Radiotherapy in the treatment of duodenal bleeding due to hepatocellular carcinoma invasion

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.

An unusual cause of upper gastrointestinal bleeding due to recurrent hepatocellular carcinoma: A case report

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Hepatocellular carcinoma invading to gastrointestinal tract can present as bleeding.

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Invasion to gastrointestinal tract by hepatocellular carcinoma is relatively rare.

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Long term survival can be achieved by en bloc resection even if hepatocellular carcinoma invades into nearby organs.

Introduction

Upper gastrointestinal bleeding (UGIB) in patients suffering from hepatocellular carcinoma (HCC) is usually due to oesophageal or gastric varices secondary to portal hypertension. Very rarely, HCC can directly invade into the stomach or duodenum resulting in UGIB.

Presentation of case

A 62-year-old man presented to the emergency department for haematemesis and tarry stool. He was a hepatitis B carrier and had received open radiofrequency ablation and wedge resection for HCC previously. Urgent endoscopy and contrast computed tomography confirmed recurrent HCC invading into the duodenum. The patient received radical resection and remained disease free for 7 years after the operation.

Discussion

Direct invasion into gastrointestinal tract by HCC is rare. Different modalities of treatment have been reported in the literature with variable success. En-bloc resection should be considered if surgically feasible in order to achieve good haemostasis and possible long term survival.

Conclusion

Upper gastrointestinal bleeding is a rare presentation of hepatocellular carcinoma and long term survival can be achieved by curative surgery.

Massive and life-threatening upper gastrointestinal bleeding due to invasive hepatocellular carcinoma: A case report

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Hepatocellular carcinoma (HCC), which constitutes more than 90% of primary liver cancers, is a major global health problem.

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In HCC, 30% of cancer related deaths is due to hepatic failure, and 10% is due to gastrointestinal (GI) bleeding. GI metastasis is reported as 0.4-2%. GI bleeding frequency due to HCC direct invasion is 0.05-2%, and may be fatal.

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Besides, the repetition of TAE, intra-arterial chemotherapy, radiotherapy, and individualized treatment plans have recently increased survival in unresectable HCC patients, and thus it is expected that GI involvement will be more commonly encountered in HCC patients in the near future.

Background

The mean survival is less than 6 months in hepatocellular carcinoma (HCC) patients with extrahepatic metastasis. Gastrointestinal(GI) bleeding frequency due to HCC invasion is 0.05% to 2.0%, and may be fatal.

Case presentation

We encountered a case of HCC with direct invasion to the gastrium that caused a life-threatening upper GI bleeding. Our patient was a 62 year old male who was a heavy smoker and drinker for almost 30 years. He had several upper GI bleeding episodes during the previous 6 months. Computed tomography (CT) revealed a 13 cm liver tumour directly invading the gastrium. Partial hepatic resection and subtotal gastrectomy were performed. Unfortunately, the patient died at the intensive care unit postoperatively due to hepatic failure.

Discussion

Although the prognosis of HCC that has invaded the gastrium is very poor due to the advanced stage of the disease, surgical resection may be a favourable treatment option for patients with a massive upper GI bleeding.

Conclusions

The incidence of patients with massive bleeding due to gastric invasion of HCC is low, and only a few cases have been reported in the literature. Our purpose while presenting this rare case is to increase the awareness about the issue.

Hepatogastric Fistula following Transcatheter Arterial Chemoembolization of Hepatocellular Carcinoma

Hepatogastric fistula (HGF) formation following transcatheter arterial chemoembolization (TACE) leads to increased morbidity and mortality. A 51-year-old Caucasian male with chronic hepatitis B virus-associated cirrhosis and unresectable hepatocellular carcinoma (HCC) presented to the Interventional Radiology Unit for TACE to achieve tumor necrosis. Following the procedure, the patient was admitted with symptoms of fever, epigastric and right upper quadrant pain secondary to the development of an abscess. The abscess was drained; however, an exceedingly rare HGF resulted that was favored to represent a direct invasion of HCC. HGF, the rare complication following TACE, leads to grave consequences and vigilant monitoring, for the development of this entity is recommended to reduce patient mortality. We present a case and literature review of HGF development following TACE for HCC.

Hepatocellular carcinoma with duodenal invasion and metastasis

BACKGROUND AND AIM

Hepatocellular carcinoma (HCC) is the leading cause of cancer-related deaths in Taiwan. HCC with duodenal involvement are rare and are associated with a poor prognosis. The purpose of this retrospective study was to collect clinical information and data regarding survival following various treatments.

METHODS

Between 1996 and 2009, 21 cases (17 men) were diagnosed with HCC and duodenal invasion and metastases by diagnostic imaging, endoscopy with biopsy, or surgically collected specimens sent to pathology. The clinical course was analyzed from the patients' medical records.

RESULTS

Gastrointestinal bleeding was reported in 18/21 patients. Diagnostic imaging showed that the majority of cases involved direct tumor invasion (predominantly from the right liver lobe) and six cases from metastasis. Tumor mass and ulcerations were the most common features noted on endoscopy. In addition to the component therapy and medication treatment, panendoscopic hemostasis, surgery, transcatheter arterial embolization, and radiotherapy were performed for the management of duodenal involvement and gastrointestinal bleeding. Survival duration after duodenal involvement ranged from 0.2 to 57.8 months (mean 10.5 months).

CONCLUSIONS

Gastrointestinal bleeding in advanced HCC should raise suspicions of duodenal involvement. HCC can involve the duodenum by direct invasion (from either the left or right liver lobes) or metastasis. The prognosis for HCC patients with duodenal involvement is poor, but is improved by supportive care and application of various treatment modalities.

Endoscopic treatment of duodenal bleeding caused by direct hepatocellular carcinoma invasion with an ethanol injection

We report a case of a man who developed duodenal bleeding caused by direct hepatocellular carcinoma (HCC) invasion, which was successfully treated with endoscopic ethanol injection. A 57-year-old man with known HCC was admitted for melena and exertional dyspnea. He had been diagnosed with inoperable HCC a year ago. Urgent esophagogastroduodenoscopy (EGD) showed two widely eroded mucosal lesions with irregularly shaped luminal protruding hard mass on the duodenal bulb. Argon plasma coagulation and Epinephrine injection failed to control bleeding. We injected ethanol via endoscopy to control bleeding two times with 14 cc and 15 cc separately without complication. Follow-up EGD catched a large ulcer with necrotic and sclerotic base but no bleeding evidence was present. He was discharged and he did relatively well during the following periods. In conclusion, Endoscopic ethanol injection can be used as a significantly effective and safe therapeutic tool in gastrointestinal tract bleeding caused by HCC invasion.

Long term survival in patients with hepatocellular carcinoma directly invading the gastrointestinal tract: case reports and literature review

Hepatocellular carcinoma (HCC) directly invading the gastrointestinal (GI) organs is rare and is associated with poor survival outcome. We report two patients with good long-term outcome following resection of HCC that invaded the stomach and duodenum, respectively. A literature review was conducted to elucidate the course of patients with this pathology. Two cases (57-year-old and 72-year-old males) with enlarged hepatic tumors directly invading the stomach and duodenum underwent hepatectomies with en-bloc resection of the involved organs. Both patients are still alive at 80 and 68 months following the surgery. Our literature review showed that most of the patients with this pathology have manifested, and died of persistent GI bleeding. Patients who were treated surgically had a statistically significant longer survival than those who were treated with non-surgical palliative treatments (P < 0.001). In addition, patients who were treated with surgery with curative intent tend to have a longer survival times than those who were treated with surgery to palliate the bleeding but the difference was not statistically significant (P < 0.174). Removing the tumor completely could significantly prolong the survival of patients with HCC invading the GI tract.

Hepatogastric fistula caused by direct invasion of hepatocellular carcinoma after transarterial chemoembolization and radiotherapy

A 63-year-old man with a history of hepatitis-B-related hepatocellular carcinoma (HCC) in the left lateral portion of the liver received repeated transcatheter arterial chemoembolization (TACE) and salvage radiotherapy. Two months after completing radiotherapy, he presented with dysphagia, epigastric pain, and a protruding abdominal mass. Computed tomography showed that the bulging mass was directly invading the adjacent stomach. Endoscopy revealed a fistula from the HCC invading the stomach. Although the size of the mass had decreased with the drainage through the fistula, and his symptoms had gradually improved, he died of cancer-related bleeding and hepatic failure. This represents a case in which an HCC invaded the stomach and caused a hepatogastric fistula after repeated TACE and salvage radiotherapy.

Consensus and controversies in platelet transfusion

Platelet transfusion therapy is the standard of care for thrombocytopenic patients with hemato-oncological disorders and bone marrow failure states due to intensive chemoradiotherapy. Guidelines to lower triggers for prophylactic and therapeutic transfusions are being developed based on better levels of evidence. The optimum transfusion dose, the choice of platelet concentrate and transfusion interval pose a challenge to balance scientific advances with cost-effective strategies. Platelet refractoriness requires "matched" platelets and is a difficult to treat phenomenon. Pathogen inactivation is a crucial issue in view of susceptibility of platelet concentrates to bacterial contamination. This article reviews the current developments and challenges in optimizing platelet transfusion therapy.

Hepatocellular carcinoma with direct invasion to the stomach causing gastrointestinal hemorrhage

A 54-year-old man had undergone transcatheter arterial embolization (TAE) three times to treat hepatitis B virus-related hepatocellular carcinoma (HCC), but recurrence was found in June 2005. A large tumor in the left lateral portion of the liver showed extrahepatic growth and was attached to the gastric wall. TAE was performed a forth time. In September 2005, the patient was admitted with worsening anemia. Computed tomography and upper gastrointestinal endoscopy revealed that the HCC had directly invaded the stomach and caused gastrointestinal hemorrhage. Endoscopic hemostasis was effective, but the patient died because of worsening hepatic failure.

Life-threatening haemorrhage from a sternal metastatic hepatocellular carcinoma

Rupture of the tumour is a catastrophic complication of hepatocellular carcinoma. The prognosis in patients with a ruptured hepatocellular carcinoma is usually unfavourable. We describe a 46-year-old man who suffered from visible massive tumour haemorrhage due to a hepatitis B-related hepatocellular carcinoma that metastasized to the sternal bone. The prominent tumour mass was bulging over the anterior chest wall on the sternum of the patient, and bled spontaneously. This episode of life-threatening haemorrhage was stopped by surgical ligation of the bleeding site. Palliative radiotherapy shrank the tumour mass size and prevented further possible bleeding. This is likely to be the first reported case with a visible spontaneous tumour bleeding from a sternal metastatic hepatocellular carcinoma.