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Hepatic artery ligation for metastatic tumor in the liver
CASE REPORTS
Hepatic Artery Ligation for Metastatic Tumor in the Liver GORDON F. MADDING, MD, Burlingarne, California PAUL tL KENNEDY, MD, Burlingame, California EBERHARD SOGEMEIER, MD, San Mateo, California
Interest in the treatment of hepatic metastases has largely been focused on two therapeutic approaches, chemotherapy by infusion and surgical resection. Jafl'e ct al [1] concluded from a study of 390 cases that the prognosis in metastatic cancer is not significantly dependent on coexisting pulmonary, peritoneal, and nodal involvement, but that hepatic nodules play a major part in the patienrs course. A number of authors have demonstrated that malignant hepatic tumors derive their main blood supply from the hepatic artery [2---4]. Based on this knowledge, Markowitz [5] in 1952 suggested therapeutic ligation of the" hepatic artery in the management of hepatic neoplasms. Mori et al [6] in 1964 reported a case of carcinoma of the stomach with liver metastasis in which the hepatic artery was accidentally obstructed at operation. Death occurred thirty hours later and at autopsy severe necrosis of the metastatic tumor in the liver was revealed with only slight damage in the surrounding liver tissue. They considered this further evidence that there is only a single blood supply (arterial) to the metastatic hepatic cancer although there is a double supply (arterial and portal) to the normal liver tissue. Nilsson [7] in 1966 reported seven cases, in three of which the artery to one lobe of the liver alone was'ligated. The liver tissue was not damaged whereas the tumor tissue d e g e n e r a t e d to some extent in two cases. In four later cases the distal hepatic artery with collaterals was ligated. Three of these patients showed remarkable clinical improvement and the tun}ors were largely necrotic. Almersjo et al [8,9] and Nilsson [7] have reported their data on liver function tests and serum enzyme changes after hepatic artery ligation and hepatic dearterialization. The purpose of the present report is to describe a patient whose metastatic disease to the liver was significantly altered after hepatic artery ligation. Moreover, it will add to other data in a final evaluation of hepatic artery ligation for secondary liver tumors.
Case Report A forty-five year old man was admitted on October 27, 1968 with complaints of inability to eat, shortness of breath, and rapid enlargement of an abdominal mass. He weighed 150 pounds. In 1965 he had undergone Vol. 120, July 1970
laparotomy for an asymptomatic tumor of the lower part of the abdomen. It proved to be a retroperitoneal tumor, the pathologic consensus being a carcinoid tumor with liver metastases. After tiffs, he was treated with intravenous 5-fluorouracil, He did well until six months prior to the present admissior~. Physical examination showed a cachectie adult man in great distress due to an extremely large abdomen. The liver extended well below the umbilicus in the midline and below the right iliac crest, filling three fifths of the abdominal c:lvity. There were no other significant findings. Liver scan showed marked diffuse involvement by metastases. Laparotomy revealed marked enlargement of the liver and almost complete replacement by tumor. The hepatic artery proper (distal to the right gastric and gastroduodenal arteries and just proximal to the bifurcation into the right and left hepatic arteries was ligated on October 30. 1968. (Table 1.) The patient subsequently improved and was discharged two weeks later. Seven months postoperatively his weight was 138 pounds and he had shown remarkable clinical improvement. The dyspnea had disappeared and the patient was able to eat three full meals daily.
Comment: Three liver scans were performed on the patient, each using 150 rtc of colloidal g o l d \ ( A u 1"8) intravenously. The first scan, performed ir~ 1 9 6 5 , showed nothing abnormal. The second scan on October 28, 1968 (Figure 1A and B) revealed a markedly enlarged irregular liver occupying almost the entire abdominal cavity and extending into the pelvis on the right. The pattern was irregular ~ n d mottled, with several large areas of decreased uptake, the largest area measuring up to 10 era. This scan was consistent with multiple foci of metastatic tumor. The most recent liver scan on January 22, 1969 (Figure I C and D) showed dramatic improvement. There had been a decrease in liver size from 29 x 30 cm~to 2 3 - x 30 cm whereas on the scan of October 28, 1968 the liver had measured 16 cm below the right costal margin and 18 cm below the xyphoid process~and on the scan of January 22, 1969 the liver measured 5 cm below the costal margin and 13 cm below the x~,phoid process. Uptake by the hepatic tissue increased and the larger areas of poor uptake regressed in size, the largest from 10 to 8 cm.
95
Madding et al
TABLE l
Liver Function Data P r e - and P o s t o p e r a t i v e l y
Before Hepatic Artery Ligati0n
Serum glutamic oxalacetic transamtnase (units) Total protein (gm) Albumin (gin %) Bilirubin. direct (rag %) Bilirubin, total (rng %) Alkaline phosphatase (Somogyi units) Thymol turbidity (units)
After HepaticArtery Ligationon October30, 1968
October28, 1968
October31, 1968
November4, 1968
24 6.2 3.7 0.2 0.4
560 6.4 3.3 0.2 0,4
96 5.4 3.0 0.5 1.4
75 5.8 2.75 ... 0.4
31.2 1
31 1
37.4 1
57 ...
Summary A case is reported of extensive metastatic disease of the liver in which hepatic artery ligation resulted in marked clinical improvement. In addition, there were dramatic changes in the liver as demonstrated by liver scan. The results in this patient support the thesis of Breedis and Young that the blood supply of secondary tumors of the liver is predominantly, if not exclusively, arterial in origin.
May 16, 1969
Addendum
Since submitting this report, three additional cases with metastatic carcinoma to the liver have been treated by proper hepatic artery ligation. In the last two, glucagon has been used in the postoperative period to enhance portal vein flow. (Based on research work of Worthington G. Sehenk, Jr, University of Buffalo, Buffalo, New York.) References
A
B
D
Figure 1. Anteroposterior and lateral liver scans performed on October 28, 1968 (A and B) and on January 22, 1969 (C and O).
96
I. Jaffe B, Donegan WL, Watson F, Spratt JS Jr: Factors influencing survival in patients with'untreated hepatic metastases. Surg Gynec Obstet 127: 1, 1968. 2. Breedis CJ, Young G: The blood supply of neoplasms in the liver. Amer J Path 30: 969, 1954. 3. Honjo I, Matsumora H: Vascular distribution of hepatic tumors. Experimental study. Rev Int Hepat 15: 681, 1965. 4. Nilsson LAV: Quoted in reference 7. 5. Markowitz J: The hepatic artery. Surg Gynec Obstet 95: 644, 1952. 6. Mori M, Masudo M, Miyanaga T: Hepatic fakery ligation and tumor necrosis in the L;ver. S u r e t y 59: 359, 1966. 7. Nilsson LAV: Therapeutic hepatic artery ligation in patients with secondary liver tumors. Rev Surg 374, 1966. 8. Almersjo O, 8engmarkfS, Hafstr6m LO, Korsan-Bergsten K, Ygge J: Changes in coagulation factors after hepatic dearterialization in man. Amer J Surg 116: 414, 1968. 9. Almersjo O, Bengmark S, Engevik L, HafstrOm LO, Loughridge BP, Nilsson LAV: Serum enzyme changes after hepatic dearterialization in man. Ann Surg 167: 9, 1968.
The American Journal of Surgery
Hepatic Artery Ligation for Metastatic Tumor in the Liver GORDON F. MADDING, MD, Burlingarne, California PAUL tL KENNEDY, MD, Burlingame, California EBERHARD SOGEMEIER, MD, San Mateo, California
Interest in the treatment of hepatic metastases has largely been focused on two therapeutic approaches, chemotherapy by infusion and surgical resection. Jafl'e ct al [1] concluded from a study of 390 cases that the prognosis in metastatic cancer is not significantly dependent on coexisting pulmonary, peritoneal, and nodal involvement, but that hepatic nodules play a major part in the patienrs course. A number of authors have demonstrated that malignant hepatic tumors derive their main blood supply from the hepatic artery [2---4]. Based on this knowledge, Markowitz [5] in 1952 suggested therapeutic ligation of the" hepatic artery in the management of hepatic neoplasms. Mori et al [6] in 1964 reported a case of carcinoma of the stomach with liver metastasis in which the hepatic artery was accidentally obstructed at operation. Death occurred thirty hours later and at autopsy severe necrosis of the metastatic tumor in the liver was revealed with only slight damage in the surrounding liver tissue. They considered this further evidence that there is only a single blood supply (arterial) to the metastatic hepatic cancer although there is a double supply (arterial and portal) to the normal liver tissue. Nilsson [7] in 1966 reported seven cases, in three of which the artery to one lobe of the liver alone was'ligated. The liver tissue was not damaged whereas the tumor tissue d e g e n e r a t e d to some extent in two cases. In four later cases the distal hepatic artery with collaterals was ligated. Three of these patients showed remarkable clinical improvement and the tun}ors were largely necrotic. Almersjo et al [8,9] and Nilsson [7] have reported their data on liver function tests and serum enzyme changes after hepatic artery ligation and hepatic dearterialization. The purpose of the present report is to describe a patient whose metastatic disease to the liver was significantly altered after hepatic artery ligation. Moreover, it will add to other data in a final evaluation of hepatic artery ligation for secondary liver tumors.
Case Report A forty-five year old man was admitted on October 27, 1968 with complaints of inability to eat, shortness of breath, and rapid enlargement of an abdominal mass. He weighed 150 pounds. In 1965 he had undergone Vol. 120, July 1970
laparotomy for an asymptomatic tumor of the lower part of the abdomen. It proved to be a retroperitoneal tumor, the pathologic consensus being a carcinoid tumor with liver metastases. After tiffs, he was treated with intravenous 5-fluorouracil, He did well until six months prior to the present admissior~. Physical examination showed a cachectie adult man in great distress due to an extremely large abdomen. The liver extended well below the umbilicus in the midline and below the right iliac crest, filling three fifths of the abdominal c:lvity. There were no other significant findings. Liver scan showed marked diffuse involvement by metastases. Laparotomy revealed marked enlargement of the liver and almost complete replacement by tumor. The hepatic artery proper (distal to the right gastric and gastroduodenal arteries and just proximal to the bifurcation into the right and left hepatic arteries was ligated on October 30. 1968. (Table 1.) The patient subsequently improved and was discharged two weeks later. Seven months postoperatively his weight was 138 pounds and he had shown remarkable clinical improvement. The dyspnea had disappeared and the patient was able to eat three full meals daily.
Comment: Three liver scans were performed on the patient, each using 150 rtc of colloidal g o l d \ ( A u 1"8) intravenously. The first scan, performed ir~ 1 9 6 5 , showed nothing abnormal. The second scan on October 28, 1968 (Figure 1A and B) revealed a markedly enlarged irregular liver occupying almost the entire abdominal cavity and extending into the pelvis on the right. The pattern was irregular ~ n d mottled, with several large areas of decreased uptake, the largest area measuring up to 10 era. This scan was consistent with multiple foci of metastatic tumor. The most recent liver scan on January 22, 1969 (Figure I C and D) showed dramatic improvement. There had been a decrease in liver size from 29 x 30 cm~to 2 3 - x 30 cm whereas on the scan of October 28, 1968 the liver had measured 16 cm below the right costal margin and 18 cm below the xyphoid process~and on the scan of January 22, 1969 the liver measured 5 cm below the costal margin and 13 cm below the x~,phoid process. Uptake by the hepatic tissue increased and the larger areas of poor uptake regressed in size, the largest from 10 to 8 cm.
95
Madding et al
TABLE l
Liver Function Data P r e - and P o s t o p e r a t i v e l y
Before Hepatic Artery Ligati0n
Serum glutamic oxalacetic transamtnase (units) Total protein (gm) Albumin (gin %) Bilirubin. direct (rag %) Bilirubin, total (rng %) Alkaline phosphatase (Somogyi units) Thymol turbidity (units)
After HepaticArtery Ligationon October30, 1968
October28, 1968
October31, 1968
November4, 1968
24 6.2 3.7 0.2 0.4
560 6.4 3.3 0.2 0,4
96 5.4 3.0 0.5 1.4
75 5.8 2.75 ... 0.4
31.2 1
31 1
37.4 1
57 ...
Summary A case is reported of extensive metastatic disease of the liver in which hepatic artery ligation resulted in marked clinical improvement. In addition, there were dramatic changes in the liver as demonstrated by liver scan. The results in this patient support the thesis of Breedis and Young that the blood supply of secondary tumors of the liver is predominantly, if not exclusively, arterial in origin.
May 16, 1969
Addendum
Since submitting this report, three additional cases with metastatic carcinoma to the liver have been treated by proper hepatic artery ligation. In the last two, glucagon has been used in the postoperative period to enhance portal vein flow. (Based on research work of Worthington G. Sehenk, Jr, University of Buffalo, Buffalo, New York.) References
A
B
D
Figure 1. Anteroposterior and lateral liver scans performed on October 28, 1968 (A and B) and on January 22, 1969 (C and O).
96
I. Jaffe B, Donegan WL, Watson F, Spratt JS Jr: Factors influencing survival in patients with'untreated hepatic metastases. Surg Gynec Obstet 127: 1, 1968. 2. Breedis CJ, Young G: The blood supply of neoplasms in the liver. Amer J Path 30: 969, 1954. 3. Honjo I, Matsumora H: Vascular distribution of hepatic tumors. Experimental study. Rev Int Hepat 15: 681, 1965. 4. Nilsson LAV: Quoted in reference 7. 5. Markowitz J: The hepatic artery. Surg Gynec Obstet 95: 644, 1952. 6. Mori M, Masudo M, Miyanaga T: Hepatic fakery ligation and tumor necrosis in the L;ver. S u r e t y 59: 359, 1966. 7. Nilsson LAV: Therapeutic hepatic artery ligation in patients with secondary liver tumors. Rev Surg 374, 1966. 8. Almersjo O, 8engmarkfS, Hafstr6m LO, Korsan-Bergsten K, Ygge J: Changes in coagulation factors after hepatic dearterialization in man. Amer J Surg 116: 414, 1968. 9. Almersjo O, Bengmark S, Engevik L, HafstrOm LO, Loughridge BP, Nilsson LAV: Serum enzyme changes after hepatic dearterialization in man. Ann Surg 167: 9, 1968.
The American Journal of Surgery