Systemic metastasis of hepatocellular carcinoma responsive to multidisciplinary treatment including debulking surgery
A 52-year-old male patient with a history of type B viral hepatitis visited the hospital with abdominal distension; at that time, a huge mass (a mass measuring approximately 7 cm on segment 8, and a mass measuring 2.5 cm on segment 6) in the right hemiliver and hematomas around the liver were observed on abdominal computed tomography (CT) scan; the diagnosis was HCC rupture (). After transarterial chemoembolization (TACE), segment 8 segmentectomy and segment 6 wedge resection were performed (); hyperthermic intraperitoneal adriamycin irrigation was then performed for prevention of peritoneal seeding. According to the biopsy report, there was no viable tumor because of TACE. The patient was discharged with no specific complication and no evidence of recurrence was observed for seven years postoperative (During the seven years, ultrasonography or CT and tumor marker check was performed every 3 months, but there was no abnormal finding). However, 84 months after the initial operation, an abnormal splenic mass was observed on follow-up ultrasonography, and his tumor marker was elevated (α-fetoprotein, 1.94; protein induced by vitamin K absence or antagonist II, 309). Therefore, we performed positron emission tomography-CT, and multiple metastases were observed. The sites of metastases were brain, adrenal gland, spleen, kidney, skin (buttock), back muscle, and buttock muscle (, ); however, there was no intrahepatic recurrence. Skin biopsy confirmed metastasis of HCC (). The patient then received radiation therapy for brain metastasis, and took oral medication with sorafenib (Nexavar, Bayer Health Care, Leverkusen, Germany). After one month, a new lesion was observed on his right thumb (). However, follow-up abdominal CT showed stable condition of the previously mentioned multiple metastases (mass of spleen, left adrenal gland, left kidney, back muscle, and buttock muscle), and the brain mass had shrunk. We performed en bloc resection of intra-abdominal metastatic masses (splenectomy, left adrenalectomy, left nephrectomy) and excision of the right thumb mass (; Edmonson-Steiner grade of these masses are grade 2, and histologic type is trabecular, and cell type is hepatic cell). Currently, 18 months after initial diagnosis of multiple metastases, he is still alive, and he takes an oral medication with sorafenib for target therapy of remnant tumor in back muscle, buttock, and brain, which are unresectable ().