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Year : 2021  |  Volume : 17  |  Issue : 3  |  Page : 814-817

Colonic metastasis from hepatocellular carcinoma after treated by ablation and transarterial chemoembolization manifested by intestinal obstruction: A case report and review of the literature

Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing 100853, China

Date of Submission24-Feb-2020
Date of Decision13-Oct-2020
Date of Acceptance23-Feb-2021
Date of Web Publication9-Jul-2021

Correspondence Address:
Jie Yu
Department of Interventional Ultrasound, Chinese PLA General Hospital, 28 Fuxing Road, Beijing 100853
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.JCRT_217_20

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 > Abstract 

Hepatocellular carcinoma (HCC) with gastrointestinal tract metastasis is a rare condition. Recently, we encountered one case of HCC with direct invasion to the colon, which was manifested by intestinal obstruction. The patient was an 86-year-old man who underwent multiple transarterial chemoembolization and microwave ablation treatment for HCC lesions for 10 years. Two months after last palliative microwave ablation, computed tomography showed a 7.0-cm liver tumor directly invading the hepatic flexure of colon with the symptom of right abdominal pain and discontinuous nausea and vomiting. HCC colon metastasis with intestinal obstruction was diagnosed. Intestinal adhesion lysis and colostomy were performed. The patient survived 10 months after surgery and died of tumor progression.

Keywords:  Gastrointestinal tract, hepatocellular carcinoma, metastasis

How to cite this article:
Mu M, Yu J, Liang P, Yu X, Cheng Z. Colonic metastasis from hepatocellular carcinoma after treated by ablation and transarterial chemoembolization manifested by intestinal obstruction: A case report and review of the literature. J Can Res Ther 2021;17:814-7

How to cite this URL:
Mu M, Yu J, Liang P, Yu X, Cheng Z. Colonic metastasis from hepatocellular carcinoma after treated by ablation and transarterial chemoembolization manifested by intestinal obstruction: A case report and review of the literature. J Can Res Ther [serial online] 2021 [cited 2021 Jul 26];17:814-7. Available from: https://www.cancerjournal.net/text.asp?2021/17/3/814/321025

 > Introduction Top

The incidence of primary liver cancer is increasing worldwide as a result of the high prevalence of hepatitis B and C.[1] Among primary liver cancers, hepatocellular carcinoma (HCC) represents the major histological subtype with relative poor prognosis, accounting for 70%–85% of the total liver cancer burden worldwide.[1] Extrahepatic metastasis from HCC is not unusual with an incidence of 10%–64% of cases.[2],[3],[4] Sites that are frequently involved are the lung, bone, adrenal gland, regional lymph nodes, and peritoneum. There are few reports of HCC invading the distant gastrointestinal (GI) tract, especially in the colon and rectum, being found only in 0.5%–2% of clinical HCC cases and 4% of autopsy cases.[3],[5],[6] These secondary lesions are usually asymptomatic, and the possible clinical manifestations of GI metastasis of HCC include abdominal pain, hemorrhage, intussusception, and intestinal obstruction. The mode of GI tract spread may be direct invasion, hematogenous, or peritoneal seeding.

Herein, we report a case of ascending colon metastasis from HCC with a review of literatures. We made the analysis for the tumor invasion mode and the possible spread reasons, patient's treatment and prognosis.

 > Case Report Top

An 86-year-old man with chronic hepatitis B has been followed up since 1971. In February 2001, computed tomography (CT) revealed a 2.5 cm tumor in the right posterior lobe of the liver, which was diagnosed as moderately differentiated HCC by biopsy pathology. The lesion was treated by transarterial chemoembolization (TACE). From February 2002 to June 2012, the patient was treated by TACE for 4 times and ultraWsound-guided percutaneous microwave ablation for 5 times because of the intrahepatic multiple recurrent lesions. In August 2012, CT revealed multiple new HCC lesions in the upper and lower segment of the right posterior lobe of the liver. After multidisciplinary joint consultation, the patient was decided to undergo supportive care. In September 2012, the patient suffered from right abdominal pain and discontinuous nausea and vomiting and was admitted to our hospital. Magnetic resonance imaging revealed that the liver tumor in lower segment of the right posterior lobe directly invaded the hepatic flexure of colon and with the proximal ascending colon and ileum canal dilation due to stenosis of the distal colon [Figure 1]. Liver function tests revealed no abnormalities. The serum α-fetoprotein (AFP) level was within normal range. HCC invading the colon and secondary intestinal obstruction were diagnosed by surgery. Since complete resection of the advanced HCC was not possible, and the patient was with advanced age and had the comorbidities of hypertension and coronary atherosclerotic heart disease, the goal of surgery was to resolve the intestinal obstruction only. Therefore, intestinal adhesion lysis and colostomy were performed. Histopathologic examination of the colon tumor specimen also showed HCC. The postoperative course was uneventful, and the patient was discharged on postoperative day 15. He was followed up at regular intervals with surveillance ultrasound scan and monitor of serum AFP. The patient died of tumor progression 10 months later.
Figure 1: An 86-year-old man with colonic metastasis from hepatocellular carcinoma. (a) Abdominal T2, contrast-enhanced cross-sectional (b) and coronal (c) magnetic resonance imaging scans show one heterogeneous high-signal neoplasm (large arrow) invading (thin arrow) the hepatic flexure of colon (arrowhead). The lesion size is 7.0 cm × 3.6 cm. (d) Contrast-enhanced computed tomography shows the proximal ascending colon and ileum canal dilation due to stenosis of the distal colon

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 > Discussion Top

HCC with GI tract metastasis is a rare condition with an extremely poor prognosis and most are discovered upon postmortem examination. The most frequently invaded GI sites are the duodenum and stomach,[5],[6],[7] and invasion into the colon is very rare. We summarized the English literatures on the report of HCC colon metastasis with 22 cases totally to date [Table 1].[5],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20] Among them, the most frequent symptom was bloody stool (11/22, 50.0%). The time to colon invasion was from simultaneous finding to 60 months. Seven patients (7/22, 31.8%) underwent TACE for HCC before the development of colon invasion. Surgical resection for colon tumor was selected in 6 cases (6/22, 27.3%). However, the outcomes were very poor, and the median survival was only 4 months. According to literature reports, our case was the only one diagnosed as HCC colon metastasis with colon obstruction symptom. Although the colon did not receive operation, the patient sustained survival for 10 months.
Table 1. Literature summary of HCC colon metastasis

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The main spread mode of HCC with GI tract metastasis was direct invasion. Some researchers thought that when a large, subcapsular, massive-type HCC was continuous with the GI and treated with TACE or ablation, the wall of the GI could be affected by the inflammatory response and become adherent to the liver or tumor capsule. The viable tumor tissue could easily invade the GI at the time of tumor recurrence. However, in some studies,[5],[7] the detection of GI invasion was simultaneous with the time of diagnosis of HCC, and these patients did not receive any therapy before the diagnosis of GI invasion. Therefore, some researchers thought that the main factor of direct invasion was the growth pattern, size, and location of the masses rather than previous regional treatment. Intraperitoneal seeding is a relative uncommon presenting feature of HCC spread with the possibility of correlation with the pathways of intraperitoneal fluid, determined by both gravity and the negative infradiaphragmatic pressure.[7],[13] Hematogenous spread is another rare factor for HCC GI invasion. The metastatic site is mainly at the distal colon such as sigmoid colon and rectum.[15],[17],[21],[22] Our patient's liver lesion was at subcapsular site in lower segment of the right posterior lobe, which was adjacent to hepatic flexure of the colon. Moreover, the tumor was treated by multiple times of microwave ablation and TACE without rupture, which might result in the colon wall to be affected by the inflammatory response and become adherent to the liver or tumor capsule, so the most possible spread mechanism of the HCC was direct invasion. Surgical resection may be the most effective treatment for GI invasion by HCC if the patient's general condition including liver function is good.

 > Conclusion Top

HCC with colon metastasis is a rare condition and is associated with an extremely poor prognosis due to the advanced stage of the disease. Blood stool, abdominal pain, perforation, and obstruction are the main clinical manifestations. The presumed mode of metastasis is generally related to a direct invasion into the adjacent intestinal tract. Surgical resection may be a favorable treatment option in patients with a good general condition.

Informed consent

Informed consent was obtained from the individual participant included in the study.

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Conflicts of interest

There are no conflicts of interest.

 > References Top

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Liang P, Yu J, Yu XL, Wang XH, Wei Q, Yu SY, et al. Percutaneous cooled-tip microwave ablation under ultrasound guidance for primary liver cancer: A multicentre analysis of 1363 treatment-naive lesions in 1007 patients in China. Gut 2012;61:1100-1.  Back to cited text no. 4
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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. 6
Park MS, Kim KW, Yu JS, Kim MJ, Yoon SW, Chung KW, et al. Radiologic findings of gastrointestinal tract involvement in hepatocellular carcinoma. J Comput Assist Tomogr 2002;26:95-101.  Back to cited text no. 7
Hashimoto M, Watanabe G, Matsuda M, Yamamoto T, Tsutsumi K, Tsurumaru M. Case report: Gastrointestinal bleeding from a hepatocellular carcinoma invading the transverse colon. J Gastroenterol Hepatol 1996;11:765-7.  Back to cited text no. 8
Chen CY, Lu CL, Pan CC, Chiang JH, Chang FY, Lee SD. Lower gastrointestinal bleeding from a hepatocellular carcinoma invading the colon. J Clin Gastroenterol 1997;25:373-5.  Back to cited text no. 9
Srivastava DN, Gandhi D, Julka PK, Tandon RK. Gastrointestinal hemorrhage in hepatocellular carcinoma: Management with transheptic arterioembolization. Abdom Imaging 2000;25:380-4.  Back to cited text no. 10
Zech CJ, Bilzer M, Mueller-Lisse UG, Steitz HO, Haraida S, Reiser MF. Perforation of the colon: A rare complication of hepatocellular carcinoma. Acta Radiol 2006;47:538-42.  Back to cited text no. 11
Hirashita T, Ohta M, Iwaki K, Kai S, Shibata K, Sasaki A, et al. Direct invasion to the colon by hepatocellular carcinoma: Report of two cases. World J Gastroenterol 2008;14:4583-5.  Back to cited text no. 12
Chow KC, Tang CN, Lai EC, Li MK. Curative treatment for recurrent tumour implantation after ruptured hepatocellular carcinoma. Hong Kong Med J 2013;19:82-4.  Back to cited text no. 13
Nozaki Y, Kobayashi N, Shimamura T, Akiyama T, Inamori M, Iida H, et al. Colonic metastasis from hepatocellular carcinoma: Manifested by gastrointestinal bleeding. Dig Dis Sci 2008;53:3265-6.  Back to cited text no. 14
Yoo DJ, Chung YH, Lee YS, Kim SE, Jin YJ, Lee YM, et al. Sigmoid colon metastasis from hepatocellular carcinoma. Korean J Hepatol 2010;16:397-400.  Back to cited text no. 15
Ng DS, Chok KS, Law WL, Collins RJ, Fan ST. Long-term survival after resection of extrahepatic recurrence of hepatocellular carcinoma at the right colon. Int J Colorectal Dis 2007;22:1411-2.  Back to cited text no. 16
Shih YJ, Hsu KF, Yu JC, Chan DC, Hsieh CB. Synchronous hepatocellular carcinoma and sigmoid colon metastasis presenting as liver and intra-abdominal abscesses. Acta Gastroenterol Belg 2012;75:278-9.  Back to cited text no. 17
Cosenza CA, Sher LS, Poletti BJ, Tschirhart D, Noguchi H, Hoffman AL, et al. Metastasis of hepatocellular carcinoma to the right colon manifested by gastrointestinal bleeding. Am Surg 1999;65:218-21.  Back to cited text no. 18
Singh Kalra TM, Mangla JC, Schwartz S, Lee JC. Hepatoma presenting as lower gastrointestinal bleeding. Am J Gastroenterol 1977;67:485-8.  Back to cited text no. 19
Fukui H, Kashiwagi T, Shirai Y, Matsuda Y, Kawata S, Nishimura T, et al. Metastasis of hepatocellular carcinoma to the colon demonstrated by Tc-99m PMT scintigraphy. Clin Nucl Med 1993;18:512-5.  Back to cited text no. 20
Huang SF, Chou JW, Lai HC. A rare cause of bloody stools in a 57-year-old woman with hepatocellular carcinoma. Gastroenterology 2011;140:e5-6.  Back to cited text no. 21
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  [Table 1]


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