A patient who has survived for a long period with repeated radiotherapies for multifocal extrahepatic metastases from hepatocellular carcinoma
A 55-year-old man with hepatitis B and C was diagnosed with HCC in September 2006, and subsequently underwent a right lobectomy of the liver and cholecystectomy. HCC was multiple and the largest lesion was 7 cm. HCC was Edmondson-Steiner grade 3/3 and complicated by cirrhosis. There wasn't vascular invasion and resection margin was clear. During follow-up, lung metastasis was found and wedge resection was undergone twice (right lower lobe, July 2009; left lower lobe, January 2011). In March 2011, he felt pain on a palpable mass of his left shoulder. He visited local clinic and a biopsy of the mass revealed metastatic HCC. He was referred to our hospital in March 2011 for further evaluation and treatment. His Eastern Cooperative Oncology Group performance status was 1. Soft tissue metastases in the left shoulder area and abdominal wall were showed on computed tomography and positron emission tomography/computed tomography (PET/CT). There was no intrahepatic lesion and α-fetoprotein (AFP) was normal. And Child-Pugh score was 5 (Class A).\nHuge hard fixed masses were detected on his left pectoralis major, deltoid, and left teres minor muscles in which metastatic HCC was confirmed (). Radiotherapy was delivered 35 Gy in 14 fractions for each lesion. After radiotherapy, back mass was softened and its size decreased. The masses of pectoralis major and deltoid muscle were also decreased (). The brain metastasis was detected during the radiotherapy. He underwent Gamma Knife (Elekta AB, Stockholm, Sweden) stereotactic radiosurgery and started to take sorafenib (200 mg/day) in other hospital.\nDue to about 6-cm sized painful abdominal mass, he underwent radiotherapy in another hospital. Radiotherapy was delivered 40 Gy in 16 fractions.\nThough left pectoralis major and deltoid lesions nearly disappeared and pain was improved after radiotherapy, pain of left teres minor muscles area was aggravated and hard fixed mass was palpable again. A total dose of 30 Gy in 12 fractions for the left teres minor muscle area was delivered over a 3-week period.\nTwo painful recurred hard fixed masses were detected on abdominal wall. A total dose of 30 Gy in 15 fractions () and 27 Gy in 9 fractions were delivered for each lesion. The masses showed decreased metabolism grossly on outside PET/CT in December 2012. In January 2013 he received excision of the abdominal wall mass due to aggravated pain. In February 2013, a recurred abdominal mass was detected again and another excision was undergone because of previous radiotherapy history.\nHe felt pain on his left shoulder, new metastatic lesion in acromial angle was detected. He received radiotherapy of 20 Gy in 5 fractions. Pain was improved after radiotherapy.\nA small scalp mass was detected, and excisional biopsy was performed on October 2012. The pathology of the lesion was metastatic HCC. He also felt a newly growing mass in his right arm. Radiotherapy was undergone for the tumor bed of his scalp and the right deltoid muscle area. A total dose of 35 Gy in 14 fractions was delivered for each lesion, and the pain was relieved.\nA 5-cm sized rapid-growing hard fixed mass was detected with pain on his left anterior chest wall again. Radiotherapy of 35 Gy in 14 fractions was delivered, and pain was improved.\nThe patient underwent 7 courses of radiotherapy and took sorafenib orally (at starting dosage of 200 mg/day and a maintaining dosage of 600 mg/day) from April 2011 to July 2013. His hepatic function has been well preserved and the level of AFP has been normal. The brain metastasis had been also stable. Lung metastasis was suspicious on chest CT but that had not been progressed though intramuscular lesions were progressed after radiotherapy. He is still alive and is possible to carry on ordinary activities.