Successful surgical resection for peritoneal implantation of hepatocellular carcinoma at the paracardial portion

Abstract

Peritoneal implantation from hepatocellular carcinoma has been rarely reported. It may occur at various sites. Here we present a surgically resected case of peritoneal implantation to the diaphragm from hepatocellular carcinoma. A 50-year-old woman underwent right hemihepatectomy extended to a medial part of Couinaud segment IV for hepatocellular carcinoma in May 2000. In December 2008, the elevation of alpha-phetoprotein and the appearance of a heterogeneously enhanced mass, with dimensions of 9 x 7 cm, and adjacent to the remnant liver and pericardium suggested intrahepatic recurrence with markedly enhanced growth. After transcatheter arterial embolization, surgical resection under laparotomy combined with median sternotomy was selected. Samples of pericardial fluid showed no malignancy after cytological examination. At the superior border of the tumor, the confluence of pericardium and diaphragm was displaced, but the tumor itself showed a generally expanding but not invasive growth. The resected tumor showed moderately differentiated hepatocellular carcinoma whose pathology revealed a peritoneal implantation to the diaphragm. The patient is in good health without any postoperative complications or any further sign of recurrence.

Figure 1

Preoperative findings. CT shows a heterogenous mass ((a)–(c), arrow), 9 cm in diameter adjacent to the remnant liver (a), displacing the IVC (b) and the pericardium (c). Angiography shows that the remnant liver is supplied by the left hepatic artery (d). Selective angiograms show a hypervascular tumor supplied from the descending branch of the inferior phrenic artery (IPA) (e) and the phrenic branch of the internal mammary artery (IMA) (f).

Figure 2

Images and schematic presentations of operative findings and procedures. By opening the pericardium, the tumor was found to be located between the remnant liver and the heart, and the diaphragm was displaced to the upper side ((a), (b)). Due to a median sternotomy with opening of the pericardium, the tumor was pulled to the right (c). The pericardium was divided from the dorsal aspect of the tumor to the left wall of the IVC (d). A complete resection can be achieved (e). Defects of the diaphragm and the pericardium were repaired ((f)–(h)).

Figure 3

Resected specimen. The tumor is covered with the diaphragm at the cranial edge with no infiltration (a). The cut surface shows focal necrosis induced by preoperative TAE (b). The tumor is composed of moderately differentiated HCC with a thick trabecular pattern (c). The diaphragm is displaced with no infiltration to the muscular layer ((d), arrow).