Gallbladder metastasis from hepatocellular carcinoma: Report of a case and review of literature

A case of clear cell-hepatocellular carcinoma accidentally found in the gallbladder wall after laparoscopic resection of gallbladder empyema: Beware of the liver bed

INTRODUCTION AND IMPORTANCE

Hepatocellular carcinoma (HCC) invading the gallbladder is a rare scenario, even in the context of an advanced tumor. The clear cell variant of HCC (CC-HCC) is also rare. However, CC-HCC is more frequent in women and those with liver cirrhosis, and the standard definition is the presence of transparent cytoplasm in at least 50 % of tumor cells.

CASE PRESENTATION

An accidental finding of HCC was made during histological examination of a gallbladder empyema specimen from a 74 year-old male patient. The tumor was found to be invading the wall of the gallbladder. On post-operative imaging, the HCC was identified in liver segments 4b, 5 and 6, with extensive portal vein thrombosis; without other distant spread. The tumor in our case was almost exclusively comprised of clear cells (>90 %); therefore, it was classified as CC-HCC.

CLINICAL DISCUSSION

Tumors are rarely discovered along with acute cholecystitis. Furthermore, HCC rarely invades the wall of the gallbladder. HCC with clear cell histology should be distinguished from other regional and metastatic tumors of similar morphology.

CONCLUSION

In this particular case, we provide an unusual circumstance in which HCC invaded the gallbladder wall and was found by chance in a specimen obtained after a cholecystectomy. Malignancy remains an under-recognized clinical scenario that is easily overlooked when assessing patients presenting with cholecystitis. We report our case with an additional focus on the findings of computed tomography (CT) as well as the clinicopathological characteristics pertinent to this distinctive histologic pattern of CC-HCC.

Case report and literature review: Isolated HCC- recurrence in gallbladder after curative resection

Background

Liver resection (LR) is considered the mainstay treatment for eligible patients with hepatocellular carcinoma (HCC) and provides a 5-year overall survival (OS) of 60%-80%. However, the recurrence rate within five years after LR remains high, ranging from 40% to 70%. Recurrence in gallbladder after liver resection is extremely rare. Here, we present a case of isolated recurrence in gallbladder after curative resection of HCC and review the relevant literature. No similar cases have been reported before.

Case presentation

A 55-year-old male patient was diagnosed with HCC in 2009 and subsequently underwent a right posterior sectionectomy of the liver. In 2015, the patient underwent liver tumor radiofrequency ablation and three transarterial chemoembolization (TACE) procedures in succession for HCC recurrence. In 2019, a gallbladder lesion was detected by computed tomography (CT) without perceivable intrahepatic focus. We performed an en bloc resection of the gallbladder and hepatic segment IVb. The pathological biopsy suggested that the gallbladder tumor was moderately differentiated HCC. The patient survived more than 3 years in good condition, and there were no signs of tumor recurrence.

Conclusions

In patients with isolated gallbladder metastasis, if the lesion can be resected en bloc without remnants, surgery should be the preferred option. Both postoperative molecularly targeted drugs and immunotherapy are expected to improve the long-term prognosis.

Imaging of gallbladder metastasis

Gallbladder metastasis (GM) is a rare condition, often with a late diagnosis or detected upon autopsy. There is no extensive literature on the imaging diagnosis of GM. Here we present a comprehensive review of the literature with the aim of helping to interpret the clinical findings and imaging features of such patients. Few studies on GM are reported in literature. GM by melanoma accounts for about 55.6% of cases. The remaining cases origin from breast cancer (13.6%), hepatocellular carcinoma (13.6%), renal cell carcinoma (6.8%), lung cancer (4.5%), lymphoma (3.5%) and gastric cancer (2.4%). The most common clinical presentation of GM is abdominal pain from cholecystitis due to obstruction of the cystic duct. The main ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI) findings that clinicians and radiologists should consider in their everyday medical activity were discussed. The diagnosis of GM was often achieved through a combination of more than one imaging modality. In more than 90% of cases, the diagnosis of GM is often late and combined with other organs involvement in the terminal stage of the malignancy. The knowledge of the clinical features and different imaging techniques through careful evaluation of the gallbladder can help to achieve early diagnosis and avoid misdiagnosis or false negative results.

A case of resected hepatocellular carcinoma with gallbladder metastasis

Background

Advanced hepatocellular carcinoma (HCC) can often spread as intrahepatic metastases. Extrahepatic metastasis (e.g., lung, lymph nodes, and bones) is rare, and gallbladder metastasis from HCC is extremely rare.

Case presentation

A 66-year-old woman who presented with right hypochondrial pain was referred to our hospital for further examination of a liver tumor. The blood chemistry data showed elevated levels of serum α-fetoprotein (AFP) (3730 ng/mL), protein induced by vitamin K absence or antagonist II (PIVKA-II) (130 mAU/mL), and carcinoembryonic antigen (CEA) (358.6 ng/mL). Hepatitis B surface antigen and hepatitis C virus antibody were negative. Dynamic computed tomography (CT) showed a tumor measuring 12 × 7 cm in the right lobe of the liver. This tumor was contrast-enhanced in the hepatic arterial phase and then became less dense than the liver parenchyma in the portal phase. A well-enhanced tumor was found in the gallbladder. No regional lymph nodes were enlarged. Contrast-enhanced magnetic resonance imaging (MRI) demonstrated that the liver tumor showed a pattern of early enhancement and washout. The gallbladder tumor was also detected as an enhanced mass. Endoscopic retrograde cholangiography (ERC) showed compression of the left hepatic duct due to the liver tumor. The patient was diagnosed with simultaneous HCC and gallbladder cancer. Right hepatic trisectionectomy and caudate lobectomy with extrahepatic bile duct resection were performed. Histopathological examination of the resected liver specimen showed a poorly differentiated HCC cell component with a trabecular and solid growth, and diffuse invasion of the portal vein. The same tumor cells were found in the gallbladder, but no continuity with the liver tumor was identified. Immunohistochemistry of the liver tumor and gallbladder was positive for AFP, Glypican 3, and CK7, and negative for CK19. The final pathological diagnosis was the gallbladder metastasis from HCC. A follow-up diagnostic image 33 months after surgery showed a mass in the upper lobe of the left lung. The patient underwent left upper lobectomy. Postoperative pathology revealed that the lung lesion was a metastasis of HCC. The patient was still alive with lung metastasis and was being treated with a molecular-targeting drug in good health 42 months after the initial surgery.

Conclusions

The standard treatment for advanced HCC with extrahepatic metastases is molecularly targeted drugs, but surgery is also an option if the lesion can be resected en bloc without remnants.

A Rare Presentation of Hepatocellular Carcinoma Infiltrating the Gallbladder

Hepatocellular carcinoma (HCC) is a solid tumor of the liver and one of the most common primary tumors of the liver. Lifestyle being a major risk factor for the development of HCC makes it a major public health concern worldwide. HCC rarely infiltrates the gall bladder because it rarely destroys the muscle layer and collagen fibers of the gallbladder wall. We report here a rare case of hepatocellular carcinoma that invaded the gallbladder and was initially misdiagnosed as primary gallbladder malignancy invading the liver.

Results of laparoscopic radiofrequency ablation for HCC. Could the location of the tumour influence a complete response to treatment? A single European centre experience

INTRODUCTION

In selected patients, radiofrequency ablation (RFA) is a well-established treatment for hepatocellular carcinoma (HCC). However, subcapsular or lesions close to adjacent viscera preclude a percutaneous approach. In this setting laparoscopic-RFA (LRFA) is a potential alternative. The aim of this study was to analyse the safety and feasibility of LRFA in patients with HCC.

PATIENTS AND METHODS

Retrospective study of patients with HCC meeting strict inclusion criteria who underwent LRFA at a single Institution from December 2000 to March 2013.

RESULTS

Forty-one patients underwent 42 LRFA of 51 nodules. The median size of the nodule was 2.5 (range 1.2-4.7) cm. Thirty-one tumours were subcapsular and 17 located near the gallbladder. Major complications occurred in 17 patients. The initial complete response (ICR) rate was 94% and was lower among tumours located adjacent to the gallbladder. At the end of the follow-up period, the sustained complete response (SCR) rate was 70% and was lower in tumours adjacent to the gallbladder while increased for subcapsular tumours. The 1-, 3- and 5-year overall survival rate was 92.6%, 64.5% and 43%, respectively.

CONCLUSION

LRFA of HCC is safe, feasible and achieves excellent results in selected patients. LRFA should be the first-line technique for subcapsular lesions as it minimizes the risk of tumoural seeding and improves ICR. Proximity to gallbladder interferes in treatment efficacy (lower rate of ICR and lower rate of SCR).

Tackling hepatitis B virus-associated hepatocellular carcinoma--the future is now

Hepatocellular carcinoma (HCC) is one of the most lethal and prevalent cancers in many developing countries including India. Among the various etiological factors being implicated in the cause of HCC, the most important cause, however, is hepatitis B virus (HBV) infection. Among all HBV genes, HBx is the most critical carcinogenic component, the molecular mechanisms of which have not been completely elucidated. Despite its clinical significance, there exists a very elemental understanding of the molecular, cellular, and environmental mechanisms that drive disease pathogenesis in HCC infected with HBV. Furthermore, there are only limited therapeutic options, the clinical benefits of which are insignificant. Therefore, the quest for novel and effective therapeutic regimen against HBV-related HCC is of paramount importance. This review attempts to epitomize the current state of knowledge of this most common and dreaded liver neoplasm, highlighting the putative treatment avenues and therapeutic research strategies that need to be implemented with immediate effect for tackling HBV-related HCC that has plagued the medical and scientific fraternity for decades. Additionally, this review proposes a novel "five-point" management algorithm for HBV-related HCC apart from portraying the unmet needs, principal challenges, and scientific perspectives that are relevant to controlling this accelerating global health crisis.