Late retroperitoneal recurrence of hepatocellular carcinoma 12 years after initial diagnosis

Surgical resection of late extrahepatic metastasis of hepatocellular carcinoma 11 years after initial diagnosis: case report and literature review

Hepatocellular carcinoma (HCC) is the second most common cause of cancer mortality worldwide. Liver resection is considered the pillar of curative treatment, although it is usually reserved for early-stage localized disease since the presence of metastases carries a poor prognosis. Despite advances in imaging, surgical techniques, and systemic therapy, the recurrence rate after oncologic resection remains high, even with localized disease. In the setting of extrahepatic HCC recurrence, there is no consensus regarding the best treatment strategy. Nevertheless, while the development of metastasis can be considered an expression of systemic disease, surgical resection may prolong survival. We report the case of a patient with a history of an oncologic hepatic resection for HCC, successfully treated with resection of an isolated peritoneal cavity metastasis. This case demonstrates that an aggressive approach involving the resection of extrahepatic HCC metastasis should be considered in select patients with the intention of achieving prolonged survival.

A Rare Case of Hepatocellular Carcinoma Recurrence in Ovarian Site after 12 Years Mimicking a Hepatoid Adenocarcinoma: Case Report

Hepatoid carcinoma of the ovary (HCO) is a tumor that resembles, both histologically and cytologically, hepatocarcinoma (HCC) in a patient with a non-cirrhotic liver not involved by the disease. Hepatoid carcinoma is an extremely rare histologic subtype of ovarian cancer and should be distinguished from metastatic HCC. Here, we report the rare case of a 67-year-old woman with ovarian recurrence of HCC 12 years after first diagnosis. The patient was being followed by oncologists because she had been diagnosed with HCV-related HCC (Edmonson and Stainer grade 2, pT2 N0 M0, G2, V1) in 2009. She had undergone surgery for enlarged left hepatectomy to the 4th hepatic segment with cholecystectomy and subsequent placement of a Kehr drain. The preoperative alpha-fetoprotein (AFP) level was 8600 ng/mL, while the postoperative value was only 2.7 ng/mL. At the first diagnosis, no other localizations of the disease, including the genital tract, were found. At the time of recurrence, however, the patient was completely asymptomatic: her liver function was within normal limits with negative blood indices, except for an increased blood dosage of AFP (467 ng/mL), and CA125, which became borderline (37.4 IU/mL). The oncologist placed an indication for a thoracic abdominal CT scan, which showed that the residual liver was free of disease, and the presence of a formation with a solid-cystic appearance and some calcifications at the left adnexal site. The radiological findings were confirmed on level II gynecological ultrasound. The patient then underwent a radical surgery of hysterectomy, bilateral oophorectomy, pelvic peritonectomy, and omentectomy by a laparotomic approach, with the sending of intraoperative extemporaneous histological examination on the annexus site of the tumor mass, obtaining RT = 0. Currently, the patient continues her gyneco-oncology follow-up simultaneously clinically, in laboratory, and instrumentally every 4 months. Our study currently represents the longest elapsed time interval between first diagnosis and disease recurrence, as evidenced by current data in the literature. This was a rather unique and difficult clinical case because of the rarity of the disease, the lack of scientific evidence, and the difficulty in differentiating the primary hepatoid phenotype of the ovary from an ovarian metastasis of HCC. Several multidisciplinary meetings for proper interpretation of clinical and anamnestic data, with the aid of immunohistochemistry (IHC) on histological slides were essential for case management.

Solitary Metastasis of Hepatocellular Carcinoma to the Rectus Abdominis 13 Years After the Initial Treatment

Solitary muscle metastasis of hepatocellular carcinoma (HCC) is extremely rare, and late metastasis is also rare. We present a 59-year-old man who had received initial treatment for HCC 13 years previously. Ultrasonography revealed a tumor between the abdominal wall and the liver surface. Tumor resection was performed with suspected intrahepatic metastasis or abdominal wall metastasis of HCC, and the tumor was found to be within the rectus abdominis without an association with the liver. Histologically, the resected material was confirmed to be a muscle metastasis of HCC. We discuss the management of muscle metastasis of HCC.

Late solitary pelvic metastasis of hepatocellular carcinoma mimicking alpha-fetoprotein-producing gynaecologic tumour

Extrahepatic spread of hepatocellular carcinoma (HCC) is uncommon; and, pelvic metastasis, in particular, is extremely rare. A 71-year-old woman was admitted for evaluation of pelvic solitary solid mass. She had undergone a left lobectomy 28 years previously. Magnetic resonance imaging of the abdomen and pelvis demonstrated a heterogeneous mass in the right pelvic cavity, whereas no space-occupying lesions or ascites were detected in the liver. CA 125 levels were within normal limits; however, serum alpha-fetoprotein levels were markedly elevated. She underwent laparoscopic pelvic mass excision, total hysterectomy, and bilateral salpingo-oophorectomy. Histopathologic findings and immunochemical staining results indicated metastatic HCC. Herein, we report an unusual case of a patient with solitary recurrence in the pelvic cavity 28 years after initial diagnosis and treatment.

Late recurrence of hepatocellular carcinoma after liver transplantation

Background

Long-term survival of patients with hepatocellular carcinoma (HCC) after liver transplantation is affected mainly by recurrence of HCC. There is the opinion that the chance of recurrence after 2 years post-transplantation is remote, and therefore lifelong surveillance is not justified because of limited resources. The aims of the present study were to determine the rate of late HCC recurrence (≥2 years after transplantation) and to compare the long-term patient survival outcomes between cases of early recurrence (<2 years after transplantation) and late recurrence.

Patients

A total of 139 adult HCC patients having liver transplantation during the period from July 1994 to December 2007 were included in the analysis. The median follow-up period was 55 months. Thirty-two patients received deceased-donor grafts and 107 received living-donor grafts.

Results

Hepatocellular carcinoma recurrence occurred in 24 (17.3%) patients, among them 22 (86%) had living-donor grafts and 7 (5%) developed late recurrence. Patients in the early recurrence group and patients in the late recurrence group had comparable demographics and disease pathology. The former group, when compared with the latter, had significantly worse overall survival at 3 years (13.3 versus 100%) and 5 years (6.67 versus 71.4%) (log-rank test; p < 0.001).

Conclusions

Both early recurrence and late recurrence of HCC after liver transplantation were not uncommon, mostly detected at a subclinical stage. Regular and long-term surveillance with imaging and blood tests is essential for early detection.