- Email: [email protected]
Chest-Wall Metastasis in a Patient who Underwent Liver Transplantation Due to Hepatocellular Carcinoma
156
Case Reports
CASE REPORTS
Heart, Lung and Circulation 2008;17:146–166
12 weeks after transplantation). No routine liver or cardiac biopsies were done. In the future, a diagnostic lung biopsy will be done if the patient is symptomatic, or a decrease in FEV1 of more than 10% from baseline, or radiological evidence of infiltrates develop. Liver and cardiac biopsies will be undertaken if clinically indicated.
These considerations stimulated us to employ an aggressive early extubation/early mobilisation strategy to minimise potential post-operative complications. In summary, early extubation and ambulation is feasible following en bloc heart–lung–liver transplantation in selected patients and may contribute to rapid recovery and early discharge.
Comment
References
In the patient described in this report, pulmonary dysfunction resulting from frequent exacerbations of pulmonary infection, combined with chronic Pseudomonas colonisation resistant to multiple antibiotics was a contraindication to liver transplantation alone. This patient also had pronounced intra-pleural adhesions due to long standing respiratory infection, large esophageal varices and enlarged intrathoracic collateral veins. This required meticulous dissection and haemostasis while on CPB resulting in a prolonged CPB time. This, in turn, may have triggered a systemic inflammatory response with increased capillary leak. Furthermore, recent rib fractures, immuno-compromised state and chronic bacterial colonisation resistant to multiple antibiotics increased the risk of early post-operative infection.
1. Debray D, Lykavieris P, Gauthier F, Dousset B, Sardet A, Munck A, et al. Outcome of cystic fibrosis-associated liver cirrhosis: management of portal hypertention. J Hepatol 1999;31:77–83. 2. Dennis CM, McNeil KD, Dunning J, Stewart S, Friend PJ, Alexander G, et al. Heart–lung–liver transplantation. J Heart Lung Transplant 1996;15:536–8. 3. Coueti JP, Soubrane O, Houssin DP, Dousset BE, Chevalier PG, Guinvarch A, et al. Combined heart–lung–liver, double lungliver, and isolated liver transplantation for cystic fibrosis in children. Transpl Int 1997;10:33–9. 4. Wallwork J, Williams R, Calne RY. Transplantation of liver, heart and lungs for primary billary cirrhosis and primary pulmonary hypertension. Lancet 1987;2:182–5. 5. Praseedom RK, McNeil KD, Watson CJ, Alexander GJ, Calne RY, Wallwork J, et al. Combined transplantation of the heart, lung, and liver. Lancet 2001;358:812–3.
Chest-Wall Metastasis in a Patient who Underwent Liver Transplantation Due to Hepatocellular Carcinoma Ahmet Onen, Aydın Sanlı, Volkan Karacam, Sami Karapolat ∗ , Banu Gokcen and Unal Acıkel Eylul University, Faculty of Medicine, Department of Thoracic Surgery, Izmir, Turkey
Hepatocellular carcinoma is a common malignancy. It may cause extrahepatic metastases through haematogenous or lymphatic dissemination or direct invasion. Furthermore, methods such as fine-needle aspiration biopsies performed to obtain a diagnosis or percutaneous ethanol injection and radiofrequency hyperthermia performed for treatment may also cause tumour dissemination. We present a 52-year-old male patient whose isolated right chest wall metastasis developed after liver transplantation due to hepatocellular carcinoma. We performed chest wall reconstruction after the mass was removed. (Heart, Lung and Circulation 2008;17:146–166) © 2006 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved. Keywords. Hepatocellular carcinoma; Liver transplantation; Chest-wall metastasis and surgery
Introduction Received 14 July 2006; received in revised form 17 October 2006; accepted 30 October 2006; available online 18 April 2007 ∗
Corresponding author. Tel.: +90 2324266989. E-mail address: [email protected] (S. Karapolat).
H
epatocellular carcinoma (HCC) is the fourth most common cancer and it has a highly malignant course. Its incidence is higher in the Far East countries. Viral hepatitides and chronic alcoholism are the primary
© 2006 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved.
1443-9506/04/$30.00 doi:10.1016/j.hlc.2006.10.023
Case Reports
157 CASE REPORTS
Heart, Lung and Circulation 2008;17:146–166
Figure 1. Chest roentgenogram shows radio opacity on the seventh rib.
a etiological factors. Extrahepatic metastasis is encountered in most of the cases. Metastasis mostly focuses on lungs, and lungs are followed by abdominal lymph nodes, bones, kidneys and adrenals.1–3 Metastases of HCC may even be seen in patients who underwent liver transplantation due to HCC.4 Chest wall invasion observed in these cases may result from possible direct invasion or tumour seeding during fine-needle aspiration biopsy.
Case Report A 52-year-old male patient who underwent liver transplantation subsequent to the diagnosis of HCC applied to our clinic with the complaint of painful swelling on the sixth and seventh ribs. The patient stated that the severity of the pain that he complained about was increasing as he coughed and rose up his right arm. According to his medical records, the patient with a history of alcohol intake (30 years, 150 g/day) was diagnosed with Child A liver cirrhosis secondary to Hepatitis B. Additionally, according to the images that were obtained by magnetic resonance imaging (MRI) five years ago, localisation of two hyperintense lesions consistent with HCC in the hepatic dome, one at the subcapsullary region and the other in hepatic segment 8, were detected. Since the results of the fine-needle aspiration biopsy performed to obtain a diagnosis were found to be consistent with HCC, laparoscopic radiofrequency ablation was applied to the lesion in segment 8 and percutaneous ethanol injection was applied to the lesion in segment 2. It was also reported that liver transplantation was performed and the patient was followed up after the transplantation. A 3 cm × 3 cm hard mass was palpated on the sixth and seventh ribs on the right chest frontal wall. The results of the other systemic examinations were normal. Laboratory and respiratory function tests revealed no pathologies. Chest X-ray revealed radio opacity on the seventh rib (Fig. 1). Consecutively, thoracic MRI was performed and it revealed a nodulated mass that was 3 cm × 2 cm in diame-
Figure 2. Coronal MRI shows a nodulated mass that was 3 cm × 2 cm in diameter and located in the right hemithorax and in the inferior section of the costophrenic sinus.
ter and located in the right hemithorax and in the inferior section of the costophrenic sinus (Fig. 2). The areas of lung parenchyma were normal. Besides the present lesion, additional pathologies were not determined during the other investigations for metastasis. Taking direct chest wall invasion and tumour seeding by fine-needle aspiration biopsy into consideration, a surgical operation was performed on the patient. During the operation, a hard, white mass, 3 cm × 4 cm in diameter and located 3 cm away from the costochondral junction, which has a tendency to bleed and extends to the sixth rib from the upper side of the seventh rib, was detected. The mass was attached to the muscle above it. The sixth and seventh ribs were partially resected together with
Figure 3. The vision of the mass peroperatively.
158
Case Reports
CASE REPORTS
Figure 4. On histopathological examination, the lesion was diagnosed as metastasis of HCC to the chest wall (hematoxylin and eosin stain ×200).
the muscle tissue above, including 3 cm of the healthy parts of the rib (Fig. 3). Pleura and lung invasion was not present. The 10 cm × 10 cm defect in the chest wall was restored by single-suture technique using Gore-Tex Dual Mesh. The muscle defect was resolved by freeing and stitching the remaining latissimus muscle in the shape of a flap. There were not any problems encountered in the postoperative period and the patient was discharged on the seventh postoperative day. The pathology report was reported as the metastasis of HCC to the chest wall (Fig. 4).
Discussion HCC is the most common carcinoma of the liver. Its incidence in the countries of Far East is higher and the highest death rate is in China. It is relatively less common in America and West Europe. The disease generally emerges at the sixth or seventh decade.1,2 The diagnosis of HCC is made through fine-needle aspiration liver biopsy or significant amount of alphafetoprotein along with radiological findings if liver biopsy cannot be performed.3 Transhepatic arterial fat chemoembolisation, percutaneous ethanol injection (PEI), percutaneous microwave coagulation therapy, radiofrequency hyperthermia (RFH), systemic chemotherapy, combination chemotherapy, radiotherapy, biotherapy, hepatectomy and liver transplantation may be used for treatment.2,3 HCC may cause metastasis through haematogenous or lymphatic dissemination or direct invasion. The rate of extrahepatic metastasis in HCC is 12% and the most common site of metastasis is the lungs. The probable reason for this is direct drainage performed on the right side of
Heart, Lung and Circulation 2008;17:146–166
the heart. The other focuses of metastasis are abdominal lymph nodes, bones, kidneys and adrenals.3,4 Katyal et al.4 determined 6 chest wall metastases in 148 metastases among patients with HCC. In the same study, extrahepatic metastasis was determined in 43 patients who underwent liver transplantation due to HCC.4 In another study, bone metastasis was determined in 20 out of 395 patients (5%) and it was reported that the most common dissemination was to the vertebrae and chest wall.5 Fine-needle aspiration biopsy performed for diagnosis and methods such as percutaneous ethanol injection or radiofrequency hyperthermia as well contribute to the dissemination of HCC to the chest wall. Takamori et al. determined dissemination to the chest wall secondary to biopsy in 3 out of 59 patients on whom fine-needle aspiration biopsy was performed and reported that its incidence of dissemination is 5%.6 In our case, the application of fine-needle aspiration biopsy to obtain a diagnosis and PEI and RFH for treatment suggests tumour seeding during diagnosis-making or the treatment. Although metastasis emerged two years after the transplantation, and the primary liver lesion’s location is close to the chest wall, the absence of diaphragm and lung involvement favors tumour seeding over direct invasion. Additionally, the presence of a single metastasis excludes haematogenous dissemination. In case of resectable primary tumours and their single metastases, surgery is the only option for treatment and long-term survival. Besides, recourse to the restoration of bone and middle line defects exceeding 5 cm in diametre is not so common in chest surgery. In such cases, rigid prostheses are required to maintain respiration mechanism and for better cosmetic results.7
References 1. Tunc B, Filik L, Filik IT, Sahin B. Brain metastasis of hepatocellular carcinoma: A case report and review of the literature. World J Gastroenterol 2004;10:1688–9. 2. Tang ZY. Hepatocellular carcinoma-cause, treatment and metastasis. World J Gastroenterol 2001;7:445–54. 3. Sithinamsuwan P, Piratvisuth T, Tanomkiat W, Apakupakul N, Tongyoo S. Review of 336 patients with hepatocellular carcinoma at Songklanagarind Hospital. World J Gastroenterol 2000;6:339–43. 4. Katyal S, Oliver 3rd JH, Peterson MS, Ferris JV, Carr BS, Baron RL. Extrahepatic metastasis of hepatocellular carcinoma. Radiology 2000;216:698–703. 5. Liaw CC, Ng KT, Chen TJ, Liaw YF. Hepatocellular carcinoma presenting as bone metastasis. Cancer 1989;64:1753–7. 6. Takamori R, Wong LL, Dang C, Wong L. Needle-tract implantation from hepatocellular cancer: is needle biopsy of the liver always necessary? Liver Transpl 2000;6:67–72. 7. Hofmann H, Spillner J, Hammer A, Diez C. A solitary chest wall metastasis from unknown primary hepatocellular carcinoma. Euro J Gastroenterol Hepatol 2003;5:557–9.
Case Reports
CASE REPORTS
Heart, Lung and Circulation 2008;17:146–166
12 weeks after transplantation). No routine liver or cardiac biopsies were done. In the future, a diagnostic lung biopsy will be done if the patient is symptomatic, or a decrease in FEV1 of more than 10% from baseline, or radiological evidence of infiltrates develop. Liver and cardiac biopsies will be undertaken if clinically indicated.
These considerations stimulated us to employ an aggressive early extubation/early mobilisation strategy to minimise potential post-operative complications. In summary, early extubation and ambulation is feasible following en bloc heart–lung–liver transplantation in selected patients and may contribute to rapid recovery and early discharge.
Comment
References
In the patient described in this report, pulmonary dysfunction resulting from frequent exacerbations of pulmonary infection, combined with chronic Pseudomonas colonisation resistant to multiple antibiotics was a contraindication to liver transplantation alone. This patient also had pronounced intra-pleural adhesions due to long standing respiratory infection, large esophageal varices and enlarged intrathoracic collateral veins. This required meticulous dissection and haemostasis while on CPB resulting in a prolonged CPB time. This, in turn, may have triggered a systemic inflammatory response with increased capillary leak. Furthermore, recent rib fractures, immuno-compromised state and chronic bacterial colonisation resistant to multiple antibiotics increased the risk of early post-operative infection.
1. Debray D, Lykavieris P, Gauthier F, Dousset B, Sardet A, Munck A, et al. Outcome of cystic fibrosis-associated liver cirrhosis: management of portal hypertention. J Hepatol 1999;31:77–83. 2. Dennis CM, McNeil KD, Dunning J, Stewart S, Friend PJ, Alexander G, et al. Heart–lung–liver transplantation. J Heart Lung Transplant 1996;15:536–8. 3. Coueti JP, Soubrane O, Houssin DP, Dousset BE, Chevalier PG, Guinvarch A, et al. Combined heart–lung–liver, double lungliver, and isolated liver transplantation for cystic fibrosis in children. Transpl Int 1997;10:33–9. 4. Wallwork J, Williams R, Calne RY. Transplantation of liver, heart and lungs for primary billary cirrhosis and primary pulmonary hypertension. Lancet 1987;2:182–5. 5. Praseedom RK, McNeil KD, Watson CJ, Alexander GJ, Calne RY, Wallwork J, et al. Combined transplantation of the heart, lung, and liver. Lancet 2001;358:812–3.
Chest-Wall Metastasis in a Patient who Underwent Liver Transplantation Due to Hepatocellular Carcinoma Ahmet Onen, Aydın Sanlı, Volkan Karacam, Sami Karapolat ∗ , Banu Gokcen and Unal Acıkel Eylul University, Faculty of Medicine, Department of Thoracic Surgery, Izmir, Turkey
Hepatocellular carcinoma is a common malignancy. It may cause extrahepatic metastases through haematogenous or lymphatic dissemination or direct invasion. Furthermore, methods such as fine-needle aspiration biopsies performed to obtain a diagnosis or percutaneous ethanol injection and radiofrequency hyperthermia performed for treatment may also cause tumour dissemination. We present a 52-year-old male patient whose isolated right chest wall metastasis developed after liver transplantation due to hepatocellular carcinoma. We performed chest wall reconstruction after the mass was removed. (Heart, Lung and Circulation 2008;17:146–166) © 2006 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved. Keywords. Hepatocellular carcinoma; Liver transplantation; Chest-wall metastasis and surgery
Introduction Received 14 July 2006; received in revised form 17 October 2006; accepted 30 October 2006; available online 18 April 2007 ∗
Corresponding author. Tel.: +90 2324266989. E-mail address: [email protected] (S. Karapolat).
H
epatocellular carcinoma (HCC) is the fourth most common cancer and it has a highly malignant course. Its incidence is higher in the Far East countries. Viral hepatitides and chronic alcoholism are the primary
© 2006 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved.
1443-9506/04/$30.00 doi:10.1016/j.hlc.2006.10.023
Case Reports
157 CASE REPORTS
Heart, Lung and Circulation 2008;17:146–166
Figure 1. Chest roentgenogram shows radio opacity on the seventh rib.
a etiological factors. Extrahepatic metastasis is encountered in most of the cases. Metastasis mostly focuses on lungs, and lungs are followed by abdominal lymph nodes, bones, kidneys and adrenals.1–3 Metastases of HCC may even be seen in patients who underwent liver transplantation due to HCC.4 Chest wall invasion observed in these cases may result from possible direct invasion or tumour seeding during fine-needle aspiration biopsy.
Case Report A 52-year-old male patient who underwent liver transplantation subsequent to the diagnosis of HCC applied to our clinic with the complaint of painful swelling on the sixth and seventh ribs. The patient stated that the severity of the pain that he complained about was increasing as he coughed and rose up his right arm. According to his medical records, the patient with a history of alcohol intake (30 years, 150 g/day) was diagnosed with Child A liver cirrhosis secondary to Hepatitis B. Additionally, according to the images that were obtained by magnetic resonance imaging (MRI) five years ago, localisation of two hyperintense lesions consistent with HCC in the hepatic dome, one at the subcapsullary region and the other in hepatic segment 8, were detected. Since the results of the fine-needle aspiration biopsy performed to obtain a diagnosis were found to be consistent with HCC, laparoscopic radiofrequency ablation was applied to the lesion in segment 8 and percutaneous ethanol injection was applied to the lesion in segment 2. It was also reported that liver transplantation was performed and the patient was followed up after the transplantation. A 3 cm × 3 cm hard mass was palpated on the sixth and seventh ribs on the right chest frontal wall. The results of the other systemic examinations were normal. Laboratory and respiratory function tests revealed no pathologies. Chest X-ray revealed radio opacity on the seventh rib (Fig. 1). Consecutively, thoracic MRI was performed and it revealed a nodulated mass that was 3 cm × 2 cm in diame-
Figure 2. Coronal MRI shows a nodulated mass that was 3 cm × 2 cm in diameter and located in the right hemithorax and in the inferior section of the costophrenic sinus.
ter and located in the right hemithorax and in the inferior section of the costophrenic sinus (Fig. 2). The areas of lung parenchyma were normal. Besides the present lesion, additional pathologies were not determined during the other investigations for metastasis. Taking direct chest wall invasion and tumour seeding by fine-needle aspiration biopsy into consideration, a surgical operation was performed on the patient. During the operation, a hard, white mass, 3 cm × 4 cm in diameter and located 3 cm away from the costochondral junction, which has a tendency to bleed and extends to the sixth rib from the upper side of the seventh rib, was detected. The mass was attached to the muscle above it. The sixth and seventh ribs were partially resected together with
Figure 3. The vision of the mass peroperatively.
158
Case Reports
CASE REPORTS
Figure 4. On histopathological examination, the lesion was diagnosed as metastasis of HCC to the chest wall (hematoxylin and eosin stain ×200).
the muscle tissue above, including 3 cm of the healthy parts of the rib (Fig. 3). Pleura and lung invasion was not present. The 10 cm × 10 cm defect in the chest wall was restored by single-suture technique using Gore-Tex Dual Mesh. The muscle defect was resolved by freeing and stitching the remaining latissimus muscle in the shape of a flap. There were not any problems encountered in the postoperative period and the patient was discharged on the seventh postoperative day. The pathology report was reported as the metastasis of HCC to the chest wall (Fig. 4).
Discussion HCC is the most common carcinoma of the liver. Its incidence in the countries of Far East is higher and the highest death rate is in China. It is relatively less common in America and West Europe. The disease generally emerges at the sixth or seventh decade.1,2 The diagnosis of HCC is made through fine-needle aspiration liver biopsy or significant amount of alphafetoprotein along with radiological findings if liver biopsy cannot be performed.3 Transhepatic arterial fat chemoembolisation, percutaneous ethanol injection (PEI), percutaneous microwave coagulation therapy, radiofrequency hyperthermia (RFH), systemic chemotherapy, combination chemotherapy, radiotherapy, biotherapy, hepatectomy and liver transplantation may be used for treatment.2,3 HCC may cause metastasis through haematogenous or lymphatic dissemination or direct invasion. The rate of extrahepatic metastasis in HCC is 12% and the most common site of metastasis is the lungs. The probable reason for this is direct drainage performed on the right side of
Heart, Lung and Circulation 2008;17:146–166
the heart. The other focuses of metastasis are abdominal lymph nodes, bones, kidneys and adrenals.3,4 Katyal et al.4 determined 6 chest wall metastases in 148 metastases among patients with HCC. In the same study, extrahepatic metastasis was determined in 43 patients who underwent liver transplantation due to HCC.4 In another study, bone metastasis was determined in 20 out of 395 patients (5%) and it was reported that the most common dissemination was to the vertebrae and chest wall.5 Fine-needle aspiration biopsy performed for diagnosis and methods such as percutaneous ethanol injection or radiofrequency hyperthermia as well contribute to the dissemination of HCC to the chest wall. Takamori et al. determined dissemination to the chest wall secondary to biopsy in 3 out of 59 patients on whom fine-needle aspiration biopsy was performed and reported that its incidence of dissemination is 5%.6 In our case, the application of fine-needle aspiration biopsy to obtain a diagnosis and PEI and RFH for treatment suggests tumour seeding during diagnosis-making or the treatment. Although metastasis emerged two years after the transplantation, and the primary liver lesion’s location is close to the chest wall, the absence of diaphragm and lung involvement favors tumour seeding over direct invasion. Additionally, the presence of a single metastasis excludes haematogenous dissemination. In case of resectable primary tumours and their single metastases, surgery is the only option for treatment and long-term survival. Besides, recourse to the restoration of bone and middle line defects exceeding 5 cm in diametre is not so common in chest surgery. In such cases, rigid prostheses are required to maintain respiration mechanism and for better cosmetic results.7
References 1. Tunc B, Filik L, Filik IT, Sahin B. Brain metastasis of hepatocellular carcinoma: A case report and review of the literature. World J Gastroenterol 2004;10:1688–9. 2. Tang ZY. Hepatocellular carcinoma-cause, treatment and metastasis. World J Gastroenterol 2001;7:445–54. 3. Sithinamsuwan P, Piratvisuth T, Tanomkiat W, Apakupakul N, Tongyoo S. Review of 336 patients with hepatocellular carcinoma at Songklanagarind Hospital. World J Gastroenterol 2000;6:339–43. 4. Katyal S, Oliver 3rd JH, Peterson MS, Ferris JV, Carr BS, Baron RL. Extrahepatic metastasis of hepatocellular carcinoma. Radiology 2000;216:698–703. 5. Liaw CC, Ng KT, Chen TJ, Liaw YF. Hepatocellular carcinoma presenting as bone metastasis. Cancer 1989;64:1753–7. 6. Takamori R, Wong LL, Dang C, Wong L. Needle-tract implantation from hepatocellular cancer: is needle biopsy of the liver always necessary? Liver Transpl 2000;6:67–72. 7. Hofmann H, Spillner J, Hammer A, Diez C. A solitary chest wall metastasis from unknown primary hepatocellular carcinoma. Euro J Gastroenterol Hepatol 2003;5:557–9.