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 Table of Contents     
UNUSUAL CASE
Year : 2018  |  Volume : 14  |  Issue : 1  |  Page : 74-75
 

Late solitary pelvic metastasis of hepatocellular carcinoma mimicking alpha-fetoprotein-producing gynaecologic tumour


1 Gynecologic Cancer Center, School of Medicine, Kyungpook National University Medical Center, Daegu, Korea
2 Department of Surgery, School of Medicine, Kyungpook National University Medical Center, Daegu, Korea

Date of Submission15-Mar-2017
Date of Acceptance30-Apr-2017
Date of Web Publication11-Dec-2017

Correspondence Address:
Prof. Gun Oh Chong
Gynecologic Cancer Center, School of Medicine, Kyungpook National University Medical Center, 807 Hogukno, Buk-Gu, Daegu 700-720
Korea
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmas.JMAS_48_17

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 ¤ Abstract 

Extrahepatic spread of hepatocellular carcinoma (HCC) is uncommon; and, pelvic metastasis, in particular, is extremely rare. A 71-year-old woman was admitted for evaluation of pelvic solitary solid mass. She had undergone a left lobectomy 28 years previously. Magnetic resonance imaging of the abdomen and pelvis demonstrated a heterogeneous mass in the right pelvic cavity, whereas no space-occupying lesions or ascites were detected in the liver. CA 125 levels were within normal limits; however, serum alpha-fetoprotein levels were markedly elevated. She underwent laparoscopic pelvic mass excision, total hysterectomy, and bilateral salpingo-oophorectomy. Histopathologic findings and immunochemical staining results indicated metastatic HCC. Herein, we report an unusual case of a patient with solitary recurrence in the pelvic cavity 28 years after initial diagnosis and treatment.


Keywords: Hepatocellular carcinoma, laparoscopy, pelvic metastasis


How to cite this article:
Kim JH, Chong GO, Kwon HJ, Lee YH, Hong DG. Late solitary pelvic metastasis of hepatocellular carcinoma mimicking alpha-fetoprotein-producing gynaecologic tumour. J Min Access Surg 2018;14:74-5

How to cite this URL:
Kim JH, Chong GO, Kwon HJ, Lee YH, Hong DG. Late solitary pelvic metastasis of hepatocellular carcinoma mimicking alpha-fetoprotein-producing gynaecologic tumour. J Min Access Surg [serial online] 2018 [cited 2018 Aug 15];14:74-5. Available from: http://www.journalofmas.com/text.asp?2018/14/1/74/209974


Common extrahepatic metastatic sites of hepatocellular carcinoma (HCC) include the lungs, peritoneum, adrenal glands and bone.[1] Moreover, solitary pelvic extrahepatic metastasis is extremely rare with only two cases reported in the English literature.[2] The majority of recurrences occur relatively early after initial diagnosis and treatment; the reported median duration between initial treatment for HCC to extrahepatic spread is 23.2 months.[3] However, the present case is extremely rare as HCC recurred 28 years after the initial diagnosis and treatment. There has only been one previous report of extrahepatic recurrence occurring 10 years after initial treatment.[4] The role of minimally invasive surgery for the treatment of extrahepatic metastasis is limited. Only one case report has demonstrated the successful laparoscopic extirpation of peritoneal dissemination of HCC.[5] To the best of our knowledge, the current report is the first to describe a case of late solitary pelvic recurrence of hepatocellular carcinoma mimicking alpha-fetoprotein (AFP) producing gynaecologic tumour, which was successfully excised laparoscopically.

A 71-year-old woman with a history of HCC secondary to chronic infection with hepatitis B virus was admitted for the evaluation of a pelvic solid mass. She was initially diagnosed with HCC 28 years ago and underwent left lobectomy of the liver. Computed tomographic (CT) imaging of the abdomen indicated a 6.5 cm × 6 cm × 5 cm well-circumscribed, contrast-enhanced mass lesion in the right pelvis, which was suspected to be a subserosal uterine myoma [Figure 1]a. Magnetic resonance imaging of the pelvis demonstrated a mass in the right pelvic cavity measuring 6.5 cm × 6 cm × 5 cm. This mass exhibited heterogeneous signal intensity on the T2-weighted image; therefore, it was suspected to be a degenerative uterine myoma or ovarian fibroma [Figure 1]b. No space-occupying lesions in the liver or ascites were detected. CA-125 levels were within normal limits; however, the serum AFP level was 875.7 ng/mL.
Figure 1: (a) Computed tomography demonstrates the contrast-enhanced mass in the right pelvic cavity (white arrowhead). (b) Magnetic resonance image indicates well-defined and heterogeneous mass in the right pelvic cavity in the T2-weighted image (white arrowhead)

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The patient underwent surgery following the tentative diagnosis of AFP-producing gynaecologic tumours. During surgery, a large vascular, friable and exophytic tumour was detected in the right pelvic cavity [Figure 2]a. The tumour was adhesive to the surrounding tissue, particularly the bladder, and was quite friable, to the extent that it inadvertently ruptured despite careful dissection. During the excision of the tumour, bladder mucosa was exposed and primary repair was conducted with 2-0 Vicryl ® (Ethicon, Edinburgh, UK). Subsequently, the patient underwent laparoscopic pelvic mass excision, total hysterectomy and bilateral salpingo-oophorectomy [Figure 2]b. The post-operative course was uneventful and the patient was discharged 3 days after the surgery. Histopathologic finding and immunochemical staining results indicated metastatic HCC. Following surgery, the patient's serum AFP level normalised. As there was no evidence of another systemic recurrence, no adjuvant chemotherapy was administered. The patient remained in good health 15 months after the surgery and her serum AFP remained normal. The latest CT scan was performed 1 year post-surgery and indicated no evidence of recurrence.
Figure 2: (a) Intra-operative laparoscopic view. (b) Post-operative laparoscopic view

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The diagnosis of extrahepatic metastasis should always be suspected in cases with a solitary pelvic mass accompanied by a high serum AFP level and a history of HCC. Laparoscopic surgery may be successful in selected cases with extrahepatic metastasis of HCC.

Acknowledgements

We would like to acknowledge the patient for allowing us to discuss her case with the academic community.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 ¤ References Top

1.
Lee JM, Park KM, Lee SY, Choi J, Hwang DW, Lee YJ. Metastasis of hepatocellular carcinoma to the ovary: A case report and review of the literature. Gut Liver 2011;5:543-7.  Back to cited text no. 1
[PUBMED]    
2.
Ishii H, Furuse J, Kinoshita T, Konishi M, Nakagohri T, Takahashi S, et al. Extrahepatic spread from hepatocellular carcinoma: Who are candidates for aggressive anti-cancer treatment? Jpn J Clin Oncol 2004;34:733-9.  Back to cited text no. 2
[PUBMED]    
3.
Wong TC, To KF, Hou SS, Yip SK, Ng CF. Late retroperitoneal recurrence of hepatocellular carcinoma 12 years after initial diagnosis. World J Gastroenterol 2010;16:2187-9.  Back to cited text no. 3
[PUBMED]    
4.
Yuce S, Sahin O, Bedir R, Ayaz T, Durakoglugil T. A case report of retroperitoneal extrahepatic hepatocellular carcinoma presented with elevated level of alpha fetoprotein. Hippokratia 2014;18:80-2.  Back to cited text no. 4
[PUBMED]    
5.
Hai S, Okada T, Iimuro Y, Hirano T, Suzumura K, Fujimoto J. Successful laparoscopic extirpation of peritoneal dissemination after hepatectomy for ruptured hepatocellular carcinoma. Asian J Endosc Surg 2015;8:465-7.  Back to cited text no. 5
[PUBMED]    


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