Complete remission of advanced hepatocellular carcinoma following transient chemoembolization and portal vein ligation

Abstract

Background: Macroscopic diffuse-type hepatocellular carcinoma with concomitant major portal vein tumor thrombus (PVTT) and peritoneal dissemination indicates poor prognosis. Additionally, triple-positive tumor marker status is a predictor of poor outcome even after hepatectomy. Sorafenib is recommended in such patients, but it has limited therapeutic effectiveness.

Case presentation: A 54-year-old man was diagnosed with a liver abscess that was treated by puncture and drainage at a regional hospital. However, the diagnosis was subsequently changed to hepatocellular carcinoma with macroscopic portal vein tumor thrombus, based on the results obtained for the triple-positive tumor markers (alpha-fetoprotein, 45,928 ng/ml; protein induced by vitamin K absence or antagonist-II, 125,350 mAU/ml; and alpha-fetoprotein-L3, 38.3%). As the patient's liver functional reserve was not adequate for curative resection, chemoembolization was performed with a hepatic arterial infusion of cisplatin (50 mg) and 5-FU (1000 mg), followed by mild embolization with cisplatin (50 mg) suspended in lipiodol (5 ml) and starch microspheres (300 mg) containing mitomycin C (4 mg). As the thrombus had progressed to the bifurcation of the right and left portal veins, the right vein was surgically ligated. Three peritoneal nodules could be identified and were removed. Three additional rounds of hepatic arterial chemotherapy/chemoembolization were performed after the initial surgery. At the 2-year evaluation, all tumor markers were observed to have normalized and diagnostic imaging showed complete remission.

Conclusions: Complete remission of hepatocellular carcinoma with macroscopic portal vein tumor thrombus and peritoneal dissemination was obtained with a treatment regimen that involved four rounds of hepatic arterial infusion chemotherapy and transient chemoembolization, portal vein ligation, and the removal of peritoneal dissemination. This regimen can be recommended for patients with advanced hemiliver lesions who cannot undergo curative resection.

Keywords: Chemoembolization; Complete remission; Hepatocellular carcinoma; Peritoneal dissemination; Portal vein ligation; Portal vein tumor thrombus.

Fig. 1

Dynamic CT scan on admission to our hospital. a Coronal view (portal phase). b Axial view (portal phase). Dynamic CT showed a large diffuse-type HCC with a PVTT in the right posterior branch of the portal vein (arrow)

Fig. 2

Diagnostic images at the fourth chemoembolization procedure. a Digital subtraction angiography. b Plain CT after chemoembolization. The main tumor is markedly diminished with no enhancement, and lipiodol showed spotty but strong accumulation

Fig. 3

Treatment course and changes in tumor markers. Tumor markers were abnormally high before the first chemoembolization, but they remained within the normal range for 18 months after the fourth chemoembolization procedure