and a right lobectomy of the liver were performed, and the pathology revealed hepatocellular carcinoma with left adrenal metastasis. The clinical significance of the present case, together with the diagnosis and management of the disease is discussed.     

Resection of solitary metachronous lymph node metastasis from hepatocellular carcinoma following transarterial chemotherapy with cisplatin: a case report

A 74-year-old female was found to have a 40-mm liver tumor (in segment VIII) by ultrasonography and was diagnosed with hepatocellular carcinoma (HCC). She underwent liver resection and was stably treated without recurrence for 19 months. A 45-mm extrahepatic tumor was then found during follow-up with enhanced computed tomography and was diagnosed as being a metachronous lymph node (LN) metastasis. Angiography revealed that the metastasis LN was fed by both the right and left gastric arteries. Transarterial chemotherapy with cisplatin was scheduled to control LN metastasis and to prevent intrahepatic metastasis, simultaneously. Blood alteration using coil embolization was performed to isolate the feeding arteries before transarterial chemotherapy with cisplatin powder. The patient was stably treated for 6 months (3 times) and no new intra- or extrahepatic metastatic lesions appeared during the chemotherapy. The patient subsequently underwent systematic LN dissection of the porta hepatis. She was successfully treated, and has remained recurrence-free for almost 5 years.     

Successful treatment of multiple pulmonary and peritoneal recurrence of hepatocellular carcinoma with bronchial artery infusion therapy and PEIT followed by surgery--a case report

A case of hepatocellular carcinoma, successfully treated with multimodal loco-regional treatments, is reported. An 80-year-old male presented with multiple pulmonary and peritoneal metastases 4 months after right heimihepatectomy for ruptured HCC. Bronchial artery infusion of mitomycin C induced pulmonary tumor regression and stabilization. Peritoneal tumor was treated by arterial infusion of SMANCS, followed by percutaneous injection of absolute ethanol, which ended in surgical removal in 28-postoperative month due to abscess formation. He had been well until right adrenal and left pulmonary metastases appeared. Resection of both metastases was carried out in 39-post hepatectomy month. Recurrent left pulmonary metastasis was treated with two sessions of bronchial artery infusion with no effect this time. Video-assisted partial resection of the left lung was performed in 54 post-hepatectomy month. But his AFP level kept rising. Eventually pulmonary metastasis recurred and tumor thrombus reached the left atrium 58 months after hepatectomy. He wanted no more treatment. He died of cerebral infarction caused by tumor thrombus. He enjoyed a good QOL for five years through multimodal loco-regional treatments.     

Triple primary malignancies (malignant melanoma, laryngeal cancer and hepatoma)

A 61 year-old male patient, diagnosed to have a malignant melanoma in the left arm in April, 1981, was treated by chemotherapy (gamma-INF and DAVP) and a left axillary lymphadenectomy. In March, 1985, he had complained of hoarseness and an early laryngeal squamous cell carcinoma was found, and was subjected to laser treatment. On May 25, 1986, during his hospitalization for treatment of a multiple metastasis of a malignant melanoma, he suddenly suffered from a gastroduodenal perforation. During an emergency operation, a third cancer, a primary mixed hepatocellular and cholangiocellular carcinoma, was discovered.     

肝泡型包虫病肝内外转移及其与肝癌的鉴别诊断

目的:探讨肝泡型包虫病肝内外转移及与肝癌的鉴别诊断。方法:分析经手术病理证实的20例肝泡型包虫合并肝内外转移患者的影像学资料,并行卡松尼试验及实验室检查。结果:20例病例中,脑转移3例,肺转移4例,脑转移合并肺转移3例,行相关影像学检查可见肝内、颅脑、肺实性占位性病变,以上病例行卡松尼皮内过敏试验均为阳性,AFP、CEA、CA199值均在正常范围内。结论:肝泡型包虫病类似肝恶性肿瘤,可从肝脏转移或扩张至其他器官,行相关影像学检查、卡松尼皮内过敏试验、AFP、CEA、CA199测定可与肝脏原发肿瘤相鉴别。     

Almost complete disappearance of metastatic pulmonary tumor and reduction of the main hepatic mass in a case of hepatocellular carcinoma treated with UFT

A 61-year-old female patient with a low density area indicated by abdominal CT was admitted to hospital. Several circular shadows 5-20-mm in diameter were visible on the chest photos. Primary hepatocellular carcinoma complicated by compensatory cirrhosis accompanying pulmonary metastasis was diagnosed from blood biochemistry tests, a high AFP value (390,000 ng/ml) and angiogram findings. After two months of daily administration of 400 mg of UFT as ftorafur, both reduced AFP (46,000 ng/ml) and a reduction of the primary nidus were observed; after four months, the circular shadows were almost completely eliminated on chest photos. Although UFT administration was discontinued (total FT dose 33.6g) due to jaundice, in the eight months after discontinuation no enlargement of the primary nidus, recurrent shadows on chest photos, or recurrent rise of AFP were observed. This case is considered to suggest the effectiveness of UFT against primary hepatocellular carcinoma with accompanying pulmonary metastasis.     

A case report of successful transcatheter arterial embolization therapy for osseous metastasis of hepatocellular carcinoma

A 74-year-old man was admitted to our hospital with a chief complaint of severe local pain of the hip joint. Radiological findings showed a metastasized lesion on the left side of the pelvic wall originated from hepatocellular carcinoma (HCC) in the anterior segment of the liver. Transcatheter arterial embolization (TAE) therapy using epirubicin, Lipiodol and Spongel was successfully performed twice for primary HCC, and four times for osseous metastasis of HCC. After TAE therapy, the size of the metastasized lesion decreased with relief of pain, and an improvement in performance status of 4 to 2 was achieved. In conclusion, TAE therapy is thought to be very useful in the treatment of osseous metastasis of HCC with severe local pain.     

A hepatocellular carcinoma with lymph node metastasis and invasion into the gallbladder: preoperative difficulty ruling out a gallbladder carcinoma

We present a case of resected hepatocellular carcinoma (HCC) which invaded the gallbladder with a metastasis to a lymph node. It was extremely difficult to make a differential diagnosis between HCC and gallbladder cancer preoperatively. A 68-year old man was admitted to hospital with complaint of a fever. Ultrasonography (US) and CT scan showed a mass, growing invasively from the gallbladder bed of the liver (S4) to the lumen of the gallbladder. A selective arteriography showed the mass stained by the cholecystic artery, internal branch of the left hepatic artery, and frontal branch of the right hepatic artery. Endoscopic retrograde cholangiopancreatography (ERCP) showed the non-visualized gallbladder, a constriction of the common hepatic duct with suspicion of metastatic lymph nodes in the hepatoduodenal ligament. The tumor markers were: alpha-fet-protein 13175 ng/ml, PIVKA-II 26200 mAU/ml and CA19-9 0.0 U/ml. Both HBs antigen and HCV antibody were negative. We performed cholecystectomy with en-block resection of the anterior and middle inferior segment of the liver, the common bile duct and a part of the transverse colon, with dissection of the lymph nodes. The tumor, 8 cm in diameter, was brown colored without a capsule, growing diffusely in the liver, to the inside of the gallbladder and the transverse colon. Histopathological inspection of the specimen revealed moderately differentiated hepatocellular carcinoma with a metastatic lymph node along the common hepatic artery. TNM classification was IVB phase [T3,N0,M1 (LYM,OTH)]. There are only 3 previous cases of HCC reported with invasion into the gallbladder. At most 2.2% of the resected cases of HCC had metastatic lymph nodes at resection, while it was as high as 20-50% of the autopsy cases. Operation on such an invasive HCC case should consider lymph node metastasis.