Metastatic seeding of bile duct carcinoma in the transhepatic catheter tract: report of a case

FDG-PET/CT Manifestation of Tumor Seeding Along Percutaneous Biliary Drainage Catheter Tract

A 55-year-old man with liver metastases from colon cancer developed obstructive jaundice secondary to bile duct compression from tumor burden, which required percutaneous biliary drainage until subsequent internal biliary stent could be placed. Follow-up FDG-PET/CT performed 2 months after removal of percutaneous biliary drainage catheter revealed FDG avid metastases along the catheter tract, extending from anterior abdominal wall to the peripheral liver at the insertion site of previous biliary catheter.

Living donor liver transplantation with abdominal wall reconstruction for hepatocellular carcinoma with needle track seeding

Malignant cell seeding in subcutaneous tissues along the needle track and/or percutaneous biliary drainage catheters is rare complication, but pose various technical issues in planning surgical treatment of such patients. If underlying primary hepatic malignancy can be treated, an aggressive resection of subcutaneous tissue bearing cancer cell with subsequent abdominal wall reconstruction has been sporadically reported. But, when hepatic resection is not possible due to underlying advanced cirrhosis, liver transplantation along with abdominal wall resection and subsequent reconstruction remains only feasible option. Herein, we describe our successful experience of living donor liver transplantation for hepatocellular carcinoma with full-thickness abdominal wall resection bearing the tumor seeding followed by reconstruction in single stage surgery.

Catheter tract recurrence after percutaneous biliary drainage for hilar cholangiocarcinoma

BACKGROUND

Despite its wide use, catheter tract recurrence after percutaneous biliary drainage (PBD) is rarely reported. However, one recent large-scale study reported a catheter tract recurrence rate as high as 5.2 % in patients with perihilar or distal bile duct cancer. We report on our 20 years of experience with catheter tract seeding after PBD for hilar cholangiocarcinoma.

METHODS

The medical records of 441 patients who underwent operation for hilar cholangiocarcinoma between 1991 and 2011 were retrospectively analyzed.

RESULTS

Of the 441 patients with hilar cholangiocarcinoma, PBD was performed in 315 patients, and 232 others underwent resection of hilar cholangiocarcinoma with PBD. Catheter tract recurrence developed in 6 patients (2.6 %). The median drainage duration was 30 days, and 1 patient had multiple PBDs. The median time to catheter recurrence after surgery was 10.9 months. Three patients underwent curative resection of the abdominal wall followed by chemotherapy, 1 patient underwent chemotherapy only, and 2 patients received conservative treatment. Five patients in whom the catheter tract recurrence was their first recurrence died of systemic recurrence at median 3.9 months after detection of catheter tract seeding. T1 or 2 disease (66.7 vs. 31.3 %; p = 0.086) tended to have catheter tract seeding with marginal significance. The overall survival rate was lower in patients with catheter tract seeding than in those without (median 17.5 vs. 23.0 months; p = 0.089).

CONCLUSIONS

The PBD catheter tract recurrence rate for hilar cholangiocarcinoma was 2.6 %. However, patients with catheter tract recurrence had a poor prognosis despite complete surgical metastasectomy.

Metastasis to the skin at the drain site after complete resection of the lower bile duct cancer: report of a case

There are extremely few reports of metastases from a lower cholangiocarcinoma to the skin except for metastatic seeding in a percutaneous transhepatic biliary drainage catheter tract. This report presents a rare case of metastases to the skin after the removal of a drain following curative pancreaticoduodenectomy for lower bile duct cancer (LBDC). A 73-year-old female had undergone subtotal stomach-preserving pancreaticoduodenectomy. Skin metastasis was noted at the site where the drain from the lower border at pancreaticojejunostomy had been removed 22 weeks postoperatively, and it was en bloc resected with the abdominal wall without exposing the carcinoma. Multiple nodules were confirmed in the axilla and chest wall 40 weeks after the initial operation. Careful discussion is necessary to avoid this mode of metastasis. The surgical field should not be exposed to pancreatic juice, even with LBDC. Nevertheless, this case is rare. Therefore, the risks and benefits of using such drains must be considered.

Reappraisal of percutaneous transhepatic biliary drainage tract recurrence after resection of perihilar bile duct cancer

BACKGROUND

The high incidence of percutaneous transhepatic biliary drainage (PTBD) tract recurrence after resection of perihilar bile duct cancer (BDC) at a reference single center has suggested the need for endoscopic biliary drainage (EBD) to prevent PTBD-related tumor recurrence. To determine the general applicability of these findings, we validated the risk of PTBD tract recurrence in patients with resected BDC in our high-volume center.

METHODS

The medical records of 306 patients with perihilar BDC who underwent hepatobiliary resection with curative intent over 10 years were reviewed retrospectively.

RESULTS

Of the 306 patients, 293 (95.8%) underwent biliary decompression, 171 (56.1%) by preoperative PTBD, 62 (20.3%) by EBD alone, and 60 (19.7%) by both. Of the 231 patients who underwent PTBD, 160 (69.3%), 62 (26.8%), and 9 (3.9%) had one, two, or three catheters, respectively (mean of 1.3 catheters per patient for a median 23 days). No patient experienced synchronous PTBD tract metastasis, whereas 4 (1.7%) experienced PTBD tract recurrence a median 13.5 months after surgery, with 3 of these patients having an intraabdominal recurrence soon afterward. Only one patient had a solitary tract recurrence without intraabdominal metastasis. These patients survived for a median 25 months, which is comparable to survival outcomes after noncurative resection. No risk factor was significantly associated with PTBD tract recurrence.

CONCLUSIONS

We think that the risk of PTBD tract recurrence after resection of perihilar BDC is not negligible but is much lower than previously reported. There is no definitive reason to avoid PTBD when it is indicated.

Solitary percutaneous transhepatic biliary drainage tract metastasis after curative resection of perihilar cholangiocarcinoma: report of a case

Percutaneous transhepatic biliary drainage (PTBD) has been widely used, but it has a potential risk of tumor spread along the catheter tract. We herein present a case of solitary PTBD tract metastasis after curative resection of perihilar cholangiocarcinoma. Initially, endoscopic nasobiliary drainage was done on a 65 year-old female patient, but the cholangitis did not resolve. Thus a PTBD catheter was inserted into the right posterior duct. Right portal vein embolization was also performed. Curative surgery including right hepatectomy and bile duct resection was performed 16 days after PTBD. After 12 months, serum CA19-9 had increased gradually without any symptoms. Finally, a small right pleural metastasis was found through strict tumor surveillance for 6 months. Chemoradiation therapy was performed, but there was no response to treatment. As the tumor progressed, she complained of severe dyspnea and finally died from tumor dissemination to the chest and bones 18 months after the first detection of PTBD tract recurrence and 36 months after surgery. No intra-abdominal recurrence was found until the terminal stage. This PTBD tract recurrence was attributed to the PTBD even though it was in place for only 16 days. Although such recurrence is rare, its risk should be taken into account during follow-up of patients who have received PTBD before.

Metastatic seeding of colon adenocarcinoma manifesting as synchronous breast and chest wall localization: report of a case

Colon carcinoma rarely metastasizes to the breast and it is usually associated with a poor prognosis. Even rarer is metastatic seeding of colon cancer cells in an intramammary location after surgery. Including a primary breast malignancy in the differential diagnosis of such cases is mandatory. We report a rare case of double seeding implantation of colon adenocarcinoma inside the breast parenchyma and intercostal muscles 6 years after resection of a pulmonary metastasis from colon adenocarcinoma. The metastasis was revealed by the presence of bone metaplasia in the intercostal muscles. We discuss how negative immunostaining for estrogen receptors, progesterone receptors, and HER-2, along with the immunohistochemical pattern of cytokeratin (CK) 20+/7-/5- and CDX2-positive immunostaining, excludes a primary breast malignancy, namely, a "matrix-producing" carcinoma, from the differential diagnosis. We also present the hypothesis of a paracrine pathogenetic mechanism to explain the bone metaplasia.

Percutaneous transhepatic biliary drainage catheter tract recurrence in cholangiocarcinoma

BACKGROUND

The aim of the study was to clarify the incidence, risk factors and treatment of percutaneous transhepatic biliary drainage (PTBD) catheter tract recurrence in patients with resected cholangiocarcinoma.

METHODS

The medical records of 445 patients with perihilar and distal cholangiocarcinoma who underwent resection following PTBD were reviewed retrospectively.

RESULTS

PTBD catheter tract recurrence was detected in 23 patients (5.2 per cent). The mean(s.d.) interval between surgery and onset of the recurrence was 14.4(13.8) months. On multivariable analysis, duration of PTBD (60 days or more), multiple PTBD catheters and macroscopic papillary tumour type were identified as independent risk factors. In four patients with synchronous metastasis, the PTBD sinus tract was resected simultaneously, at the time of initial surgery. Of 19 patients with metachronous metastasis, 15 underwent surgical resection of the metastasis. Survival of the 23 patients with PTBD catheter tract recurrence was poorer than that of the 422 patients without recurrence (median 22.8 versus 27.3 months; P = 0.095). Even after surgical resection of PTBD catheter tract recurrence, survival was poor.

CONCLUSION

PTBD catheter tract recurrence is not unusual. The prognosis for these patients is generally poor, even after resection. To prevent this troublesome complication, endoscopic biliary drainage is first recommended when drainage is indicated.

Surgical treatment of abdominal wall tumor seeding after percutaneous transhepatic biliary drainage

Occasional cases of malignant seeding of cancer cells along the catheter tract, particularly affecting the skin, have been reported after percutaneous biliary drainage. Although radical resection of the abdominal wall may achieve long-term postoperative survival, reconstruction of large abdominal defects that cannot be closed primarily is problematic. We describe the successful surgical repair of a full-thickness defect of the abdominal wall using a free tensor fascia lata musculofasciocutaneous flap anastomosed to the intraabdominal gastroepiploic vessels.

Lack of tumor seeding of hepatocellular carcinoma after percutaneous needle biopsy using coaxial cutting needle technique

OBJECTIVE

The objective of our study was to determine the incidence of tumor seeding after biopsy of hepatocellular carcinoma (HCC) using a coaxial cutting needle technique. Seeding along the needle track is a dreaded complication of percutaneous biopsy in patients with HCC, particularly in potential liver transplant recipients. Reported seeding rates range from 0.6% to 5.1% using various biopsy techniques. To our knowledge, the rate of seeding using a coaxial cutting needle technique has not been reported.

MATERIALS AND METHODS

Retrospective review identified 128 patients with imaging-guided percutaneous liver biopsies positive for HCC. A coaxial cutting needle technique was uniformly used with a 17-gauge introducer and 18-gauge biopsy needle. Radiology and clinical reports were reviewed, and findings at clinical and imaging follow-up were assessed.

RESULTS

During the 6-year study period, 1,012 liver mass biopsies were performed, with 128 positive for HCC (100 men and 28 women; average age, 58.4 years). One hundred one patients had more than 30 days of clinical or imaging follow-up (or both) after biopsy (mean, 410 days; range, 33-1,989 days) and constituted the study population. The remaining 27 were excluded because of inadequate follow-up. No suspected or confirmed tumor seeding on imaging, physical examination, or laparotomy was identified.

CONCLUSION

We found no tumor seeding after percutaneous biopsy of HCC using a coaxial cutting needle technique. This rate, 0%, is lower than those reported with other techniques. The use of a needle introducer that remains in position during multiple cutting needle passes protects normal tissue along the track and may reduce seeding. This has particular importance for patients with stage I-II HCC, for whom liver transplantation may be curative.

Catheter tract implantation metastases associated with percutaneous biliary drainage for extrahepatic cholangiocarcinoma

AIM

To estimate the incidence of catheter tract implantation metastasis among patients undergoing percutaneous transhepatic biliary drainage (PTBD) for extrahepatic cholangiocarcinoma, and to provide data regarding the management of this unusual complication of PTBD by reviewing cases reported in the literature.

METHODS

A retrospective analysis of 67 consecutive patients who underwent PTBD before the resection of extrahepatic cholangiocarcinoma was conducted. The median follow-up period after PTBD was 106 mo. The English language literature (PubMed, National Library of Medicine, Bethesda, MD, USA), from January 1966 through December 2004, was reviewed.

RESULTS

Catheter tract implantation metastasis developed in three patients. The cumulative incidence of implantation metastasis reached a plateau (6%) at 20 mo after PTBD. All of the three patients with implantation metastasis died of tumor progression at 3, 9, and 20 mo after the detection of this complication. Among the 10 reported patients with catheter tract implantation metastasis from extrahepatic cholangiocarcinoma (including our three patients), two survived for more than 5 years after the excision of isolated catheter tract metastases.

CONCLUSION

Catheter tract implantation metastasis is not a rare complication following PTBD for extrahepatic cholangiocarcinoma. Although the prognosis for patients with this complication is generally poor, the excision of the catheter tract may enable survival in selected patients with isolated metastases along the catheter tract.