© 2004 Foundation for Promotion of Cancer Research
Case Report |
Aggressive Multimodal Treatment for Peritoneal Dissemination and Needle Tract Implantation of Hepatocellular Carcinoma: a Case Report*
1 Department of Surgery and Clinical Oncology, Osaka University, Graduate School of Medicine, Osaka and 2 Division of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
For reprints and all correspondence: Hidenori Takahashi, Department of Surgery and Clinical Oncology, Osaka University, Graduate School of Medicine, 2–2, Yamadaoka, Suita, Osaka 565-0871, Japan. E-mail: h-takaha{at}dd.iij4u.or.jp
Received March 11, 2004; accepted June 16, 2004
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Abstract |
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 TOP Abstract INTRODUCTIONCASE REPORTDISCUSSIONCONCLUSIONReferences |
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We encountered a patient with hepatocellular carcinoma (HCC) with peritoneal dissemination and needle tract implantation, both of which were strongly suspected to have been caused by percutaneous needle biopsy. The patient was a 65-year-old man. Partial hepatectomy of subsegment VI had been performed following the diagnosis of HCC by percutaneous needle biopsy in February 1997. After this first surgery, the patient additionally underwent five further surgeries for the treatment of intrahepatic recurrences, peritoneal recurrences and needle tract implantation caused by the percutaneous needle biopsy. The intrahepatic and peritoneal recurrences were surgically controlled for 3 years after the fifth operation. The needle tract implantation was first resected in February 2001. Since then, treatment by surgery and radiotherapy has been administered twice for local recurrences forming tumor thrombosis of the abdominal wall. Now, 7 years after the first surgery, the patient remains alive without any evidence of recurrence. This case report serves to emphasize that needle tract implantation and peritoneal seeding caused by percutaneous needle biopsy are rare but possible complications. When such iatrogenic spreading of malignant cells occurs, aggressive multimodal treatment is well worth considering. Wide resection of the tumor including the adjacent soft tissues should be performed in these cases, considering that the tumor spreads along the subcutaneous veins in needle tract implantation of HCC and repeated aggressive surgeries could provide good local control.
Key Words: hepatocellular carcinoma • percutaneous needle biopsy • peritoneal recurrence • needle tract implantation
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INTRODUCTION |
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TOPAbstractINTRODUCTIONCASE REPORTDISCUSSIONCONCLUSIONReferences |
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Ultrasonically guided percutaneous needle biopsy of liver tumors has been widely performed for the diagnosis of these tumors. It is generally considered to be a safe and non-invasive procedure, with a low incidence of complications (1–3). However, rare but serious complications associated with this procedure have been reported, including needle tract implantation and peritoneal seeding of hepatocellular carcinoma (HCC) (1–10). We encountered an HCC patient with both needle tract implantation and peritoneal dissemination following percutaneous needle biopsy, which was successfully treated with aggressive multimodal treatment, including six surgical procedures and radiation therapy.
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CASE REPORT |
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TOPAbstractINTRODUCTIONCASE REPORTDISCUSSIONCONCLUSIONReferences |
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The patient was a 65-year-old man. Partial hepatectomy of subsegment VI had been conducted at another hospital in February 1997 following the diagnosis of HCC by percutaneous needle biopsy of a liver tumor (Table 1). The primary tumor was localized within the liver without any evidence of rupture of the tumor and a curative resection had, therefore, been conducted. Since then, two additional surgeries had been undertaken for peritoneal recurrences, presumably caused by the percutaneous needle biopsy (Table 1). In January 1999, the patient was admitted to our hospital with multiple peritoneal recurrences as revealed by a follow-up radiographic examination conducted following the third surgery.
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The hematological findings at admission were all within normal limits. Liver function tests showed a total bilirubin of 0.5 mg/dl, AST of 22 IU/L, ALT of 26 IU/L and an ICG retention at 15 min of 6.2%. Serological analysis showed that the serum level of
-fetoprotein (AFP) and protein induced by vitamin K absence (PIVKA-II) were 469.0 ng/ml and 3070 mAU/ml, respectively. Serological markers for hepatitis B virus and hepatitis C virus were negative. Abdominal computed tomography (CT) revealed a tumor 12 mm in diameter on the surface of subsegment III of the liver, a tumor 20 mm in diameter in the right subphrenic area, a tumor 30 mm in diameter at the superior splenic pole, a tumor 30 mm in diameter in the pouch of Douglas and several tumors with an average diameter of 10 mm at the ventral aspect of the transverse colon. Based on these findings, the patient was diagnosed as having multiple peritoneal recurrences of HCC. We performed the fourth surgery for recurrent HCC on January 22, 1999 (Table 1). Histopathological examination revealed that the tumors were composed of well-differentiated HCC. In February 2001, CT scans showed intrahepatic recurrences, peritoneal recurrences and a tumor 30 mm in diameter in the upper abdominal wall at the site of the previous needle biopsy (Fig. 1). The tumor in the abdominal wall was thought to have been caused by the percutaneous needle tract biopsy in 1997, diagnosed as needle tract implantation. We performed a fifth surgery on the patient on February 15, 2001 (Table 1). Histopathological examination revealed that the tumors were composed of well-differentiated and some moderately differentiated HCC and the margin was negative. The tumor in the abdominal wall was histopathologically revealed to be associated with tumor venous thrombosis in the soft tissues. In February 2002, CT scans showed two tumors in the abdominal wall and local recurrences of the needle tract implantation were diagnosed (Fig. 2A). We performed the sixth surgery on the patient on February 28, 2002 (Table 1). The abdominal wall tumors were resected en bloc with a surgical margin of about 5 mm, including the adjacent soft tissues (Fig. 2B). Histopathological examination revealed that the tumors were composed of well-differentiated and some moderately differentiated HCC (Fig. 2C). One of the two tumors was histopathologically diagnosed as representing a tumor venous thrombosis of HCC (Fig. 2D). In December 2002, subcutaneous tumors in the abdominal and thoracic wall appeared and local recurrences of needle tract implantation in the form of tumor venous thrombosis of HCC were diagnosed (Fig. 3A, B and C). We decided against surgical treatment, because the subcutaneous tumor had spread so widely that curative resection was difficult (Fig. 3B and C). Radiation therapy was administered and the subcutaneous tumors disappeared macroscopically. At the time of writing, the patient has been recurrence free for 14 months since the radiation therapy and alive for 7 years since the first surgery.
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DISCUSSION |
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TOPAbstractINTRODUCTIONCASE REPORTDISCUSSIONCONCLUSIONReferences |
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Percutaneous needle biopsy of liver tumors is widely performed for histopathological confirmation of the diagnosis. This procedure is considered to be generally safe, but some complications have been reported, such as hemorrhage, biliary leak and drainage to an adjacent organ, needle tract implantation and peritoneal seeding (1–3). Needle tract implantation and peritoneal seeding caused by percutaneous needle biopsy have been previously reported as rare but serious complications (1–9). The incidence of needle tract implantation of HCC caused by percutaneous needle biopsy has been reported to be in the range of 1.6–5% (2,3). With regard to peritoneal seeding of HCC caused by percutaneous needle biopsy, there have been few reports (7,9,10). Some authors reported that a ruptured HCC could cause peritoneal dissemination (11,12). The primary tumor in the present case was not ruptured and had been curatively resected in the first operation. We therefore considered that the peritoneal dissemination in this case was presumably caused by the percutaneous needle tract biopsy, which had been performed before the first operation. Both of the complications of percutaneous needle biopsy present in the same patient, as was the case in our present patient, is very rare.
In all the previously reported cases with needle tract implantation, complete local control was achieved after resection of the subcutaneous tumors (2–6,8). Therefore, local resection of subcutaneous tumors arising from needle tract implantation has been recognized as the treatment of choice. Kim et al. reported that needle tract implantation itself did not change the ultimate clinical outcome of the patients, because the clinical course after local resection for needle implantation was uneventful and no recurrence was observed (6). Durand et al. reported that local resection for needle tract implantation was efficient, because tumorous involvement was strictly limited to the subcutaneous tissue at the puncture site (3). In the present case, however, local recurrence was observed after resection for needle tract implantation, involving and spreading widely along the veins of the abdominal wall, causing tumor venous thrombosis. Among the 11 cases of needle tract implantation of HCC that have been surgically treated at our hospital since 1992, including the present case, local recurrences were observed in three cases, in all of which venous thrombosis was produced by the tumor. In two of the three cases we achieved good local control for needle tract implantation with repeated surgical procedures. In the third case (the present case), however, we failed to control needle tract implantations surgically, but radiation therapy proved effective. These findings seem to suggest that needle tract implantation is certainly not a local and limited disease as reported previously. Careful examination of the cutaneous puncture site after performing percutaneous needle biopsy to confirm the diagnosis of HCC is therefore very necessary to detect needle tract implantation before the tumor has spread. In treating needle tract implantation surgically, wide resection of the tumor including the adjacent soft tissues should be performed, considering the possibility that the tumor can spread along the subcutaneous veins. Furthermore, radiation therapy might be effective for needle tract implantation which has spread too widely to be treated with surgery.
Peritoneal seeding of HCC induced by percutaneous needle biopsy is a rare complication, on which only a few reports have been published (7,9,10). All of these reported cases were successfully treated by surgical resection, but it still remains controversial as to whether surgical resection for peritoneal dissemination of HCC would improve patient survival rates (13–15). Uenishi et al. reported a case of HCC with peritoneal dissemination induced by needle biopsy which was successfully treated by surgical resection and concluded that local control can be achieved by surgical treatment in cases with peritoneal dissemination of HCC (10). On the other hand, some reports have indicated that peritoneal dissemination may be a reflection of widespread disease (1,10). Tanaka et al. (13) reported a case of HCC with peritoneal dissemination in which multimodal treatment was indicated, including four surgical resections. Their patient finally died of cancer 26 months after the first admission; they nevertheless emphasized the usefulness of aggressive treatment for such advanced cases of HCC, in terms of prolongation of life and maintenance of a good quality of life. We performed surgical treatment four times for peritoneal dissemination and there was no evidence of recurrence in the peritoneal cavity for 3 years after the last of these procedures. We also believe that surgical treatment may provide good local control for peritoneal dissemination but that the strategy of repeated surgery for peritoneal dissemination will be beneficial for selected patients. In general, patients with HCC are in such a poor condition owing to liver dysfunction and diffusely disseminated and recurrent tumors in the peritoneal cavity that surgical resection is not indicated (1,10,13). In contrast, aggressive repeated surgeries could offer benefits as far as survival is concerned in those patients with peritoneal recurrent HCC who maintain good liver function and in whom tumor recurrence is relatively limited, such as our patient.
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CONCLUSION |
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TOPAbstractINTRODUCTIONCASE REPORTDISCUSSIONCONCLUSIONReferences |
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We have reported on a patient of HCC with needle tract implantation and peritoneal dissemination following percutaneous needle biopsy performed to confirm the diagnosis of a liver tumor and who has been alive for 7 years since the first surgery. Wide resection of the tumor including the adjacent soft tissues should be conducted for needle tract implantation of HCC, considering that the tumor spreads along the subcutaneous veins and the strategy of aggressive repeated surgical procedures is well worth considering for cases of peritoneal dissemination.
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Notes |
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* This paper was presented at the 5th World Congress of the International Hepato-Pancreato-Biliary Association, Tokyo, April 25–29, 2002.
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References |
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