Direct biliopancreatoduodenal invasion by hepatocellular carcinoma: report of the first resected case and review of the literature

Duodenal Hemorrhage Due to an Invasive Hepatocellular Carcinoma Controlled by Transarterial Embolization

Upper gastrointestinal (GI) bleeding due to duodenal invasion is a very unusual presentation revealing the initial diagnosis of hepatocellular carcinoma (HCC), especially in patients without cirrhosis. No clear recommendations are available in this setting. A 68-year-old man was admitted to the emergency department with melena. The esophagogastroduodenoscopy (EGD) revealed an oozing hemorrhagic ulcer of the duodenal bulb (Forrest I b) secondary to an invasive, undetermined bulky liver mass that was biopsied. The histopathological examination confirmed an HCC. The patient was started on chemotherapy (Gemcitabine and Oxaliplatin) with good initial response. Nevertheless, after eight months of treatment, there was a recurrence of the ulcer bleeding and a disease progression was identified. Selective transarterial embolization (TAE) was used to control the duodenal bleeding, permitting the patient to receive immunotherapy with a long-lasting control of the disease. Our case report suggests that selective TAE is a therapeutic option that can be used to stop GI bleeding due to invasive HCC in order to allow oncological treatment.

Hepatocellular Carcinoma with Gastrointestinal Involvement: A Systematic Review

In this paper, we aimed to evaluate clinical and imagistic features, and also to provide a diagnostic algorithm for patients presenting with gastrointestinal involvement from hepatocellular carcinoma (HCC). We conducted a systematic search on the PubMed, Scopus and Web of Science databases to identify and collect papers oncases of HCC with gastrointestinal involvement. This search was last updated on 29 April 2022. One hundred and twenty-three articles were included, corresponding to 197 patients. The majority of the patients were male (87.30%), with a mean age of 61.21 years old. The analysis showed large HCCs located mainly in the right hepatic lobe, and highly elevated alfa-fetoprotein (mean = 15,366.18 ng/mL). The most frequent etiological factor was hepatitis B virus (38.57%). Portal vein thrombosis was present in 27.91% of cases. HCC was previously treated in most cases by transarterial chemoembolization (32.99%) and surgical resection (28.93%). Gastrointestinal lesions, developed mainly through direct invasion and hematogenous routes, were predominantly detected in the stomach and duodenum in equal measure—27.91%. Gastrointestinal bleeding was the most common presentation (49.74%). The main diagnostic tools were esophagogastroduodenoscopy (EGD) and computed tomography. The mean survival time was 7.30 months. Gastrointestinal involvement in HCC should be included in the differential diagnosis of patients with underlying HCC and gastrointestinal manifestations or pathological findings in EGD.

Hepatocellular carcinoma with duodenal invasion resected subsequent to multimodal therapies: A case report

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Hepatocellular carcinoma (HCC) with duodenal invasion is a very rare occurrence.

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Aggravated disease condition of HCC with duodenal invasion usually makes surgical treatment not advisable.

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We present the first case of HCC with duodenal invasion resected following a multimodal therapy that included sorafenib.

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Partial hepatectomy in conjunction with partial duodenectomy was selected to lessen surgical stress.

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Surgical resection should be taken into consideration as a therapeutic choice even in progressive HCC disease condition.

Introduction

Gastrointestinal (GI) involvement in hepatocellular carcinoma (HCC) is uncommon. In particular, HCC with duodenal invasion is known to be a rare condition. In such cases, surgical indication has been generally negative except in few reported cases. To our knowledge, this report describes the first case of HCC with duodenal invasion, resected by hepatectomy accompanied by pancreas-preserving partial duodenectomy (HPPD) following multimodal therapies including systemic sorafenib administration.

Case presentation

A 65-year-old man had been repeatedly treated for multiple HCCs by transarterial chemoembolization (TACE) and sorafenib. However, the main tumor formerly ruptured began to involve his duodenum, causing GI bleeding. The collateral vessels from the pancreatic and omental branches entered the tumor and nullified the transarterial hemostatic embolization. Hence, HPPD was performed to preserve the major Vater papilla. Histopathological examination revealed poorly-to -moderately differentiated HCC cells invading the duodenum.

Discussion and conclusion

HPPD treatment successfully removed HCC with duodenal invasion achieving viable tumor clearance status (R0). We underline the importance of achieving viable tumor clearance status at any time during the treatment course of patients with advanced HCC as this approach may be the only approach to enable HCC patients with duodenal invasion to resume a healthy life.