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Computed tomography arteriography (CTA) of the liver tumor in the early phase (A) and the delayed phase (B). C) Computed tomography during arterial portography (CTAP) showing a portal vein tumor thrombus (arrow) and a perfusion defect in the entire right lobe.
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Figure 1: Computed tomography arteriography (CTA) of the liver tumor in the early phase (A) and the delayed phase (B). C) Computed tomography during arterial portography (CTAP) showing a portal vein tumor thrombus (arrow) and a perfusion defect in the entire right lobe.

Mentions: Despite the adjuvant treatment, abdominal computed tomography (CT) 13 months after surgery showed a liver tumor in segment 8 based on Couinaud's classification [16]. Our patient was subsequently readmitted to our hospital for full diagnosis and treatment of the liver tumor. Hepatitis B surface antigen, hepatitis B core antibody, and hepatitis C antibody test results were negative. Tumor markers including CEA, CA19-9, α-fetoprotein, and protein induced by vitamin K absence or antagonist II, were all within normal limits. CT arteriography (CTA) showed a tumor of approximately 25 mm in diameter consisting of two components: an apparently solid part and a cystic component. The solid component of the tumor was enhanced in the early phase of the CTA and was washed out in the delayed phase, a pattern compatible with HCC (Figure 1A). However, based on the cystic component, the tumor was also suspected to be a cystadenocarcinoma. The right portal vein was not visible on portography, but CT during arterial portography (CTAP) revealed defective portal perfusion in the whole right lobe of the liver (Figure 1C). This finding was suggestive of PVTT. Endoscopic retrograde cholangiography was performed to differentiate cystadenocarcinoma connected to a biliary duct. However, no specific findings of biliary carcinoma were noted and the collected bile sample was cytologically negative. For preoperative differential diagnosis of the tumor, echo-guided biopsy was performed. The biopsy revealed that the liver tumor was a liver metastasis from the colon cancer. With a preoperative diagnosis of liver metastasis from colon cancer, laparotomy was performed. Neither peritoneal dissemination nor hilar lymph node metastasis was detected. The liver tumor, measuring 28 × 25 mm in size, was located in segment 8, while PVTT was located in the right portal vein in direct communication with the liver tumor. Our patient underwent a right lobectomy (Figure 2A). The resected tumor, which had a fibrotic capsule, macroscopically resembled HCC. The cystic component observed on preoperative examination was not detected in the resected specimen. Histopathology of the resected liver tumor and PVTT revealed a moderately differentiated adenocarcinoma (Figure 2B). The histopathological findings from the resected tumor were similar to the previously resected ascending colon cancer. Based on the similarity, the final diagnosis for the liver tumor was a liver metastasis from the ascending colon cancer accompanied by macroscopic PVTT in the right portal branch. Histopathological infiltration into the endothelial layer of the portal vein was not seen. All resected margins were free from cancer. Postoperatively, our patient agreed to receive adjuvant chemotherapy. Our patient remains healthy, with no evidence of recurrence 51 months after the hepatectomy.

Liver metastasis originating from colorectal cancer with macroscopic portal vein tumor thrombosis: a case report and review of the literature

Tomimaru Y, Sasaki Y, Yamada T, Gotoh K, Noura S, Eguchi H, Miyashiro I, Ohue M, Ohigashi H, Yano M, Ishikawa O, Imaoka S - J Med Case Rep (2010)

Bottom Line: Histopathological examination of the liver tumor revealed adenocarcinoma, consistent with that of the previous colon cancer, confirming that the liver tumor was a metastasis from the colon cancer.Our patient remains well without recurrence at 51 months after the liver surgery.The prognosis of patients with liver metastasis accompanied by a portal vein tumor thrombus remains unknown, but, considering several previous reported cases together with our case report, a better prognosis may be expected if the tumor is successfully removed by anatomical liver resection.

Affiliation: Department of Surgery, Yao Municipal Hospital, Osaka, Japan. yosasaki@hcn.zaq.ne.jp.

ABSTRACT

Introduction: Macroscopic tumor thrombi occupying the main portal branch are rarely seen in patients with liver metastasis.

Case presentation: A 55-year-old Japanese man who had previously undergone surgery for adenocarcinoma of the ascending colon presented with a metastatic liver tumor accompanied by a macroscopic tumor thrombus in the right portal branch. Right lobectomy and removal of the tumor thrombus were performed, and the liver metastasis and tumor thrombus were successfully resected. Histopathological examination of the liver tumor revealed adenocarcinoma, consistent with that of the previous colon cancer, confirming that the liver tumor was a metastasis from the colon cancer. Our patient remains well without recurrence at 51 months after the liver surgery.

Conclusion: The prognosis of patients with liver metastasis accompanied by a portal vein tumor thrombus remains unknown, but, considering several previous reported cases together with our case report, a better prognosis may be expected if the tumor is successfully removed by anatomical liver resection.

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