Case Presentation
A 66-year-old male with a history of Hepatitis C treated in 2009 with
Ledipasvir/Sofosbuvir (Harvoni®) initially presented
to the Medical Oncology team in Hackensack University Medical Center, NJ
with abdominal discomfort and distention for 4-5 months associated with
an approximate 15 pounds of weight loss. He underwent CT scan of the
abdomen with contrast and was found to have a large 15.0 x 11.0 x 13.0
cm heterogenous mass attached to the left lobe of the liver, with
compression of surrounding intra-abdominal contents including the
stomach and transverse colon, as well as the abdominal wall [figure
1]. Subsequent percutaneous biopsy was performed, demonstrating
hepatocellular carcinoma with extensive necrosis. He was then referred
to the Surgical Oncology team for further workup and management. Follow
up MRI demonstrated two additional satellite lesions consistent with
multifocal hepatocellular carcinoma without evidence of invasion into
surrounding vital structures. Surgical intervention was deemed necessary
given the size of the mass and symptomology.
In the operating room, two large-bore intravenous catheters were placed
but fluid was kept at a low rate along with placement of a foley
catheter. A laparotomy was performed; making a midline sub-xiphoid
incision, which was extended down to the pubic symphysis due to the
shear size of the tumor [figure 2]. Multiple friable blood vessels
were noted at the umbilicus. The omentum as then resected, freeing the
anterior abdominal wall. The transverse colon was then carefully
separated away from the tumor using an Echelon Endo-GIA stapler with a
white load. The transverse colon and its mesentery were preserved and
protected from the dense mass. It was also noted that the distal stomach
was adhered to the mass along the greater curvature. A sleeve
gastrectomy was completed using 60mm stapler, requiring three firings
for completion.
At this time, the retroperitoneal attachment to the duodenum was
carefully dissected, followed by separation of the pancreatic head using
Endo-GIA white load stapler. This allowed the tumor to be separated from
the retroperitoneum and lifted out of the abdomen. A Pringle maneuver
was performed using a vascular clamp, and the satellite lesions were
transected using parenchymal ablation using the NeuWave Microwave
Ablation system. The midline laparotomy was closed in the usual fashion.
On gross inspection, the resected specimen was a 21.0 x 20.0 x 10.7 cm,
tan-yellow mass weighing 1948 grams (Figure 2). The tumor is partially
adhered to a portion of the stomach and surrounded by adjacent
background liver. Microscopically, the tumor shows solid and trabecular
growth pattern with round nucleus, prominent nucleoli, abundant
cytoplasm and distinct cell border typical for hepatocellular carcinoma
(Figure 3). Mitotic figures are frequent and tumor necrosis is also
seen. Multiple satellite nodules are seen adjacent to the main tumor and
extensive small vessel invasion is present (Figure 4). The tumor also
invades into the gastric wall. The background non-tumor liver shows
well-formed cirrhotic liver with mild to moderate activity. The attached
portion of the stomach demonstrated negative margins (R0). The specimen
from the partial hepatectomy, which was the satellite lesion of segment
3, demonstrated a similar pattern.
Post-operative course was significant for urinary retention after
failure of trial of void. Given his history of benign prostate
hyperplasia (BPH), a foley catheter was reinserted and tamsulosin was
added to his regimen. He successfully passed his second trial of void.
On post-operative day 2 (POD2), the patient developed nausea and an
episode of vomiting, with obstructive series demonstrating ileus. A
nasogastric tube was placed and was ultimately removed on POD7 after
ileus resided. On POD5, he developed serosanguineous drainage from his
incision site after a bout of heavy coughing. A Prevena VAC was placed
but was discontinued one week later when the output was reduced to zero,
and he was discharged from the hospital later in the day.