-Case Reports-

Surgical Treatment of a Patient with Diaphragmatic Invasion by a Ruptured Hepatocellular Carcinoma with Biliary and Portal Venous Tumor Thrombi

Hiroshi Maruyama^1,2, Hiroshi Yoshida^1,2, Atsushi Hirakata^1,2, Takeshi Matsutani^1,2, Tadashi Yokoyama^1,2, Seiji Suzuki^1,2, Akira Matsushita^1,2, Koji Sasajima^1,2, Yuta Kikuchi¹ and Eiji Uchida¹

¹Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
²Department of Surgery, Nippon Medical School Tama Nagayama Hospital

We describe the surgical treatment of a patient with diaphragmatic invasion by a ruptured hepatocellular carcinoma (HCC) associated with biliary and portal venous tumor thrombi. A 67-year-old man was admitted because of jaundice (total serum bilirubin, 6.6 mg/dL). The serum concentration of alpha-fetoprotein was 236.1 ng/mL. The anti-hepatitis C virus antibodies were present in the serum. Computed tomography showed a large hypervascular mass in the right subphrenic region, surrounded by local effusion. Endoscopic retrograde cholangiography revealed dilatation of the left intrahepatic bile duct caused by biliary tumor thrombi extending from the right hepatic duct to the common bile duct. Endoscopic nasobiliary drainage was performed, and the total serum bilirubin level returned to the normal range. Angiography revealed a hypervascular tumor without extravasation of contrast medium in the right lobe and obstruction of the right anterior branch of the portal vein. Right hepatectomy was attempted 15 days after drainage. Severe invasion of the diaphragm by the ruptured HCC was detected. Bleeding of the ruptured HCC stopped spontaneously. Partial resection of the diaphragm was performed, followed by primary suture, without an artificial patch. Tumor thrombectomy was performed from the common bile duct. Macroscopic examination revealed that the ruptured HCC had invaded the diaphragm. Biliary and portal venous tumor thrombi were present. Histopathological examination showed a moderately differentiated HCC with biliary and portal venous tumor thrombi. The postoperative course was uneventful. The patient was discharged on postoperative day 14. Five months after the operation, local and intrahepatic recurrences of HCC were detected. Six months after operation, the patient died of liver failure. In conclusion, the outcome of a patient with diaphragmatic invasion by a ruptured HCC with biliary tumor thrombi was poor, even after curative hepatic resection.

J Nippon Med Sch 2012; 79: 147-152

Keywords
hepatocellular carcinoma, obstructive jaundice, hemobilia, rupture, biliary tumor thrombi

Correspondence to
Hiroshi Yoshida, MD, Department of Surgery, Nippon Medical School Tama Nagayama Hospital, 1-7-1 Nagayama, Tama, Tokyo 206-8512, Japan
hiroshiy@nms.ac.jp

Received, March 15, 2011
Accepted, October 12, 2011