Prolonged survival after repeat resection of pulmonary metastasis from hepatocellular carcinoma

We report a patient in whom two pulmonary resections were performed for lung metastasis after hepatic resection of hepatocellular carcinoma (HCC). A 56‐year‐old Japanese man with an 8‐year history of chronic liver disease was admitted with elevated serum alpha‐fetoprotein (AFP) and a liver tumor that had been detected by ultrasonography. Computed tomography showed a 6‐cm tumor in the medial segment of the liver, and partial resection of the medial segment was performed. Thirty‐six months after the first operation, pulmonary resection was performed for a solitary metastasis in the left lung. Fifty‐one months after the second operation, a solitary metastatic tumor was detected in the right lung, without any evidence of recurrence or other metastatic foci, and thoracoscopic partial resection of the right lung was performed as the third operation. The patient is alive 36 months after the second pulmonary resection, has a normal AFP value, and shows no signs of recurrent or metastatic foci. Repeat pulmonary resection for metastasis from HCC resulted in long‐term survival in this patient.     

Hepatectomy following transarterial chemotherapy for a metastasis in the caudate lobe

We describe a solitary liver metastasis in the caudate lobe from a colon cancer treated with a hepatic resection following transarterial chemotherapy. A 73-year-old male was admitted with a complaint of melena. The findings from endoscopic examination of the colon showed a type 3 cancer at the hepatic flexure. Computed tomography revealed a metastatic lesion in the caudate lobe of the liver, which was three centimeters in diameter and located between the roots of the middle and the left hepatic vein. A right hemicolectomy was performed and the surgical findings revealed extended lymph node metastasis and the serosal exposure of the primary lesion. A transarterial catheterization to the liver for chemotherapy was placed instead of performing a hepatic resection. After six months of the transarterial chemotherapy, the metastatic tumor was decreased to less than one centimeter and no other new lesion was developed in and out of the liver. The patient underwent a resection of the Spiegel lobe 8 months after the first operation. There were small lesions of viable metastatic cells in the tumor histologically. The patient is currently well without any signs of recurrence 28 months after the first operation.     

The significance of portal vein embolization in the treatment of colorectal liver metastases

The first aim of the present paper was to evaluate hypertrophy of liver parenchyma after portal vein embolization in patients after systemic chemotherapy for colorectal carcinoma metastases and planned extensive liver resections. The second aim was to study whether hypertrophy of the liver parenchyma remnant after could influence the postoperative course large liver resections in long-term chemotherapy within complex therapy of colorectal carcinoma.The prospective study comprised of 43 patients with colorectal hepatic metastases in whom liver resections of 4-5 segments were planned (Table 1). All patients underwent complex therapy of colorectal carcinoma, including chemotherapy consisting of 6-12 therapeutic cycles. Time interval between chemotherapy and liver resection was 2-24 months (mean interval of 8 months). Twenty patients whose presumed liver parenchyma remnant was less than 40% of total liver volume were indicated for portal vein embolization (mean liver parenchyma remnant of 29%). This was always embolization of the right portal branch. Twenty-three patients were primarily indicated to liver resection. RESULTS: Hypertrophy of the left liver lobe occurred in all 20 patients. After portal vein embolization, the volume of left liver increased on average from 476 ml (282-754) to 584 ml (380-892) (P < 0.05). Mean hypertrophy of left liver lobe after portal vein embolization was 28.5%. The measured parenchyma remnant after tumor resection increased from 29% up to 38% by hypertrophy. Mean values of ALT and AST in the postoperative period were significantly different in the groups in this study. The values of alkaline phosphatase (ALP) and gamma glutamyl transpeptidase (GMT) were lower in patients after portal vein embolization (P < 0.05). Significant differences were in postoperative level of serum bilirubin, bilirubin levels in patients after portal vein embolization were 2-3 times lower than in the group of patients after immediate surgery (P < 0.05). he values of prothrombin time were also significantly lower in patients who underwent surgery without previous portal vein embolization (P < 0.05).     

The repeated hepatectomy for frequent recurrence of hepatic metastasis from gastrointestinal stromal tumor of the stomach

Although in recent years hepatic resection has become a safe procedure, there are few data on repeat liver resection for hepatic metastases from gastrointestinal stromal tumor. A 60-year-old Japanese man underwent partial gastrectomy and extended right hepatectomy for gastrointestinal stromal tumor of the stomach with liver metastasis. However, liver metastasis recurred at the interval of less than 1 year. Therefore, the patient underwent a total of six liver resections. The liver resections comprised four R0, one R1 and one R2 resection. To our knowledge, six times for liver resection performed on one patient is a maximum. This patient survived 43 months after the first surgery. Despite frequent recurrence of hepatic metastasis from gastrointestinal stromal tumor, repeated hepatectomy provides a survival benefit if complete removal of all tumorous masses appears possible.     

Liver metastasis of rectal cancer with intraluminal growth in the extrahepatic bile duct

Metastatic liver tumors are considered to have a tendency for expansive growth and rarely invade the bile duct. We recently encountered a resected case of liver metastasis from rectal cancer with intraluminal growth in the extrahepatic bile duct with a successful left trisegmentectomy of the liver. A 54-year-old woman underwent a posterior total pelvic exenteration for advanced rectal cancer. Ultrasonography and computed tomography four months after the first operation demonstrated a solitary occupied lesion in the liver with dilation of the left hepatic duct. Endoscopic retrograde cholangiopancreatography disclosed a filling defect in the intra- to extrahepatic bile duct. Liver metastasis from rectal cancer with intraluminal growth in the bile duct was suspected despite a consideration of primary bile duct cancer. A left trisegmentectomy of the liver and resection of the extrahepatic bile duct with a right hepatojejunostomy were performed. The tumor had invaded the intrahepatic bile duct and had developed intraluminally in the extrahepatic bile duct. Tumor thrombi were microscopically found in the bile duct of the left caudal lobe. Liver metastasis arising from colorectal cancer with intraluminal growth in the bile duct is rare, however we encountered such a case with a successful resection involving a left trisegmentectomy of the liver.     

Patient with advanced intrahepatic cholangiocarcinoma with long-term survival successfully treated with a combination of surgery and chemotherapy

Intrahepatic cholangiocarcinoma (ICC) is a relatively rare malignancy arising from the biliary epithelium. Prognosis is typically poor. Currently, aggressive surgical resection is the only treatment modality that offers patients any chance of long-term survival. Here, we present the case of a 57-year-old woman in whom we diagnosed ICC, with the tumor occupying the entire left and caudate hepatic lobes and daughter nodules in the right lobe. She underwent hepatectomy of segments I to VI, combined with intraoperative microwave coagulation therapy for nodules in the residual liver. Three months after the surgical resection, she had recurrence of the disease. The patient subsequently received weekly intraarterial chemotherapy with irinotecan (CPT-11), and a partial response was observed which persisted for 18 months. Subsequent computed tomography revealed the regrowth of three tumors, and she therefore underwent a repeat resection 24 months after the first surgical operation. In postoperative-month (POM) 32, she received systemic chemotherapy with tegatur/gimeracil/oteracil potassium (S-1)/cisplatin for multiple small nodules in her lung. Following three cycles of chemotherapy with a stable disease response, partial resections of the lung were performed. Third and fourth hepatectomies were performed in POMs 46 and 59, respectively. Five years and 5 months after the first hepatectomy, she is alive with small lesions in her lung. This multimodal approach may be effective for ICC.     

How far should we treat metastatic liver cancer? Report of three long-term survivors

The major issue in treating metastatic liver cancer is: how far should we perform resection? We believe that only reports of long-term survival afford an answer to this problem. We report three such patients. The first patient underwent pancreatoduodenectomy for cancer of the papilla of the duodenum and resection of metastatic liver cancer. She is alive without recurrence 15 years and 1 month after the initial surgery. The second patient received low anterior resection for rectal cancer, extended right lobectomy for liver metastasis, and pancreatoduodenectomy for metastasis at the common bile duct. She survived 6 years and 9 months after the initial surgery. The third patient underwent right nephrectomy for Wilms' tumor (adult type), extended right lobectomy for liver metastasis, and repeat resection of recurrences at the mediastinum and in the thoracic and abdominal walls. She is alive 21 years and 2 months after the initial surgery. These experiences have prompted us to carry out resection when surgery is deemed feasible.     

Adrenal metastasis from hepatocellular carcinoma (HCC): report of 3 cases.

Although autopsy reports show that the adrenal gland is the second most common organ of hematogeneous metastasis from hepatocellular carcinoma (HCC), paradoxically there is found to be a very scarce number of the adrenal metastasis in clinical practice. We have recently experienced rare patients with right adrenal metastasis from HCC. Case 1: A 51 year-old man with a 5-year history of chronic hepatitis was admitted with hematemesis to Nippon Medical School Hospital. CT revealed a main tumor associated with a few daughter tumors in the hepatic posterior segment and in addition another tumor located between the right hepatic lobe and right kidney. The diagnosis of HCC with a right adrenal gland metastasis was made, and hepatectomy and right adrenalectomy was performed. Twenty months after operation he was alive and free of disease. Case 2: A 78 year-old man underwent resection of the lateral segment of the left hepatic lobe for HCC. Twelve months later, recurrent foci in the residual liver were found and those were treated with transarterial embolization (TAE). Right adrenal metastasis was found on CT 26 months after hepatectomy. TAE was done for the hepatic recurrent tumors and adrenal metastasis. Twelve months after, he survived in good condition. Case 3: A 47 year-old man presented with liver cirrhosis with a long history. He was diagnosed as having HCC with multiple intrahepatic metastases and was treated with TAE 4 times. Follow-up CT revealed right adrenal metastasis. TAE was done for hepatic recurrent tumor and right adrenal metastasis. Three months later the patient died of liver failure.     

Liver metastases with massive portal venous tumor thrombi from colorectal cancer: can be treated by surgical resection?

BACKGROUND/AIMS: The surgical treatments for liver metastases from colorectal cancer with massive portal venous tumor thrombi were evaluated. METHODOLOGY: Five patients, among the 142 patients who underwent hepatic resection for liver metastases from colorectal cancer from 1989 to 1998, were included in this study. The tumor thrombi in the main portal vein were removed by the following procedures; (1) the circumferential incision of the first branch of the portal vein and removal of the exposed tumor thrombi with ring forceps and suction, (2) temporary clamping of the distal end, (3) dilatation of the round ligament and the venous cannula was inserted into the umbilical portion, (4) washing out of the residual tumor thrombi, (5) declamping of the distal end and closing suture of the cut end of the portal branch. RESULTS: All patients had metachronous metastases and underwent resections of the primary tumor within 2 years. The surgical procedures performed were as follows: two cases that underwent right hepatectomies with portal venous tumor thrombectomies, one right trisectionectomy with portal venous tumor thrombectomy, one right hepatectomy plus limited resection of the contralateral lobe, and one left lateral sectionectomy with limited resection of the right lobe. All patients had no major postoperative complications and returned to their social lives within 1 month after operation. The intra-arterial catheter devices were implanted in four patients in order to receive adjuvant chemotherapy. One patient survived the 36-month period after liver resection, although 4 patients died of liver recurrence within 12 months. The mean survival time was 14.4 months and the overall 1-year survival rate was 20.0 percent. CONCLUSIONS: Surgical resection for this disease may bring longer survival rates for some patients, but not be an effective therapeutic option in our series. We should create other adjuvant therapies to improve these survival rates.     

Ultrasound and biochemical evaluation of liver regeneration process after resections for primary and metastatic tumors

BACKGROUND/AIMS: The liver regeneration process after resective procedures is an important clinical problem especially in view of the growing population of patients requiring liver transplantations or undergoing resective procedures as well as those with toxic or viral liver injures. The aim of the study was to analyze liver regeneration potential using ultrasound examination, and liver function biochemical tests in the patients after liver resections. METHODOLOGY: Twenty-one patients with primary or metastatic liver cancer were included in the study (17 males, 4 females, mean age: 59.8, SD 10.3). The patients were undergoing gastrointestinal tract primary tumor resections with extended lymphadenectomy and liver metastatic tumor excisions. Liver volume was measured postoperatively in the follow-up ultrasound examinations and biochemical tests were performed before and after the procedure. Liver function and activity of p-450 cytochrome was tested with IRIS 13C stable isotope breath analyzer. RESULTS: The mean time of follow-up was 12.6 months (SD 7.8) during which volume of liver increased on average in the first five months to 105.7, 112.1, 125.7, 131.2, and 138.4% of the immediate postoperative value. Biochemical parameters returned to normal after 2-3 weeks. Four patients in whom liver failed to regenerate died due to cancer spread in the mean time of 6.5 months. CONCLUSIONS: Liver has tremendous regeneration potential. In spite of this fact, extended hepatectomies affect largely the functional status of residual parenchyma which may lead to a fatal outcome.     

Two-step hepatectomy with right portal branch ligature for a right lobe metastasis

Hepatic resection is the only treatment with possible curative effect both for primary and secondary tumors. An increase of the rate of resectability for tumors considered inoperable at first, and a decrease of the postoperative morbidity and mortality can be realized by right portal branch ligature and two-step hepatectomy. We would like to present the case of a patient with left bowel cancer with a hepatic metastasis. Right portal branch ligature was performed which was followed by systemic postoperative chemotherapy. The right portal branch occlusion was followed by right lobe atrophy and left lobe hypertrophy, confirmed by CT scanning. Three months after the portal occlusion the patient underwent a right lobe hepatectomy. The postoperative evolution was favorable, eight days of hospitalization were necessary. The portal branch ligature can be made in several cases of hepatic tumors to increase the resectability rate.     

Selective hypertrophy of the lobus caudatus as a novel approach enabling extended right hepatectomy in the presence of a non-perfused left lateral liver lobe

Introduction

Portal vein embolization (PVE) is a well-established technique to enhance functional hepatic reserves of segments II and III before curative extended right hepatectomy for tumors of the right liver lobe. However, an adequate hepatopetal flow of the left lateral portal vein branches is required for a sufficient PVE-associated hypertrophy.

Case report

Here, we report a 65-year old patient suffering from a locally advanced intrahepatic cholangiocarcinoma in the right liver lobe and segment IV. A curative extended right hepatectomy after preoperative PVE of liver segments IV–VIII was initially impossible because of partial thrombosis of the left lateral portal vein branches resulting in an ischemic-type atrophy of segments II and III. However, due to a massive hypertrophy of the caudate lobe following PVE of liver segments IV–VIII, subsequent extended right hepatectomy with intraoperative thrombectomy of segments II and III was made possible.

Conclusions

To our knowledge this is the first case in which an extended right hepatectomy for a liver malignancy, in the presence of atrophic left lateral section, was made possible by a massive PVE-associated hypertrophy of the caudate lobe.     

Liver resection for breast cancer metastases

BACKGROUND/AIMS: The prognosis of patients with hepatic metastases (HM) from breast cancer receiving no treatment is extremely poor. Results of systemic and regional chemotherapy as well as other treatment modalities, such as immunotherapy or hormonal therapy, are disappointing in this group of patients, with median survival rates hardly exceeding 1 year. METHODOLOGY: We performed a retrospective analysis of patients undergoing resection of isolated HM from breast cancer to determine the morbidity, mortality and prognosis following this procedure. RESULTS: Fifteen female patients underwent liver resection between September 1985 and April 1997. Two patients had synchronous and 13 patients had metachronous HM. The mean number of HM was 3.3 (1-9) (bilobar in 6 patients) with a mean diameter of 5.3 cm (2-11 cm). The following resections were performed: wedge resection (4), left lateral segmentectomy (2), right hemihepatectomy (3), left hemihepatectomy (1), extended right hemihepatectomy (3) and extended left hemihepatectomy (2). There was no hospital mortality. Morbidity (transient hepatic failure (n=2) and intra-operative hemorrhage necessitating splenectomy (n=1)) occurred in 3 patients. Median follow-up was 12 (1-88) months. Six patients developed recurrent liver disease; 2 relapsed elsewhere. Six of these 8 patients died. Overall median survival following liver resection was 57 months with 1-, 2- and 3-year survival rates of 100%, 71.4% and 53.6% respectively. CONCLUSIONS: Liver resection is a viable treatment option for selected patients with isolated HM from breast cancer that can be performed safely. It should be considered in individual patients if the operative risk is low, if no extrahepatic disease is present and provided a complete resection with clear margins is technically feasible.     

Aggressive hepatectomy for complete remission of metastatic germ cell tumor following chemotherapy: report of a case

A 12-year-old girl presented with hemoperitoneum caused by disseminated liver tumors accompanying a retroperitoneal germ cell tumor and was rescued by transcatheter hepatic arterial embolization. Following systemic chemotherapy, the liver tumors decreased in size and number, although the retroperitoneal tumor was resistant to therapy. We simultaneously resected the retroperitoneal tumor, and the liver lesions by extended left lobectomy combined with resection of the three major (right, middle, and left) hepatic veins, while preserving the inferior right hepatic vein. The postoperative course was uneventful, and liver regeneration evaluated by serial computed tomography was almost completed by three months following surgery. Pathological examination of the resected tumors revealed benign (mature) teratomas. Since complete removal of tumors critically influences the outcome in patients with mature teratoma, aggressive surgery is advocated for extensive tumors. The present case clearly demonstrated that extended hepatectomy with resection of three major hepatic veins is feasible and provides an opportunity for achieving complete remission in patients with metastatic germ cell tumor of the liver.     

Efficacy of only left side approach in a case of unsuccessful reconstruction of the right hepatic artery after left hepatic lobectomy with caudal lobectomy

We report two cases that underwent extended left hepatic lobectomy combined with resection of the caudate lobe and extrahepatic bile duct only from the left side approach for hilar cholangiocarcinoma. The first case was a 54-year-old man and the second one was a 63-year-old man. Both patients had hilar cholangiocarcinoma with predominant left hepatic duct involvement and required resection and reconstruction of the right hepatic artery as well as left hepatic lobectomy. In both cases, the right hepatic lobe was never mobilized to protect the mechanical damage in the remnant liver and keep co-lateral blood supply route to the remnant liver from the diaphragm or retroperitoneum. Although arterial blood flow to the remnant right hepatic lobe was unfortunately insufficient after reconstruction of the right hepatic artery, the postoperative course was uneventful. The postoperative angiography showed co-lateral arterial blood supply to the right lobe via the subdiaphragmatic artery. In case of extended left hepatic lobectomy combined with resection of the caudate lobe and right hepatic artery, ipsilateral approach (approach only from the left side) is recommended.     

Laparoscopic hepatic resection for hepatocellular carcinoma. Retrospective study of 12 patients

AIMS: To assess the results of laparoscopic liver resection for hepatocellular carcinoma. PATIENTS AND METHODS: From 1998 to 2003, 12 laparoscopic liver resections for hepatocellular carcinoma were performed. RESULTS: There were no operative complications and no deaths. Conversion to laparotomy was required in one patient (8%) and transfusion in three patients (25%). One patient died of liver failure. Postoperative complications occurred in three patients (25%): trocar site bleeding, cardiac failure and biliary collection. The mean hospital stay was 5 days. No ascites and no transient liver failure occurred. During the mean follow up of 15 months the recurrence rate was 45.5%. No port site or peritoneal metastases were observed. Treatment of recurrence was second resection in two patients and microwave coagulation therapy in two other patients. Mean survival was 24 months. CONCLUSION: Laparoscopic liver resection is feasible in hepatocellular carcinoma if the tumor is unique, smaller than 5 centimeters and located in the left lateral segments or in the anterior or inferior segments of the right liver. Postoperative morbidity is low and long-term results seem to be similar to laparotomy.     

Successful resection of cecal hepatic metastasis extending into the right side of the heart under cardiopulmonary bypass

Resection is the best hope for the cure of colorectal metastasis to the liver. However, surgery is indicated for only a few patients, especially those who have major vascular involvement. We report a 55-year-old woman with a liver metastasis from the cecum that showed a tumor thrombus in the right side of the heart. She had undergone laparoscopic right hemicolectomy for cecal cancer 6 months before, and presented with a palpable mass in the epigastrium. Abdominal ultrasonography, computed tomography, hepatic angiogram, and echocardiography showed a huge mass on the left lobe of the liver, with a tumor thrombus which extended to the right ventricle through the left hepatic vein and inferior vena cava. Tumor thrombectomy, through a right atriotomy, was success-fully performed under cardiopulmonary bypass, followed by left hepatic lobectomy. The patient's postoperative course was uneventful.     

Leiomyosarcoma of the heart--interdisciplinary therapeutic approach of systemic chemotherapy and subsequent heart transplantation

HISTORY AND ADMISSION FINDINGS: A 35-year-old man reported progressive exercise dyspnea, decreased exercise tolerance and weight loss of 10 kg in 2 months. Imaging tests demonstrated a tumor of maximally 7 cm diameter in the region of the left atrium. Histologically it was a poorly differentiated leiomyosarcoma G 3, which could not be completely resected (R 2 resection). SUBSEQUENT INVESTIGATION: Six weeks after surgical resection a rapidly growing tumor, maximally 7.5 cm in diameter, was visualized at the right lateral region of the left atrium. It filled it almost completely and extended via the right upper pulmonary vein to the right hilus. TREATMENT AND COURSE: As part of a multimodal therapeutic approach he was given 6 cycles of chemotherapy (doxorubicin and ifosfamide), bringing about significant reduction of the tumor size. The tumor was then completely resected, followed by an orthotopic heart transplantation with right pneumonectomy. The resected surgical specimen indicated complete remission, no vital tumor cells being demonstrated. No tumor recurrence or distal metastasis was seen during a follow-up period of 36 months. The patient died from right heart failure with advanced pulmonary hypertension 45 months after the diagnosis had first been made, 37 months after the cardiac transplantation.     

Spontaneous regression of colorectal liver metastasis

A 72-year-old woman with advanced ascending colon cancer and an intraductal papillary mucinous neoplasm (IPMN) of the pancreatic head was treated by right hemicolectomy (RHC) and pylorus-preserving pancreaticoduodenectomy (PpPD). Adjuvant chemotherapy was not administered. Multimodal examinations at 5 months after surgery detected a solitary metastatic liver tumor derived from cancer of the ascending colon. Liver resection proceeded at 7 months after the first surgery. A pathological study of a surgical specimen of the liver identified a necrotic nodule that did not contain viable tumor cells. However, an immunohistological study of the hepatic mass indicated metastasis derived from cancer of the ascending colon. These findings were consistent with total necrosis of a liver metastasis of colorectal cancer. The mechanism of spontaneous regression of tumors remains unexplained. In our case, pancreaticoduodenectomy was performed at the same time as right hemicolectomy, which involved a risk of continuous biliary infection after biliary tract reconstruction. A host immune response to chronic biliary tract infection might have been involved in the spontaneous regression of liver metastasis. Spontaneous regression of colorectal liver metastasis is rare, and the mechanism remains unknown. This needs to be investigated in more tissues from patients who have experienced this phenomenon.     

Anatomic resection of segments 5, 6 and 7 of liver for hepatocellular carcinoma: prior control of right paramedian Glisson

Anatomic resection is theoretically effective in eradicating intrahepatic metastasis of hepatocellular carcinoma (HCC). In patients who undergo a larger volume of hepatectomy or who have hepatic dysfunction, the extent of hepatectomy is limited to avoid postoperative hepatic failure. In the present case, a limited anatomic resection according to Couinaud's segment was performed because of the large volume of the right hemi-liver. A 62-year-old male was found to have a 12-cm HCC in segments 5, 6 and 7, with alcoholic liver disease. The total liver function was Child-Pugh grade A, as indocyanine green retention rate at 15 minutes (ICGR15) was 12%. The resected liver volume of right hemihepatectomy estimated by CT volumetry was 72% and the permitted resected volume based on Takasaki's formula applying ICGR15 was 65%. As the portal branches of segment 8 was free from HCC involvement and the estimated volume of segments 5, 6 and 7 was 51%, we scheduled anatomic resection of these segments to secure remnant liver function. Under Pringle's maneuver, hepatic transection on the border between right and left liver was performed and the right paramedian Glisson's pedicle was exposed in the first step. Branches of segment 5 were divided and the border between segments 5 and 8 was confirmed. Then, the right lateral sector was resected and the right hepatic vein draining segment 8 was secured. Postoperative course was satisfactory and the patient was free from tumor relapse for 16 months after hepatectomy. Under a balance between tumor location and hepatic functional reserve, anatomic resection would be necessary for the treatment of HCC patients.