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CORRESPONDENCE
Year : 2018  |  Volume : 14  |  Issue : 12  |  Page : 1230-1232

Gastric metastasis of recurrent hepatocellular carcinoma: A case report and literature review


1 Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
2 Department of Pathology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China

Date of Web Publication11-Dec-2018

Correspondence Address:
Weidong Xiao
Department of General Surgery, The First Affiliated Hospital of Nanchang University, No. 17, Yongwai Zhengjie, Nanchang, Jiangxi 330006
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.199379

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 > Abstract 


Hepatocellular carcinoma (HCC) with gastric metastasis is seldom reported. It is extremely easy to misdiagnose for primary gastric cancer with liver metastasis, especially gastric hepatoid adenocarcinoma. Here, we report a case of recurrent HCC with gastric metastasis in a 22-year-old man. He had a history of left side hepatic tumor local resection due to ruptured HCC 10 years ago. Computed tomography revealed tumors in the right liver and stomach. Endoscopy identified a massive protrusion-like malignant stromal tumor at the greater curvature of gastric body. Curative resection was performed, and HCC with gastric metastasis was diagnosed by histological and immunohistochemical findings. The patient received two times of chemotherapy and remained tumor free for 15 months. Previous studies and our experience suggested that surgical resection could significantly prolong the survival and improve patients' quality of life. A brief literature review was conducted to elucidate the differential diagnosis and treatment of HCC with gastric metastasis.

Keywords: Differential diagnosis, gastric metastasis, hepatocellular carcinoma, surgical resection


How to cite this article:
Peng L, Yu K, Li Y, Xiao W. Gastric metastasis of recurrent hepatocellular carcinoma: A case report and literature review. J Can Res Ther 2018;14, Suppl S5:1230-2

How to cite this URL:
Peng L, Yu K, Li Y, Xiao W. Gastric metastasis of recurrent hepatocellular carcinoma: A case report and literature review. J Can Res Ther [serial online] 2018 [cited 2019 Sep 15];14:1230-2. Available from: http://www.cancerjournal.net/text.asp?2018/14/12/1230/199379




 > Introduction Top


Hepatocellular carcinoma (HCC) is the fifth most common malignancy and the second leading cause of cancer-related mortality worldwide.[1] Extrahepatic metastasis is found in 30%–75% patients at the initial diagnosis of HCC.[2] The lung is the most common site of metastasis followed by regional lymph nodes, bone, and adrenal glands.[2] However, gastric metastasis is very rare, which occurs in 0.08%–0.22% of clinical HCC cases.[3],[4] Because of HCC with gastric metastasis is very rare, it is extremely easy to misdiagnose for primary gastric cancer with liver metastasis, especially gastric hepatoid adenocarcinoma. Here, we report a case of recurrent HCC with gastric metastasis and review of the literature to provide a helpful reference to aid in the differential diagnosis and treatment of this disease.


 > Case Report Top


A 22-year-old man was admitted to our hospital with hepatalgia and hypodynamia for 1 week. He had a history of left side hepatic tumor local resection due to ruptured HCC 10 years ago, and chronic hepatitis B was diagnosed at the same time. No additional therapy was performed after surgery. Physical examination showed conjunctival pallor, mild epigastric tenderness, and hepatomegaly. Laboratory studies showed anemia, the erythrocyte count was 2.69 × 1012/L, and hemoglobin level was 63 g/L. Serum level of alpha-fetoprotein (AFP) was >1210 ng/mL (normal value <10 ng/mL). Serum was positive for hepatitis B surface antigen, hepatitis B e antibody, and hepatitis B core antibody - IgG, and the level of hepatitis B virus (HBV) DNA was <500 IU/mL. Serum antihepatitis C virus was negative. Fecal occult blood test was 4 (+). The liver function was Child-Pugh A Stage, and the indocyanine green retention rate at 15 min was 9%. Contrast enhanced CT revealed a 5.0 cm ×7.0 cm lesion at the greater curvature of the stomach, and a 7.0 cm × 8.0 cm lesion at hepatic segment VII and VIII [Figure 1]. Endoscopy identified a massive protrusion-like malignant stromal tumor at the greater curvature of gastric body.
Figure 1: Computed tomography reveals tumors in the right lobe of the liver and the greater curvature of the stomach

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Laparotomy was performed, after transfusing of 4 units of packed red cells with the hemoglobin level reached to 76 g/L. There were two lesions in the liver, a 7.0 cm × 8.0 cm tumor located at segment VII and VIII and a 1.0 cm × 1.5 cm tumor located at segment III. Meanwhile, a 5.0 cm ×7.0 cm exophytic tumor was found at the greater curvature of the stomach with splenic capsule involvement. Based on those findings, right hemihepatectomy combined with left lateral tumor local resection, cholecystectomy, gastric tumor local resection, and splenectomy were performed. The specimens showed a 7.0 cm × 8.0 cm tumor at the right liver [Figure 2]a and a 5.0 cm ×7.0 cm exophytic tumor at the stomach with splenic capsule involvement [Figure 2]b. Histology of the liver revealed moderately differentiated HCC [Figure 3]a. The gastric tumor revealed metastatic HCC invading from submucosa to serosa, and splenic capsule was also invaded [Figure 3]b. Immunological staining of gastric tumor was positive for hepatocyte paraffin 1 (Hep Par 1) and negative for cytokeratin 20 (CK20) and carcinoembryonic antigen (CEA) [Figure 4]a, [Figure 4]b, [Figure 4]c. The patient's postoperative course was uneventful and discharged on the 10th postoperative day. Entecavir, as a routine anti-HBV drug, was prescribed. Two times of transcatheter hepatic arterial chemoembolization (TACE) were performed at the 1st and 2nd month after surgery. The regimens consisted of tegafur 0.8 g, mitomycin C 10 mg, oxaliplatin 200 mg, and interleukin II 10 million units. The patient remained tumor free for 15 months after surgery.
Figure 2: Gross photo (a) A 7.0 cm × 8.0 cm tumor at the right liver. (b) A 5.0 cm × 7.0 cm exophytic tumor at the stomach with splenic capsule involvement.

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Figure 3: Histological examination. (a) Right hepatic tissue shows moderately differentiated hepatocellular carcinoma (H and E, ×100). (b) Gastric tissue shows normal gastric mucosa (black arrow) and metastatic hepatocellular carcinoma (white arrow) (H and E, ×40)

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Figure 4: Immunohistochemistry of gastric tumor tissues. (a) Positive staining for hepatocyte paraffin 1 (×100). (b) Negative staining for cytokeratin 20 (×100). (c) Negative staining for carcinoembryonic antigen (×100)

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 > Discussion Top


Extrahepatic metastasis of HCC usually occurs in the lung, regional lymph nodes, and bone, and direct gastric invasion is rare. For example, Wu et al.[4] reviewed the medical records of 48,473 patients with solid cancers, but only 6 patients with gastric metastasis of HCC were found. Chen et al.[5] reported 8 patients with gastrointestinal (GI) tract involvement among 396 HCC patients, including 3 (0.76%) patients involved the stomach. Lin et al.[3] reported 11 of 2237 HCC patients had GI metastasis, and 5 (0.22%) patients were gastric metastasis.

Patients with gastric metastasis of HCC usually present GI tract symptoms. Among the 44 patients of HCC with GI involvement reviewed by Lin et al.,[6] the most common initial presentation was GI bleeding (84%) followed by abdominal pain (23%), GI obstruction (16%), and abdominal fullness (9.0%). In the present case, the main symptom was hepatalgia, hypodynamia, and melena. Gastric metastasis of HCC should be differed from primary gastric cancer with liver metastasis, especially hepatoid adenocarcinoma of the stomach. Usually, primary gastric cancer with liver metastasis is easily differentiated by gastroscopy and biopsy. However, hepatoid adenocarcinoma of the stomach is more confusing, because it shares numerous clinicopathological features with HCC, including the elevated serum AFP level, immunoreactivity with AFP, and hepatoid morphology.[7],[8] Moreover, it tends to metastasize to the liver even in early stage.[7] Histopathologically, the tumor is composed of two closely related areas, including hepatoid-like foci and adenocarcinomatous lesions. Hep Par 1 reacts with a hepatocyte-specific epitope, and 82% sensitivity and 90% specificity for Hep Par 1 have been reported in HCC. However, just focal positivity for Hep Par 1 was reported in carcinoma with hepatoid differentiation.[8] Therefore, immunonegative for Hep Par 1 and immunoreactivity with both CK20 and CEA of hepatoid adenocarcinoma may be helpful for the differential diagnosis. In the present case, immunological staining of gastric tumor was positive for Hep Par 1 and negative for CK20 and CEA.

Although the prognosis of gastric metastasis of HCC is dismal, surgical resection may significantly prolong the survival and improve patients' quality of life. Fujii et al.[9] reviewed 29 patients with HCC invading the GI tract, in which the median survival was 1.2, 3.0, and 9.7 months in patients who underwent supportive therapy, nonsurgical therapy, and curative resection, respectively. Lin et al.[6] reported two cases with long-term survival following resection of HCC with gastric invasion, and they were still alive at 80 and 68 months after the surgery. Ong et al.[10] also reported a case of HCC with gastric metastasis has remained alive 33 months after surgery.

In the present study, the patient underwent curative resection followed by two times of TACE and has remained tumor free for 15 months after surgery. Because HCC with gastric metastasis is extremely rare, the standardization of its treatments is still controversial. Previous studies and our experience suggest surgical resection may improve prognosis. Furthermore, this case could provide a helpful reference to aid in the decision-making process for the diagnosis and treatment of HCC with gastric metastasis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
McGlynn KA, Petrick JL, London WT. Global epidemiology of hepatocellular carcinoma: An emphasis on demographic and regional variability. Clin Liver Dis 2015;19:223-38.  Back to cited text no. 1
    
2.
Uka K, Aikata H, Takaki S, Shirakawa H, Jeong SC, Yamashina K, et al. Clinical features and prognosis of patients with extrahepatic metastases from hepatocellular carcinoma. World J Gastroenterol 2007;13:414-20.  Back to cited text no. 2
    
3.
Lin CP, Cheng JS, Lai KH, Lo GH, Hsu PI, Chan HH, et al. Gastrointestinal metastasis in hepatocellular carcinoma: Radiological and endoscopic studies of 11 cases. J Gastroenterol Hepatol 2000;15:536-41.  Back to cited text no. 3
    
4.
Wu MH, Lin MT, Lee PH. Clinicopathological study of gastric metastases. World J Surg 2007;31:132-6.  Back to cited text no. 4
    
5.
Chen LT, Chen CY, Jan CM, Wang WM, Lan TS, Hsieh MY, et al. Gastrointestinal tract involvement in hepatocellular carcinoma: Clinical, radiological and endoscopic studies. Endoscopy 1990;22:118-23.  Back to cited text no. 5
    
6.
Lin TL, Yap AQ, Wang JH, Chen CL, Iyer SG, Low JK, et al. Long term survival in patients with hepatocellular carcinoma directly invading the gastrointestinal tract: Case reports and literature review. Surg Oncol 2011;20:e207-14.  Back to cited text no. 6
    
7.
Yasawy MI, Tamimi DM, Al-Quorain A, Wosornu L, Al-Mulhim A, Zakaria H. Hepatoid gastric adenocarcinoma. Saudi J Gastroenterol 2003;9:23-5.  Back to cited text no. 7
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8.
Terracciano LM, Glatz K, Mhawech P, Vasei M, Lehmann FS, Vecchione R, et al. Hepatoid adenocarcinoma with liver metastasis mimicking hepatocellular carcinoma: An immunohistochemical and molecular study of eight cases. Am J Surg Pathol 2003;27:1302-12.  Back to cited text no. 8
    
9.
Fujii K, Nagino M, Kamiya J, Uesaka K, Sano T, Yuasa N, et al. Complete resection of hepatocellular carcinoma with direct invasion to the stomach remnant. J Hepatobiliary Pancreat Surg 2004;11:441-4.  Back to cited text no. 9
    
10.
Ong JC, Chow PK, Chan WH, Chung AY, Thng CH, Wong WK. Hepatocellular carcinoma masquerading as a bleeding gastric ulcer: A case report and a review of the surgical management. World J Gastroenterol 2007;13:4523-5.  Back to cited text no. 10
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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