1
|
Wu WK, Patel K, Padmanabhan C, Idrees K. Hepatocellular carcinoma presenting as an extrahepatic mass: A case report and review of literature. World J Gastrointest Oncol 2024; 16:2241-2252. [PMID: 38764834 PMCID: PMC11099426 DOI: 10.4251/wjgo.v16.i5.2241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/03/2024] [Accepted: 03/20/2024] [Indexed: 05/09/2024] Open
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is a primary liver tumor generally diagnosed based on radiographic findings. Metastatic disease is typically associated with increased tumor diameter, multifocality, and vascular invasion. We report a case of a patient who presented with extrahepatic HCC metastasis to a portocaval lymph node with occult hepatic primary on computed tomography (CT). We review the literature for cases of extrahepatic HCC presentation without known hepatic lesions and discuss strategies to differentiate between metastatic and ectopic HCC. CASE SUMMARY A 67-year-old male with remotely treated hepatis C was referred for evaluation of an enlarging portocaval, mixed cystic-solid mass. Serial CT evaluations demonstrated steatosis, but no cirrhosis or liver lesions. Endoscopic ultrasound demonstrated a normal-appearing pancreas, biliary tree, and liver. Fine needle aspiration yielded atypical cells. The differential diagnosis included duodenal or pancreatic cyst, lymphoproliferative cyst, stromal or mesenchymal lesions, nodal involvement from gastrointestinal or hematologic malignancy, or duodenal gastro-intestinal stromal tumor. After review by a multidisciplinary tumor board, the patient underwent open surgical resection of a 5.2 cm × 5.5 cm retroperitoneal mass with pathology consistent with moderately-differentiated HCC. Magnetic resonance imaging (MRI) subsequently demonstrated a 1.2 cm segment VIII hepatic lesion with late arterial enhancement, fatty sparing, and intrinsic T1 hyperintensity. Alpha fetoprotein was 23.3 ng/mL. The patient was diagnosed with HCC with portocaval nodal involvement. Review: We surveyed the literature for HCC presenting as extrahepatic masses without history of concurrent or prior intrahepatic HCC. We identified 18 cases of extrahepatic HCC ultimately found to represent metastatic lesions, and 30 cases of extrahepatic HCC found to be primary, ectopic HCC. CONCLUSION Hepatocellular carcinoma can seldomly present with extrahepatic metastasis in the setting of occult primary. In patients with risk factors for HCC and lesions suspicious for metastatic disease, MRI may be integral to identifying small hepatic lesions and differentiating from ectopic HCC. Tumor markers may also have utility in establishing the diagnosis.
Collapse
Affiliation(s)
- Wei Kelly Wu
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, United States
| | - Krutika Patel
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN 37232, United States
| | - Chandrasekhar Padmanabhan
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, United States
| | - Kamran Idrees
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, United States
| |
Collapse
|
2
|
Mochizuki Y, Mizokami K. Adrenalectomy in a Patient With Recurrent Hepatocellular Carcinoma in the Adrenal Gland: A Case Report. Cureus 2023; 15:e45682. [PMID: 37868545 PMCID: PMC10590059 DOI: 10.7759/cureus.45682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2023] [Indexed: 10/24/2023] Open
Abstract
Hepatocellular carcinoma recurrence in the adrenal gland is clinically rare, for which there are no clear criteria for examination or treatment. A 70-year-old man underwent laparoscopic low anterior resection seven years prior and was diagnosed with rectal cancer stage 1 (T2N0). Right hepatic resection for suspected hepatocellular carcinoma in his liver six years and nine months prior was performed. Thereafter, the patient was diagnosed with hepatocellular carcinoma stage 3 (T3N0). During the follow-up period, elevated alpha-fetoprotein levels were detected, indicating hepatocellular carcinoma recurrence. Follow-up computed tomography in the delayed phase detected a heterogeneous 5 cm mass in the left adrenal gland. Therefore, we diagnosed the patient with recurrent hepatocellular carcinoma in the adrenal gland, for which we performed an adrenalectomy with a favorable prognosis.
Collapse
Affiliation(s)
| | - Ken Mizokami
- General Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, JPN
| |
Collapse
|
3
|
Wei N, Wong V, Matz A, Vemulakonda LA, Wang X, Phillips J. Ectopic hepatocellular carcinoma presenting as a right adrenal mass with IVC thrombus: Case report and review of the literature. Urol Case Rep 2021; 40:101900. [PMID: 34712591 PMCID: PMC8528669 DOI: 10.1016/j.eucr.2021.101900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 10/13/2021] [Indexed: 11/09/2022] Open
Abstract
Hepatocellular carcinoma (HCC) arises from several different etiologies and carries a poor prognosis. Extrahepatic metastases of HCC are most frequently found in the lungs, lymph nodes, and bones, with adrenal metastases reported in less than 15% of metastatic cases. Herein, we report a case of a 71-year-old man without prior liver disease who presented with a 9-cm right adrenal mass extending into the IVC consistent with HCC on subsequent surgical pathology and immunohistochemical staining. Etiological possibilities for an adrenal tumor as the first presentation of HCC include metastasis from occult primary liver HCC, intra-adrenal hepatic heterotopia, and adrenohepatic fusion.
Collapse
Affiliation(s)
- Nancy Wei
- New York Medical College, Valhalla, NY, USA
| | - Vincent Wong
- Department of Urology, New York Medical College, Valhalla, NY, USA
| | | | | | - Xiaotong Wang
- Department of Pathology, Westchester Medical Center, Valhalla, NY, USA
| | - John Phillips
- Department of Urology, New York Medical College, Valhalla, NY, USA
| |
Collapse
|
4
|
Survival After Adrenalectomy for Metastatic Hepatocellular Carcinoma: A 25-year Institutional Experience. World J Surg 2020; 45:1118-1125. [PMID: 33354731 PMCID: PMC7921034 DOI: 10.1007/s00268-020-05909-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2020] [Indexed: 12/30/2022]
Abstract
Background Extrahepatic manifestation of hepatocellular carcinoma (HCC) is rare and primarily affects lung, lymph nodes and bone. Metastases to the adrenal glands are relatively infrequent. This 25-year institutional experience aimed for an analysis of factors influencing survival in patients undergoing surgery for HCC adrenal metastasis. Methods A retrospective analysis of the institutional database of the Clinic for General-, Visceral- and Transplantation Surgery of the University Medical Center Mainz, Germany, was performed. Patients who underwent surgery for HCC adrenal metastases from January 1995 to June 2020 were included. Pre-, peri- and postoperative factors with potential influence on survival were assessed. Results In 16 patients (14 males, two females), one bilateral and 15 unilateral adrenalectomies were performed (13 metachronous, three synchronous). Thirteen operations were carried out via laparotomy, and three adrenalectomies were minimally invasive (two laparoscopic, one retroperitoneoscopic). Median overall survival (after HCC diagnosis) was 35 months, range: 5–198. Median post-resection survival (after adrenalectomy) was 15 months, range: 0–75. Overall survival was longer in patients with the primary HCC treatment being liver transplantation (median 66 months) or liver resection (median 51 months), compared to only palliative intended treatment of the primary with chemotherapy (median 35 months) or local ablation (median 23 months). Conclusions Surgery is a feasible treatment option for patients with adrenal metastases originating from HCC. In patients who underwent adrenalectomy for HCC adrenal metastasis, overall survival was superior, if primary HCC treatment was potentially curative (liver transplantation or resection).
Collapse
|
5
|
Nugroho A, Lee KW, Lee KB, Kim HS, Kim H, Yi NJ, Suh KS. Adrenal metastasis in sequentially developed combined hepatocellular carcinoma-cholangiocarcinoma: A case report. Ann Hepatobiliary Pancreat Surg 2018; 22:287-291. [PMID: 30215052 PMCID: PMC6125274 DOI: 10.14701/ahbps.2018.22.3.287] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 05/16/2018] [Accepted: 05/24/2018] [Indexed: 12/15/2022] Open
Abstract
The incidence of combined hepatocellular carcinoma-cholangiocarcinoma (cHCC-CC) in a single patient accounts for only 0.4 to 14% of all primary liver cancer. However, the prognosis of its intrahepatic cholangiocarcinoma (ICC) component is poor. We experienced a unique case of a sequentially developed cHCC-CC with adrenal metastasis as the primary presentation and a hidden primary hepatocellular carcinoma. A 65-year-old female with a history of jaundice and abdominal discomfort was diagnosed with S4 ICC measuring 5 cm in diameter, and characterized histologically as papillary adenocarcinoma with intraductal growth, but without any evidence of malignant hepatocyte. S4 segmentectomy with hepaticojejunostomy revealed no additional masses. A follow-up CT scan 3 months after surgery showed a right adrenal mass with markedly increased serum AFP (4950 ng/mL), which was treated with right adrenalectomy. Histopathology revealed a metastatic hepatocellular carcinoma testing positive for AFP, glypican-3, and hepatocytes, but negative for CD-10, inhibin-α, EMA, S-100, and cytokeratin-7. Serum AFP level immediately plummeted to 4.1 ng/mL upon adrenal mass removal. A recurrent S7 liver mass was suspected 1 year later with serum AFP value of 7.6 ng/mL, and characteristic CT imaging of HCC. TACE was performed with good response. Adrenal metastasis may manifest as the primary focus of hepatocellular carcinoma in sequentially developed cHCC-CC patients with hidden primary HCC. cHCC-CC should be considered in the differential diagnosis of cholangiocarcinoma with elevated AFP.
Collapse
Affiliation(s)
- Adianto Nugroho
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Department of Surgery, Fatmawati General Hospital, Jakarta, Indonesia
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung-Bun Lee
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Hyo-Shin Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyeyoung Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
6
|
Adrenal Metastasis of Hepatocellular Carcinoma in Patients following Liver Resection or Liver Transplantation: Experience from a Tertiary Referral Center. Int J Surg Oncol 2018; 2018:4195076. [PMID: 30151282 PMCID: PMC6087597 DOI: 10.1155/2018/4195076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 07/18/2018] [Indexed: 12/13/2022] Open
Abstract
Introduction Adrenal metastasis of hepatocellular carcinoma (HCC) is a rare entity and can be treated by resection, local ablative therapy, or systemic therapy. Unfortunately, data about treatment outcome, especially in liver transplant recipients, are rare. Patients and Methods From 2005 to 2015, 990 liver resections and 303 liver transplantations because of HCC were performed at our clinic. We retrospectively analyzed treatment outcome of the patients with metachronous adrenal metastasis of HCC, who received either resection, local ablation, or surveillance only. Results 10 patients were identified (0.8%). 7 patients received liver transplantation for primary HCC therapy, 3 liver resection, and 1 a local ablative therapy. 8 patients underwent adrenalectomy (one via retroperitoneoscopy), one was treated with local ablation, and one had surveillance only. Seven out of eight patients had no surgical complications and one experienced a pancreatic fistula, treated conservatively. 37.5% of the resected patients had recurrence 1 year after adrenalectomy and 75% after 2 years. The mean survival time after primary diagnosis of HCC was 96.6±22.4 months. After adrenalectomy, the mean survival time was 112.4±25.2 months. The mean time until tumor recurrence was 13.2±3.8 in the total cohort and 15.8±3.8 months in patients after adrenalectomy. The estimated overall survival after adrenalectomy was 77.2±17.4 months. Conclusion Metachronous adrenal metastasis occured in less than 1% of HCC patients. Adrenalectomy is a safe procedure and leads to acceptable survival rates even after liver transplantion. Therefore, it should be performed whenever the primary tumor is well controlled and the patient is in adequate physical condition.
Collapse
|
7
|
Adrenal metastasis as presentation of hepatocellular carcinoma. GASTROENTEROLOGIA Y HEPATOLOGIA 2018; 42:171-172. [PMID: 29650454 DOI: 10.1016/j.gastrohep.2018.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 02/28/2018] [Accepted: 03/05/2018] [Indexed: 11/20/2022]
|
8
|
Alfaqeeh FA, Algehani G, Hassanain M, Alsharaabi A, Alsohaibani M. Adrenocortical carcinoma co-occurrence with a hepatocellular carcinoma within an adrenohepatic fusion: a case report. J Surg Case Rep 2017; 2017:rjw210. [PMID: 28458841 PMCID: PMC5400440 DOI: 10.1093/jscr/rjw210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 03/21/2017] [Indexed: 12/01/2022] Open
Abstract
Adrenohepatic fusion is a relatively common condition that has been reported in the literature and explained as a result of normal aging. However, the presence of a neoplastic process in the adrenohepatic fusion is relatively uncommon. A 48-year-old male presented with RUQ abdominal pain with findings of a huge liver mass with adrenohepatic fusion in the computed tomography scan. Histopathological studies revealed a mixed, although distinctly separated, adrenocortical carcinoma and a hepatocellular carcinoma within an adrenoheaptic fusion.
Collapse
Affiliation(s)
| | - Ghadeer Algehani
- Department of Surgery, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Mazin Hassanain
- Liver Disease Research Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulsalam Alsharaabi
- Liver Disease Research Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mohammad Alsohaibani
- Department of Pathology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| |
Collapse
|
9
|
Scherzer TM, Reddy KR, Wrba F, Hofer H, Staufer K, Steindl-Munda P, Gangl A, Ferenci P. Hepatocellular carcinoma in long-term sustained virological responders following antiviral combination therapy for chronic hepatitis C. J Viral Hepat 2008; 15:659-65. [PMID: 18637075 DOI: 10.1111/j.1365-2893.2008.01006.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Antiviral treatment results in a sustained virologic response (SVR) in 50-75% of patients with chronic hepatitis C. Long-term follow up studies have observed ongoing SVR in the overwhelming majority of them. Thus chronic hepatitis C is considered 'cured' if an SVR is achieved. Consequently, it is expected that in sustained virologic responders long-term complications of hepatatic C virus (HCV) related chronic liver disease including hepatocellular carcinoma are eliminated or have a decreased incidence. We report on five patients (three from Austria, two from USA) who developed hepatocellular carcinoma during follow up (3-6 years) after achieving SVR. During follow up and at diagnosis all were HCV-RNA neg. None of the patients had other liver diseases. One patient presented with bilateral adrenal metastasis, the remaining four with large hepatic tumours. Three patients were noncirrhotic at the start of treatment at the time of tumour diagnosis. Successful antiviral treatment in HCV patients does not prevent development of hepatocellular carcinoma even in non-cirrhotic livers. Long-term follow up of patients with SVR is mandatory and should include surveillance for hepatocellular carcinoma.
Collapse
Affiliation(s)
- T-M Scherzer
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | | | | | | | | | | | | | | |
Collapse
|
10
|
Vasinanukorn P, Rerknimitr R, Sriussadaporn S, Wisedopas N, Kongkam P, Chaopapsomkul B, Snabboon T. Adrenal hemorrhage as the first presentation of hepatocellular carcinoma. Intern Med 2007; 46:1779-82. [PMID: 17978534 DOI: 10.2169/internalmedicine.46.0194] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We report a 67-year-old man who presented with sudden onset of pain in the left flank in association with anemia and hypotension. Imaging studies revealed hepatocellular carcinoma (HCC) at the right lobe of the liver with bilateral adrenal metastases and recent hemorrhage in the left adrenal gland. His serology for hepatitis C was positive. Abdominal exploration with left adrenalectomy was performed. The postoperative course of the patient was uneventful and three cycles of transarterial chemoembolization (TACE) were administered. His general condition gradually deteriorated, and he died 6 months after surgery. Spontaneous massive AH due to metastatic HCC is unusual. Considering the high incidence of HCC in Asia, clinicians should be aware of this atypical and fatal presentation.
Collapse
Affiliation(s)
- Padiporn Vasinanukorn
- Department of Internal Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok
| | | | | | | | | | | | | |
Collapse
|
11
|
Popescu I, Alexandrescu S, Ciurea S, Brasoveanu V, Hrehoret D, Gangone E, Boros M, Herlea V, Croitoru A. Adrenalectomy for metastases from hepatocellular carcinoma - a single center experience. Langenbecks Arch Surg 2006; 392:381-4. [PMID: 17187285 DOI: 10.1007/s00423-006-0135-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2006] [Accepted: 10/26/2006] [Indexed: 11/28/2022]
Abstract
BACKGROUND Adrenal metastases (AM) from hepatocellular carcinoma (HCC) are rarely seen in clinical practice. The treatment is not standardized, the indications and efficacy of different therapeutic approaches being still controversial. PATIENTS Between January 1995 and December 2005, 174 patients underwent liver resection for HCC in our center. AM were detected in four patients (2.3%): three of them had HCC and synchronous AM, and the remaining one developed AM 10 months after liver resection. All the patients with AM were treated by adrenalectomy (simultaneously with liver resection in synchronous metastases), followed by systemic chemotherapy. Non-resectable multifocal liver recurrences occurred in two patients, one of them having also a contralateral adrenal metastasis; these two patients are presently alive 26 and 43 months after adrenalectomy, respectively. Another patient died by liver recurrence 27 months postoperatively. The fourth patient is disease-free at 17 months after the initial operation. CONCLUSIONS Adrenalectomy for AM from HCC should be performed whenever the primary tumor is well therapeutically controlled and the patient has a good performance status. Adrenalectomy offers the chance of more than 2 years survival in many patients. However, once AM are detected, the prognosis remains poor.
Collapse
Affiliation(s)
- Irinel Popescu
- Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Sos. Fundeni 258, sector 2, 022328 Bucharest, Romania.
| | | | | | | | | | | | | | | | | |
Collapse
|