Malignant pheochromocytoma with liver invasion treated successfully by combined retroperitoneal laparoscopic control of arterial in-flow followed by open hepatectomy: A case report

Abstract

Introduction: Pheochromocytoma surgery is generally challenging for surgeons and anesthesiologists for cardiovascular complications.

Presentation of case: A 54-year-old Japanese man was found to have a large right pheochromocytoma infiltrating the posterior part of his liver and vena cava and multiple lung metastases. After retroperitoneal laparoscopic dissection of the dorsal side of the tumor and ligation of the feeding vessels, total resection of the primary tumor, extended posterior sectional hepatectomy, and partial vena cava resection were performed by open surgery via a thoracoabdominal approach. Abundant congestive bleeding with instability of vital signs occurred during transection. It could be finally controlled by dissect the remnant feeding artery in the inmost space. Prior control of arterial in-flow enabled successful completion of the planned surgical procedure. The patient has now survived for 27 months since resection of the primary lesion.

Conclusion: Ligation of the feeding arteries to this hypervascular catecholamine-releasing tumor via a retroperitoneal laparoscopic approach prior to performing combined organ resection facilitated successful excision of this large malignant pheochromocytoma.

Keywords: Combined hepatectomy; Liver invasion; Malignant pheochromocytoma; Retroperitoneal laparoscopic surgery.

Fig. 1

A. Axial contrast-enhanced computed tomography (CT) image showing a 14-cm diameter right adrenal tumor and left adrenal metastasis (red arrow). B. Coronal CT showing feeding arteries arising from the renal artery (yellow arrows). C. Three-dimensional CT showing many feeding arteries (white arrows) branching from the celiac trunk (red star) and renal artery (yellow star). D. 18F-fluoro-2-deoxyglucose positron emission tomography/computed tomography showing abnormal uptake in lung metastases (yellow arrows).

Fig. 2

A. The tumor’s feeding arteries were ligated using Hem-o-lok clips. B. The dorsal side of the tumor was dissected via a retroperitoneal laparoscopic approach. C. A partial hepatectomy achieved complete resection of the tumor. The adrenal vein (yellow arrow), hepatic artery (blue tape), and portal vein (red tape) have been identified. D. Macroscopic appearance of the tumor with the posterior segment of the liver. Liver invasion is apparent (white arrow).

Fig. 3

A. Macroscopically, the tumor appeared as a gray and yellowish, well-circumscribed, cystic mass. B. Photomicrograph showing invasion of the liver parenchyma by tumor cells (black arrow) (hematoxylin–eosin, 40×). C. CT image showing progressive lung metastases 27 months after resection of the primary tumor (yellow arrows).