Intracranial Metastasis in a Patient with Hepatocellular Carcinoma and Gastric Cancer
A 76-year-old man visited our hospital because of visual disturbance, weakness of the left upper and lower limbs, and gait disturbance. The patient had been treated for cirrhosis caused by chronic hepatitis C virus (HCV) infection. Because HCC was detected, approximately 60 mm in diameter, in the right lobe, he had undergone transarterial chemoembolization 3 and 10 years earlier. When radiofrequency ablation was performed for the recurrent HCC 2 years ago, gastric cancer was incidentally found (fig. ). Subsequently, he underwent gastrectomy with D1 lymphadenectomy and the tumor was successfully removed. Pathological examination revealed that the tumor was composed of moderately differentiated tubular adenocarcinoma. The staging of the lesion was T3N0. Additionally, multiple lung tumors were concurrently detected (fig. ). The patient had neither a history of smoking nor an elevation of tumor markers for primary lung cancer (such as squamous cell carcinoma antigen and neuron-specific enolase). Since the resected gastric cancer histologically lacked an involvement of lymph nodes, we considered the possibility that lung tumors were of HCC origin. Subsequently, sorafenib was administered. Because of adverse events such as a hand-foot skin reaction, the dose of sorafenib was reduced from 800 to 200 mg/day.\nOn admission, serum levels of hepatobiliary enzymes and renal function markers such as blood urea nitrogen and creatinine were normal. The serum level of ammonia was 91 μg/dl. Although blood count tests showed slight anemia (hemoglobin: 11.5 g/dl) and thrombocytopenia (8.5 × 104/μl), his white blood cell count was normal (4,000/μl). Anti-HCV antibody was positive, but hepatitis B surface antigen was negative. The level of carcinoembryonic antigen markedly increased to 44.1 ng/ml.\nHowever, the levels of alpha-fetoprotein (AFP), des-gamma-carboxy prothrombin (DCP), and carbohydrate antigen 19–9 (CA19–9) were within the normal range (5.6 ng/ml, 21 U/ml, and 10.2 U/ml, respectively). Although the patient's consciousness level was normal [Glasgow Coma Scale was a full score (E4V5M6)], he exhibited left-sided hemifield visual disturbance and left-sided hemiparesis. Enhanced MRI revealed an intra-axial tumor in the right occipital cerebral lobe (fig. ). Taking into consideration the markedly elevated level of carcinoembryonic antigen, but not AFP or DCP, we made a preoperative diagnosis of intracranial metastasis of gastric cancer, and a craniotomy of the tumor was performed. Macroscopic examination of the resected specimen revealed that the tumor was yellowish-white, solid, and accompanied by necrosis (fig. ). The size of the tumor was 38 × 30 × 32 mm. Pathological examination revealed that the tumor was consistent with metastatic adenocarcinoma of gastric cancer origin (fig. ).\nThe postoperative course was uneventful. The patient's visual disturbance, hemiparesis, and gait disturbance markedly recovered to normal after surgery. Follow-up MRI conducted 1 week after the craniotomy revealed the successful removal of the tumor. Because a small lesion was detected in the left precentral gyrus, the patient received additional gamma-knife treatment (20 Gy). Sorafenib administration was discontinued and S-1 (tegafur/gimeracil/oteracil potassium, 50 mg/day) was administered postoperatively. He was alive for 5 months after the gamma-knife treatment, without any recurrence.