A patient with hepatocellular carcinoma who underwent resection of the primary lesion 10 years ago and resection of a giant adrenal metastasis 8 and a half years later

Clinical features and prognosis of patients with extrahepatic metastases from hepatocellular carcinoma

AIM: To assess the clinical features and prognosis of 151 patients with extrahepatic metastases from primary hepatocellular carcinoma (HCC), and describe the treatment strategy for such patients.

METHODS: After the diagnosis of HCC, all 995 consecutive HCC patients were followed up at regular intervals and 151 (15.2%) patients were found to have extrahepatic metastases at the initial diagnosis of primary HCC or developed such tumors during the follow-up period. We assessed their clinical features, prognosis, and treatment strategies.

RESULTS: The most frequent site of extrahepatic metastases was the lungs (47%), followed by lymph nodes (45%), bones (37%), and adrenal glands (12%). The cumulative survival rates after the initial diagnosis of extrahepatic metastases at 6, 12, 24, and 36 mo were 44.1%, 21.7%, 14.2%, 7.1%, respectively. The median survival time was 4.9 mo (range, 0-37 mo). Fourteen patients (11%) died of extrahepatic HCC, others died of primary HCC or liver failure.

CONCLUSION: The prognosis of HCC patients with extrahepatic metastases is poor. With regard to the cause of death, many patients would die of intrahepatic HCC and few of extrahepatic metastases. Although most of HCC patients with extrahepatic metastases should undergo treatment for the primary HCC mainly, treatment of extrahepatic metastases in selected HCC patients who have good hepatic reserve, intrahepatic tumor stage (T0-T2), and are free of portal venous invasion may improve survival.

Management of Bilateral Adrenal Metastases from Hepatocellular Carcinoma: A Case Report

The adrenal glands rarely are an extrahepatic site for metastasis from hepatocellular carcinoma (HCC). Once identified, adrenal metastasis requires aggressive management, due to the risk of rupture and internal hemorrhaging. Disease management of adrenal metastasis from HCC is limited, given the relative lack of available knowledge, and the present report details our efforts in managing bilateral adrenal metastases from HCC. For this patient, we used radiation therapy and transcatheter arterial chemoembolization (TACE). The left adrenal tumor was treated by 3D conformal radiation therapy, following the failure of TACE. The size of the left adrenal tumor decreased and no evidence of recurrence after management was noted. One right adrenal tumor was treated using two sessions of TACE, and the size of the tumor did not decrease. We later observed that the right tumor actually progressively increased in size. The tumor was then treated by 3D conformal radiation therapy (total 5400 cGy), and the size decreased by 10 mm, 1 month after treatment. The patient's condition was stable and liver function was maintained at early stage liver cirrhosis (Child A). Renal function was maintained within normal ranges after diagnosis of HCC and throughout the entire follow-up period, and no complications secondary to radiation therapy were noted. Our experience may provide useful information in disease management for these patients.

[Adrenal metastases of hepatocellular carcinoma. Therapeutic options]

AIM OF THE STUDY

The aim of this study was to evaluate the therapeutic modalities, particularly surgical treatment, for adrenal metastasis of hepatocellular carcinomas.

PATIENTS AND METHODS

This series included 13 patients (mean age: 64 years) with hepatocellular carcinoma on cirrhotic liver (n = 8) or healthy liver (n = 5). The adrenal metastasis was synchronous in four cases, metachronous in nine, unilateral in ten cases, and bilateral in three. Resection of the adrenal metastasis was performed in seven patients, combined with the resection of the hepatic carcinoma in three cases or secondarily performed in four. The metastasis was not resected in six patients because of poor liver function or poor patient conditions; two patients were treated with percutaneous ethanol injection, one with radiation and three received only a symptomatic treatment.

RESULTS

After adrenalectomy combined with liver resection, two patients died in the postoperative course in relation with pulmonary embolism (n = 1) or acute pancreatitis (n = 1). The mean survival in the five other patients was 38 months after the adrenalectomy and 58.6 months after the liver resection. After percutaneous ethanol injection, one patient survived 47 months and the other one 7 months only. After radiation, the patient survived 18 months. After symptomatic treatment, the mean survival was only 7.3 months.

CONCLUSION

The present data suggest that adrenal metastasis, either isolated or associated with a well-controlled intrahepatic recurrence, could be treated surgically when the resection is technically feasible. This aggressive management seems the only chance to offer a long-term survival to selected patients.

Right-sided pedunculated hepatocellular carcinoma: a form of adrenal metastasis

Pedunculated hepatocellular carcinoma (HCC) or extrahepatic growth of HC C is an uncommon but not rare pathological form, but its genesis is unknown. Right-sided adrenal metastases of HCC that were abutting on or about to fuse with the right hepatic lobe were resected in three patients. The masses seemed to have originated in the para-adrenal tissue, leaving the adrenal gland intact. They were partially supplied by the hepatic artery as well as by the suprarenal artery. Four cases of autopsied pedunculated HCC of the right lobe were also studied. The mass was protruding caudad from the noncancerous parenchyma of the right lobe. Postmortem angiography carried out on one liver showed that only a small portion of the mass toward the liver was supplied from the hepatic artery. These observations suggest that some, perhaps most, of the right-sided pedunculated HCCs represent fusion of the right lobe and para-adrenal or adrenal metastatic HCC. This phenomenon may be explained by possible transport of cancer cells toward the right adrenal gland through the so-called adrenohepatic fusion, a relatively common anatomical change in advanced age.

Case report: right-sided periadrenal metastasis supplied by the hepatic artery. Clue to the genesis of pedunculated hepatocellular carcinoma

The adrenal is the second most common site of haematogenous metastasis of hepatocellular carcinoma (HCC). The right adrenal is much more frequently affected than the left, but no reason has been offered for this difference. An aetiological connection has never been suggested between adrenal metastasis and pedunculated HCC. Hepatocellular carcinoma was resected in two patients who subsequently developed right-sided adrenal metastasis diagnosed by imaging. The adrenal mass was enhanced by hepatic arteriography and took up lipiodol injected into the hepatic artery. Reoperation was performed to remove the adrenal mass, which was abutting on the liver but was readily separable. Histopathologically, the adrenal gland was compressed by a metastatic HCC that developed in the immediate periadrenal tissue or adrenal capsule. By conventional imaging, the adrenal gland could not be recognized and the mass was thought to have arisen within the adrenal gland. In conclusion, periadrenal growth of HCC is a hitherto unrecognized type of metastasis and must have been mistaken either for an adrenal metastasis or a pedunculated HCC in the past. If left unresected, it would have fused with the liver and grown into a pedunculated HCC. Cancer cell invasion through an adrenohepatic fusion is the most likely mode of periadrenal metastasis; it explains the arterial communication between the mass and the liver.