Recurrent obstructive jaundice caused by fibrolamellar hepatocellular carcinoma

Summary A 24-year-old man with hepatocellular carcinoma presented with recurrent obstructive jaundice caused by bile duct invasion and distal migration of necrotic tumor fragments. After resection of an isolated left lobe tumor, he was well for 2 years until he again presented with obstructive jaundice caused by necrotic tumor and clot in the common bile duct. Analysis of his tumor revealed the fibrolamellar histologic variant of hepatocellular carcinoma. This case is unique in that the hepatocellular carcinoma was of the fibrolamellar variant and presented both intially and when recurrent 2 years later with obstructive jaundice caused by invasion of the common bile duct.     

Fibrolamellar liver cell cancer. A case report

Fibrolamellar hepatocellular carcinoma of the liver is a rare variant of hepatocellular carcinoma with characteristic morphological patterns and a good prognosis. Preoperatively the tumor is rarely diagnosed. Surgical treatment is resection, hemihepatectomy or transplantation of the liver. We report a case of a 51 years old patient with fibrolamellar hepatocellular carcinoma of the liver.     

Favorable quality of life after repeat hepatic resection for recurrent hepatocellular carcinoma

BACKGROUND/AIMS: The appropriate choice of treatment for recurrent hepatocellular carcinoma after hepatic resection remains controversial. The aim of this study is to clarify prognostic factors and quality of life in patients with tumor recurrence after hepatic resection for hepatocellular carcinoma. METHODOLOGY: We retrospectively analyzed 188 patients with hepatocellular carcinoma who underwent curative hepatic resection between 1988 and 1997. Statistical analysis was performed to identify prognostic factors involved after recurrence. Furthermore, quality of life after treatment for recurrence was compared between patients with repeat hepatic resection or hepatic arterial infusion chemotherapy. RESULTS: In 123 patients with recurrence, unfavorable predictors after recurrence are pTNM Stage III/IV at initial surgery, receiving chemotherapy before initial surgery and presence of extrahepatic recurrence. In contrast, favorable predictors are 3 years or more of disease-free interval and repeat hepatic resection. The incidence of deteriorated performance status in the repeat hepatic resection group was lower than in the hepatic arterial infusion chemotherapy group because of better psychological function in patients undergoing repeat hepatic resection. CONCLUSIONS: Repeat hepatic resection provides a good prognosis and a favorable quality of life in patients with recurrence after hepatic resection for hepatocellular carcinoma.     

Fibrolamellar hepatocellular carcinoma with a recurrence of classic hepatocellular carcinoma: a case report and review of Oriental cases

A 72-year-old Chinese male, hepatitis B carrier, received a right hepatic trisegmentectomy in 1997 for fibrolamellar hepatocellular carcinoma. Serum alpha-fetoprotein was in the normal range until two years after the operation, a rapid increase to 241 ng/mL occurred and computed tomography showed a 2-cm-sized recurrent nodule in the caudate lobe. Because computed tomography arterioportography showed additional multifocal nodules in the residual liver, transarterial embolization was performed. Four months after the first transarterial embolization, the caudate tumor grew to 6 cm and serum alpha-fetoprotein increased to 6090 ng/mL. Prior to the second transarterial embolization, this new hepatic lesion received a biopsy and showed a characteristic feature of classic hepatocellular carcinoma, which was different from the previous one. Four months after the second transarterial embolization, computed tomography showed no recurrent tumor and serum alpha-fetoprotein subsequently normalized. Twenty-two months after the first transarterial embolization, a 2.5-cm-sized tumor recurred again at the lateral segment. At this time, serum alpha-fetoprotein (3.6 ng/mL) was not elevated. He received the third transarterial embolization and is still alive. Recurrence of fibrolamellar hepatocellular carcinoma after hepatic resection has been reported to be high, but a case report with a character of muticentric, multifocal, and metachronous recurrences of fibrolamellar and classic type hepatocellular carcinoma is very rare. This is the second case report in the literature.     

Clinicopathological risk factors and prognostic evaluation in hepatocellular carcinoma recurrence after surgery

AIM: To analyze the clinicopathological risk factors in hepatocellular carcinoma recurrence after surgery.METHODS: We used significance testing (χ² and Student’s t-test) of single and multiple factors, and Wilcoxon Cox tropic examination; a retrospective clinicopathological analysis was performed on 156 cases of hepatocellular carcinoma after hepatectomy.RESULTS: Of the 156 cases, 68.4%, 57.3%, 46.7%, 31.5%, and 28.6% had one, two, three, four, and five postoperative tumor-free years, respectively; the total recurrence rate was 53.2% (83/156). In the 83 recurrent cases, 65 were intrahepatic subclinical, with a resection rate of 78.3% (65/83). The relevant factors involved in recurrence were: male gender, tumor number and size, capsule infiltration, and portal vein involvement. These factors were an obvious influence on the prognosis of the patients with postoperative hepatocellular carcinoma (P < 0.05). In the recurrent liver carcinomas, 63.1% of tumor nodes (41/65) were at the ipsilateral segment of the primary tumor nodes.CONCLUSION: Male gender, tumor number and size, capsule infiltration, and portal vein involvement are factors for postoperative hepatocellular carcinoma recurrence. Recurrence is mainly unicentral. The right front liver lobe is the segment with a high rate of recurrence.     

Fibrolamellar hepatocellular carcinoma: report of a case

We report a case of fibrolamellar hepatocellular carcinoma, which occurred in a 58-year-old man with normal liver function. Preoperative ultrasonography, computed tomography and magnetic resonance imaging depicted a large tumor in the left lateral segment, which was compatible with the typical radiological features of fibrolamellar hepatocellular carcinoma. He underwent left lobectomy and no lymphadenopathy or distant metastasis was demonstrated. Macroscopic findings of the resected liver demonstrated a well-defined whitish-yellow tumor with a central scar. Microscopic findings of the tumor showed cords of tumor cells, which were surrounded by abundant collagenous fibrous tissue arranged in a lamellar distribution. He has been doing well for approximately one year since the surgery without any signs of recurrence. In addition, we discuss the clinicopathological features of fibrolamellar hepatocellular carcinoma based on a review of 22 Japanese patients who have been previously reported.     

Curative reoperation for recurrent cancer of the extrahepatic bile duct: report of two cases

Local recurrence, following a resection for cancer of the extrahepatic bile duct, is usually incurable with second curative surgery being almost impossible. To determine the feasibility and significance of second curative surgery, our experiences are presented in this study. The medical records and clinical outcomes of two patients that underwent a re-resection for recurrent cancer of the extrahepatic bile duct were retrospectively reviewed. A 50-year-old female patient that had a recurrent disease at the intrahepatic and intrapancreatic bile duct, 66 months after a segmental resection of the bile duct for common bile duct (CBD) cancer, underwent a hepatopancreatoduodenectomy. A 29-year-old female patient had a recurrent tumor mass in the distal CBD, 28 months after a right hemihepatectomy and Roux-en-Y hepaticojejenostomy for a type IIIa Klatskin tumor, and underwent a segmental resection of the bile duct. The gross type of the above two cases was a papillary tumor. There was no operative mortality or morbidity. All patients are still alive after 46 and 9 months, respectively, without recurrence after the reoperation. It is concluded that a surgical re-resection is possible in selected patients with recurrent bile duct cancer, mostly of the papillary type. A primary operation for bile duct cancer should be performed with a wide surgical margin, and secondary curative surgery should be considered whenever possible in cases of recurrence.     

Successful diagnosis and resection of icteric type hepatocellular carcinoma

We report a rare case of icteric type hepatocellular carcinoma with successful preoperative diagnosis and curative resection. A 50-year-old man was admitted to our hospital with fever elevation and jaundice. Endoscopic retrograde cholangiography revealed a tumor at the hepatic hilum, which caused obstruction of the right and left hepatic duct. The tumor was suspected of being a hilar cholangiocarcinoma, but it was diagnosed as being a hepatocellular carcinoma by endoscopic retrograde bile duct biopsy. After percutaneous transhepatic biliary drainage a right hemihepatectomy was performed. Subsequent pathological finding showed the tumor to be moderately-differentiated hepatocellular carcinoma (Edmondson III) which invaded into the right hepatic duct. The patient survived for three years without recurrence. Although patients with icteric type hepatocellular carcinoma have been reported to have a poor prognosis, earlier diagnosis and curative resection may occasionally bring them an improved prognosis.     

Transcatheter arterial embolization for bleeding from bile duct tumor thrombi of hepatocellular carcinoma

BACKGROUND/AIMS: Advanced hepatocellular carcinoma usually invades the portal vein, forming tumor thrombi. Invasion of the bile duct, i.e., intrabile tumor growth or bile duct tumor thrombi is rare. Patients with bile duct tumor thrombi present with obstructive jaundice, abdominal pain or hemobilia. Hemobilia due to bile duct tumor thrombi is sometimes massive and fatal. The purpose of our study was to evaluate the effectiveness of transcatheter arterial embolization for hemobilia caused by bile duct tumor thrombi of hepatocellular carcinoma. METHODOLOGY: Between 1993 January and 2000 December, transcatheter arterial embolization was performed in 4 patients with hemobilia and gastrointestinal bleeding from bile duct tumor thrombi of hepatocellular carcinoma. RESULTS: In all 4 patients, transcatheter arterial embolization was successfully performed and resulted in cessation of bleeding. One patient had recurrent hemobilia, which was controlled by another transcatheter arterial embolization. Three patients were discharged from hospital after transcatheter arterial embolization. Patients died of hepatic failure or multiple tumors 5 to 7 months after the onset of hemobilia, although hemobilia had been fully controlled. CONCLUSIONS: Transcatheter arterial embolization seemed to be effective for the control of massive hemobilia caused by bile duct tumor thrombi associated with hepatocellular carcinoma.     

Fibrolamellar carcinoma of the liver: hepatocellular carcinoma with favourable prognosis

The authors report a case of fibrolamellar carcinoma of the liver in a young woman with bilateral lung metastases. This tumour was surgically unremovable. Presently, after a chemotherapy with adriamycin and mitomycin, this patient is in good health, two years after initial diagnosis. Review of the literature shows that fibrolamellar carcinoma of the liver occurs mainly in young patients. This tumor is characterised by large polygonal eosinophilic hepatocytes and an abundant fibrous stroma. It can be confused with focal nodular hyperplasia. Resection of the tumor and the methodical, repeated resections of metastases must be performed when possible. Prognosis of this tumor is better than that of the other variants of hepatocellular carcinoma.     

Prognosis of hepatocellular carcinoma with no tumor stain treated by percutaneous ethanol injection.

BACKGROUND/AIMS: Some hepatocellular carcinoma nodules do not show tumor stain by hepatic angiography or enhanced computed tomography. The aim of this study was to clarify the prognosis of hepatocellular carcinoma with no tumor stain treated by percutaneous ethanol injection. METHODOLOGY: Twenty patients who had hepatocellular carcinoma with no tumor stain were treated by percutaneous ethanol injection between January 1990 and June 1998. No patients had received any anticancer treatments before percutaneous ethanol injection. Recurrence-free survival, predictive factors for recurrence and recurrent patterns were examined. Overall survival was also examined. RESULTS: Ten of the 20 patients showed intrahepatic recurrences in other parts of the treated lesions, although no local recurrence was observed. Median recurrence-free survival time, 1-, 3- and 5-year recurrence-free survival rates were 2.8 years, 66%, 43% and 22%, respectively. A serum alpha-fetoprotein level of 20 ng/mL or less was the only factor that was significantly associated with prolonged recurrence-free survival. Of the 12 recurrent nodules in 10 patients, 9 occurred in different segments of the treated lesion and 8 were histopathologically confirmed to be well-differentiated hepatocellular carcinoma. Overall survival rates 1, 3, and 5 years after percutaneous ethanol injection were 100%, 82%, and 75%, respectively. CONCLUSIONS: Percutaneous ethanol injection may be useful for the treatment of hepatocellular carcinoma with no tumor stain.     

Percutaneous microwave coagulation therapy for primary or recurrent hepatocellular carcinoma: long-term results.

BACKGROUND/AIMS: To clarify the indication of percutaneous microwave coagulation therapy for hepatocellular carcinoma. METHODOLOGY: Thirty-three hepatocellular carcinoma patients who underwent percutaneous microwave coagulation therapy were enrolled in this study, including 18 primary and 15 recurrent hepatocellular carcinoma patients. We examined the local recurrence rates and the long-term results after the treatment. RESULTS: The overall survival rates of the primary group at 1, 2, 3, 4 and 5 years were 94.4%, 77.8%, 77.8%, 77.8% and 48.6%, respectively, whereas those of the recurrent group were 100%, 85.7%, 66.7% and 50.0% at 1, 2, 3 and 4 years, respectively. Local recurrence after percutaneous microwave coagulation therapy was found in about 50% of patients in both groups. Seventeen of the 27 patients (63.0%) with a moderately or poorly differentiated hepatocellular carcinoma tumor had local recurrence, while none of the 6 patients with a well-differentiated hepatocellular carcinoma tumor did (P = 0.005). CONCLUSIONS: Irrespective of primary or recurrent hepatocellular carcinoma, the indication of percutaneous microwave coagulation therapy as an alternative to hepatic resection should be limited to cases of a well-differentiated hepatocellular carcinoma tumor smaller than 2 cm in diameter.     

Surgically treated cases of mixed hepatocellular carcinoma and cholangiocarcinoma

The mixed type of combined hepatocellular carcinoma and cholangiocarcinoma is particularly rare. Hepatic resection was performed for two patients with mixed hepatocellular carcinoma and cholangiocarcinoma. In case 1, a 55-year-old Japanese man was found to have a hepatic tumor on ultrasonography. Since ultrasonically-guided needle biopsy revealed that the tumor was poorly differentiated hepatocellular carcinoma, the patient underwent a limited hepatic resection. Histologic and immunohistochemical examination revealed that the tumor had elements of both hepatocellular carcinoma and cholangiocarcinoma. Six months after surgery, the patient died of systemic recurrences. In case 2, a 58-year-old man was found by ultrasonography to have a hepatic tumor occupying the entire right hepatic lobe. Computed tomography revealed that the tumor had a portal tumor thrombus. The diagnosis of hepatocellular carcinoma was made because of a markedly elevated serum alpha-fetoprotein concentration, and a right hepatic lobectomy was performed. Histologic and immunohistochemical examination confirmed that the lesion was mixed hepatocellular and cholangiocellular carcinoma. The patient died of multiple recurrent tumors in the remnant liver 3 months after surgery. Surgical control of mixed hepatocellular carcinoma and cholangiocarcinoma is difficult.     

Caution for Diagnosis and Surgical Treatment of Recurrent Cholangitis: Lessons From 5 Cases of Bile Duct Tumor Thrombus Without a Detectable Intrahepatic Tumor

The hepatocellular carcinoma (HCC) patients with bile duct tumor thrombus (BDTT) usually have no specific clinical symptoms at early stages. HCC with BDTT was usually misdiagnosed when the intrahepatic tumor was small, even undetectable.In this study, 5 cases of HCC with BDTT misdiagnosed as choledocholithiasis and cholangitis in the local hospital are described. We analyzed retrospectively and summarized our experiences of these 5 HCC patients with BDTT misdiagnosed in the local hospital during the past 5 years. The diagnosis, treatment, and outcome of the patients are discussed.Three patients underwent hepatectomy with thrombectomy and T-tube drainage. One patient underwent hepatectomy with the resection of the common bile duct and hepatojejunostomy, and palliative surgery was performed in 1 patient with portal vein tumor thrombus and intrahepatic metastasis. The patients were followed for 6–22 months; 4 patients died of tumor recurrence and metastasis or hepatic failure, despite 3 of these patients having received transhepatic arterial chemotherapy and embolization or radiofrequency ablation therapy.Early and accurate diagnosis of HCC with BDTT is very important. When patients have a history of abnormal recurrent cholangitis, HCC with BDTT should be highly suspected. Intraductal ultrasonography (US), intraoperative US, and histopathological examination are very valuable for the diagnosis. The prognosis of HCC patients with BDTT is dismal. Identification of this type of patient is clinically important, because surgical treatment may be beneficial.     

A resected case of fibrolamellar hepatocellular carcinoma with chronic hepatitis (type B)]

We report a case of a 34-year-old woman who tested positive for HBs Ag with fibrolamellar hepatocellular carcinoma of the liver. The sister of this patient, who was also positive for HBs Ag, died of hepatocellular carcinoma (HCC). The patient showed elevation of alpha-fetoprotein. Abdominal CT scan showed a tumor in the posterior segment of the liver and hepatic angiography revealed marked neovascularity in the tumor. Partial resection of the liver was performed, and the histological diagnosis was fibrolamellar hepatocellular carcinoma. The patient is now tumor free and doing well 20 months after the operation.     

Recurrent hepatocellular carcinoma with rapid growth after cardiac surgery

A 65-year-old man diagnosed with hepatitis C virus-positive hepatitis and severe valvular heart disease was scheduled to undergo cardiac valve replacement. We then found hepatocellular carcinoma in the liver. Because of his severe cardiac dysfunction, we treated him surgically with radiofrequency ablation for the hepatocellular carcinoma only. We continued medical treatment of the heart disease. He hoped to undergo with cardiac surgery one year later for the cardiac dysfunction. There was no evidence of tumor recurrence. We informed him that cardiac surgery requiring extracorporeal circulation might lead to tumor recurrence. He agreed to cardiac valve replacement, and the surgery was successful. Recurrent hepatocellular carcinoma was found in the liver 1 month after the surgery. Over the next month, the tumor progressed rapidly, showing portal vein thrombi. We believe the use of extracorporeal circulation in particular triggered the rapid growth of the recurrent hepatocellular carcinoma. This is the first report of a recurrent hepatocellular carcinoma associated with hepatitis C virus that progressed extensively after cardiac surgery.     

Resection of an icteric type hepatoma with tumor thrombi filling the right posterior bile duct

A 67-year-old male with jaundice was found to have hepatocellular carcinoma in the right hepatic lobe and tumor thrombi in the common hepatic duct. Physicians initially considered the tumor unresectable, and treated the patient with transcatheter arterial infusion chemotherapy and biliary endoprosthesis. The patient developed a liver abscess after the second transcatheter arterial infusion, and the physicians consulted our department for another form of therapy. Percutaneous transhepatic biliary drainage was performed to relieve revived obstructive jaundice. Cholangiography revealed tumor thrombi extending through the right posterior segmental bile duct into the common hepatic duct. Most biliary branches of the caudate lobe joined with the left lateral posterior segmental branch. Arterial and portal venous branches of the caudate lobe were not involved. Right hepatic lobectomy and extrahepatic bile duct resection were performed 1 year after initial diagnosis. On histologic examination, the epithelium of the right posterior segmental bile duct, which was filled with the tumor thrombi, was not detected. The patient is alive without recurrence 24 months after surgery. Careful investigation of biliary branches of the caudate lobe on cholangiography is essential to determine the necessity of caudate lobectomy in patients with hepatocellular carcinoma and tumor thrombi filling the right posterior segmental bile duct.     

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.     

Successful hepatic resection for recurrent hepatocellular carcinoma after lenvatinib treatment: A case report

BACKGROUNDLenvatinib has been shown to be noninferior to sorafenib regarding prognosis and recurrence rate in patients with unresectable hepatocellular carcinoma (HCC) who have not received prior systemic chemotherapy. In patients treated with lenvatinib, 40% of cases achieved sufficient tumor reduction to make potential surgery possible. However, the outcomes of such surgery are unknown. We report a successful case of hepatic resection for recurrent HCC after lenvatinib treatment.CASE SUMMARYA 69-year-old man underwent right anterior sectionectomy for HCC in segment 8 of the liver. Ten months later, he was found to have an intrahepatic HCC recurrence that grew rapidly to 10 cm in diameter with sternal bone metastases. After confirming partial response to lenvatinib administration for 2 mo, a second hepatectomy was performed. Pathological examination showed that 80% of the tumor was necrotic. The patient did not develop any adverse effects under lenvatinib treatment. He was discharged at 25 d after surgery. Radiation therapy for bone metastases continued to be given under lenvatinib, and the patient has remained alive for 1 year after the second hepatectomy.CONCLUSIONThe prognosis of patients with recurrent HCC may be improved by liver resection combined with prior lenvatinib therapy.     

Recurrent carcinoma of cystic duct remnant with subcutaneous implantation in abdominal wall

A case of recurrent carcinoma of the cystic duct remnant invading the common bile duct and portal vein with subcutaneous implantation of the abdominal wall is presented. The patient was a 55-year-old woman with an abdominal wall tumor at the site of the surgical scar of a cholecystectomy, performed at a local hospital 5 years ago for symptomatic cholelithiasis. The diagnosis was made by incisional biopsy of the tumor, computed tomography, percutaneous transhepatic cholangiography, and angiography. She underwent extended right hepatic lobectomy with en bloc resection of the caudate lobe, extrahepatic bile duct, and portal vein. The abdominal wall tumor was resected concomitantly. Histological examination showed that both the recurrent carcinoma of the cystic duct remnant and the abdominal wall implantation were moderately differentiated adenocarcinoma. This recurrence probably could have been prevented if both the macroscopic and microscopic examinations of the resected specimen had been precisely carried out after the previous cholecystectomy and the primary carcinoma identified and treated at that time.