The hanging manoeuver to complete liver resection for a locally advanced angiosarcoma: A case report

Liver Angiosarcoma with Poor Prognosis in a 61-Year-Old Woman: A Case Report and Literature Review

PURPOSE

Hepatic angiosarcoma is very rare malignancy and more common in men than in women. To date, only a few female cases of liver angiosarcoma have been reported. Here, we report a female case of liver angiosarcoma, first detected in Vietnam, with a high malignancy stage, rapid progression, and poor prognosis.

CASE PRESENTATION

A 61-year-old woman was admitted to the Bach Mai Hospital with fatigue, anorexia, weight loss, and severe pain in the right upper quadrant for 2 weeks prior. Clinical examination detected a firm 4-cm hepatomegaly below the right costal margin and grade I splenomegaly. Abdominal ultrasonography and CT revealed diffuse lesions in the entire liver parenchyma, spreading to the spleen, while MRI showed signs of bone metastasis. Blood tests showed elevated transaminase enzymes, especially Gamma Glutamyl Transferase 501 U/L; thrombocytopenia; no anemia; and other tumor markers such as AFP, CEA, and CA19-9 were within normal limits. On CT images, the dots and nodules in the liver and spleen appeared hyperenhanced in the arterial phase and washout in the venous phase. The results of both histopathology and immunohistochemistry showed liver angiosarcoma. Surgery and radiation were not indicated due to the suspicion of bone metastasis. Chemotherapy with doxorubicin at a dose of 60 mg/m2 and intravenous infusion once every 21 days was administered. Unfortunately, during the first dose of chemotherapy with doxorubicin, side effects appeared. Since the disease developed continuously and uncontrollably, the patient was subsequently exhausted, anemic, presented peritoneal fluid, and eventually died of intra-abdominal bleeding.

CONCLUSION

For the diagnosis of liver angiosarcoma, ultrasound-guided liver biopsy could be applied for safe and effective histopathology, and selective embolization of the hepatic artery is necessary to prevent bleeding complications. The disease has a very poor prognosis, and if chemotherapy does not respond, the patient can die within six months of diagnosis.

Paraneoplastic Phenomena of Disseminated Intravascular Coagulopathy in Hepatic Angiosarcoma – Rare, Challenging and Fatal. Case Report and Literature Review

Background.

Hepatic angiosarcoma is an uncommon, malignant, primary liver tumor, comprising 2% of liver cancers and accounting for < 1% of all sarcomas. Patients usually present with nonspecific symptoms, such as fatigue, weight loss, right upper quadrant pain, anemia, which leads to late diagnosis of an advanced stage tumor. The median life expectancy after the diagnosis of hepatic angiosarcoma is about 6 months, with only 3% of patients surviving more than 2 years. Liver failure and hemoperitoneum are the leading causes of death in patients with liver angiosarcoma. In rarer cases, it might cause paraneoplastic syndromes such as disseminated intravascular coagulopathy. The treatment of angiosarcomas is complicated as there are no established and effective treatment guidelines due to the tumor’s low frequency and aggressive nature.

Case summary.

We present the case of a 68-year old woman who was admitted to the hospital due to fatigue and severe anemia (hemoglobin 65 g/l). Laboratory results also revealed high-grade thrombocytopenia (8 × 10⁹/l). The abdominal ultrasound and computed tomography scan showed multiple lesions throughout the liver, spleen and kidneys. After the histological examination of the liver biopsy, the patient was diagnosed with hepatic angiosarcoma. The treatment with first-line chemotherapy (doxorubicin) was initiated despite ongoing paraneoplastic syndrome – disseminative intravascular coagulopathy. However, the disease was terminal, and the patient died 2 months since diagnosed.

Conclusions.

Hepatic angiosarcoma is a rare and terminal tumor. Therefore, knowledge about its manifestations and effective treatment methods is lacking. Disseminative intravascular coagulopathy is a unique clinical characteristic of angiosarcoma seen in a subset of patients.

Venous drainage of the left liver: an evaluation of anatomical variants and their clinical relevance

AIM

To evaluate the variations in venous drainage from the left liver.

MATERIALS AND METHODS

A retrospective evaluation was performed of all consecutive abdominal computed tomography (CT) examinations at a tertiary referral facility between 1 January and 30 June 2018. Osirix (Pixmeo SARL, Bernex, Switzerland) was used to examine the major hepatic veins and their tributaries in each scan. The classification of variants as proposed by Nakamura and Tsuzuki was used to describe the findings. The following information was collected: ramification pattern, number, length and diameter of middle (MHV) and left (LHV) hepatic vein tributaries. Two researchers collected data independently, and the average measurements were used as the final dimensions.

RESULTS

Of 102 examinations evaluated, only 27 demonstrated the conventional venous drainage patterns. The LHV and MHV combined to form a common trunk that emptied into the inferior vena cava (IVC) in 75 (73.5%) cases. The common trunk had a mean length of 8.89 mm and mean diameter of 20.18 mm. Other patterns included Nakamura and Tsuzuki type I (27.5%), type II (29.4%) and type III variants (16.7%). In addition, 4.9% of patients had absent superior middle veins and 80% had supernumerary short hepatic veins (4%).

CONCLUSION

Only 26.5% of patients in this population had conventional venous drainage from the left liver. Surgeons and radiologists in hepatobiliary practice should be aware of these variants in order to minimise morbidity when performing invasive procedures.

Clinical outcomes after major hepatectomy are acceptable in low-volume centers in the Caribbean

BACKGROUND

Major hepatectomies are routinely performed because they are often the only curative treatment for metastatic liver disease. There has been a trend to concentrate major hepatectomies in referral hospitals that perform these operations at high volumes. These high volume referral centers are usually located in developed countries, but many patients in developing nations are not able to access these centers because of financial limitations, lack of social support and/or travel restrictions. Therefore, local hospitals are often the only options many of these patients have for surgical treatment of metastatic liver disease. This is the situation in many Caribbean countries.

AIM

To determine the clinical outcomes after major liver resections in a low-resource hepatobiliary center in the Caribbean.

METHODS

We prospectively studied all patients who underwent major liver resections over five years. The following data were extracted: patient demographics, diagnoses, ECOG status, operation performed, post-operative morbidity and mortality. Statistical analyses were performed using SPSS ver 16.0

RESULTS

There were 69 major liver resections performed by two teams at a mean case volume of 13.8 major resections/year. Sixty-nine major hepatic resections were performed for: colorectal liver metastases 40 (58%), non-colorectal metastases 9 (13%), hepatocellular carcinoma 8 (11.6%), ruptured adenomas 4 (5.8%), hilar cholangiocarcinomas 4 (5.8%), hemangiomata 2 (2.9%), trauma 1 (1.5%) and hepatoblastoma 1 (1.5%). Twenty-one patients had at least one complication, for an overall morbidity rate of 30.4%. There were minor complications in 17 (24.6%) patients, major complications in 11 (15.9%) patients and 4 (5.8%) deaths.

CONCLUSION

There are unique geographic, political and financial limitations to healthcare delivery in the Caribbean. Nevertheless, clinical outcomes are acceptable in the established, low-volume hepatobiliary centers in the Eastern Caribbean.

Liver Angiosarcoma: Rare tumour associated with a poor prognosis, literature review and case report

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Liver Angiosarcoma is rare and aggressive tumour that requires surgical management.

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Partial Hepatectomy is the ideal surgical management for Liver Angiosarcoma.

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Liver transplant does not improve the survival of Liver Angiosarcoma patients.

Introduction

Liver angiosarcoma is a very uncommon tumour of mesenchymal origin, representing between 0.1–2% of all primary tumours of the liver, affecting mainly men in their sixth or seventh decade of life, with a high mortality in the first years (Chaudhary et al., 2015). Literature reports of its surgical treatment vary from a total or partial hepatectomy with or without liver transplant.

Presentation of case

A 37 year old male, with a 7 year history of a fatty liver, was found to have a 12 cm diameter tumour in a cirrhotic liver, during an abdominal Computed Tomography (CT) scan. Patient was asymptomatic with negative tumour markers, yet tumour liver biopsy revealed a Liver Angiosarcoma with positive immunohistochemistry for neoplastic cells CD31 and CD34.

Patient was deemed candidate for a partial hepatectomy of the affected liver segments which was done without complications and no evidence of other tumour lesions was found during surgery. Patient continued oncologic management with ongoing chemotherapy.

Discusion

Liver Angiosarcoma, although rare, persists with a high mortality due to its aggressive nature. Never the less liver transplantation, although proven to be an effective treatment for many pathologies that culminate in liver failure, fails to improve patients’ survival and prognosis, when compared to partial hepatectomy as surgical management to for liver Angiosarcoma,

Conclusion

Partial hepatectomy as surgical management, followed by adjuvant therapy, for Liver Angiosarcoma continues to prove favourable results and prognosis compared to Liver Transplantation.