PMC3994601_01
Initial computed tomography image. A huge mass was observed in segment 8 (A), and an additional mass in segment 6 (B). Perihepatic leakage of contrast (C) was also seen, compatible with rupture of hepatocellular carcinoma.
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F1
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 (Fig. 1).
(A) Gross findings after segmentectomy of segment 8, and wedge resection of segment 6. (B) Microscopic findings. Microscopic finding showed no viable hepatocellular carcinoma, believed to be due to initial transarterial chemoembolization (H&E: Left, x10; Right, x20).
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F2
After transarterial chemoembolization (TACE), segment 8 segmentectomy and segment 6 wedge resection were performed (Fig. 2); hyperthermic intraperitoneal adriamycin irrigation was then performed for prevention of peritoneal seeding.
Computed tomography image shows multiple extrahepatic metastases spleen (A), left adrenal gland (B), back muscle (C), buttock muscle (D), and skin of hepatocellular carcinoma (E).
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F3
The sites of metastases were brain, adrenal gland, spleen, kidney, skin (buttock), back muscle, and buttock muscle (Figs. 3, 4); however, there was no intrahepatic recurrence.
Magnetic resonance imaging (A, focal strong enhancing mass at left precentral gyrus) and positron emission tomography image (B, focal fludeoxyglucose hot uptake nodule on left parietal lobe) of brain metastasis. Brain metastasis was treated with radiation therapy. After radiation therapy, tumor had shrunk (C)
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F4
The sites of metastases were brain, adrenal gland, spleen, kidney, skin (buttock), back muscle, and buttock muscle (Figs. 3, 4); however, there was no intrahepatic recurrence.
Skin lesion on computed tomography image (A, arrow) and excised mass on buttock (B). (C) Microscopic finding reveals skin metastasis of hepatocellular carcinoma (H&E: Left upper, x10; Right upper, x20; Left lower, x20; Right lower, x30).
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F5
Skin biopsy confirmed metastasis of HCC (Fig. 5).
(A) After diagnosis of multiple metastases, a new skin lesion was identified on the right thumb. (B) Magnetic resonance imaging also shows a pedunculated soft tissue mass.
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F6
After one month, a new lesion was observed on his right thumb (Fig. 6).
(A) Gross findings of multiple extrahepatic metastases after en bloc resection. (B) Microscopic findings reveal metastases of hepatocellular carcinoma (H&E, x30).
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F7
We performed en bloc resection of intra-abdominal metastatic masses (splenectomy, left adrenalectomy, left nephrectomy) and excision of the right thumb mass (Fig. 7; Edmonson-Steiner grade of these masses are grade 2, and histologic type is trabecular, and cell type is hepatic cell).
Remnant metastatic masses are still observed on back muscle (A) and buttock (B). Coronal view (C) also shows these masses.
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F8
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 (Fig. 8).