C. Kyaw1, A. Pihokken1, A. Carroccio1, M. Westcott1, J. Wong1 1Lenox Hill Hospital, Northwell Health,Department Of Surgery,New York, NY, USA
Introduction:
Hepatocellular carcinoma (HCC) rarely presents with major vascular tumor thrombus (TT), with an incidence of 3.8% in the inferior vena cava (IVC) (3,24). We report a patient who presented years after initial diagnosis with an IVC HCC lesion via an accessory vein and reviewed the literature.
Methods:
The PubMed database was searched from 1985-2019 using terms: recurrent HCC, HCC IVC, IVC tumor thrombus, and isolated HCC metastasis.
Results:
Thirty-five studies were included: 12 cohort studies, 12 case reports, and 11 review articles; included were 111 with hepatic vein (HV)/IVC TT, 110 with IVC/ right atrium (RA) TT, 90 with IVC TT, 6 with RA TT, 986 with HV TT, and 2609 with portal vein TT. All had hepatic lesions in continuity with the major vascular TT. Treatment varied widely, including supportive care, systemic chemotherapy, chemoradiation, transarterial chemoembolization (TACE), intra-arterial chemotherapy, surgery, and combinations of above; those who underwent any treatment fared better than supportive care alone (median survival 4 vs 2mo.)(27). The majority underwent a combination of surgery and adjuvant therapy. Prognosis following resection was better than TACE alone or no treatment (19, 4.5, and 5mo., respectively)(5). TACE and surgery exhibited a longer survival, 59 mo. (6).
Hepatic vein TT and early recurrence were found to be independent poor prognostic factors in those undergoing hepatic resection(2,25). Only four cases demonstrated isolated extrahepatic metastases of HCC, localized to omentum, paracervical muscle, adrenal gland, and biceps femoris(9,10,11,12).
Our patient, a 53-year-old man with hepatitis B, was initially diagnosed with HCC and underwent left hepatectomy in February 2014. In January 2018, the AFP level increased; CT showed an IVC thrombus <2cm and enhancing lesion in segment VI. The hepatic lesion was treated with alcohol and subsequent microwave ablation. The IVC lesion was thought to be in continuity via a small accessory vein but presumed to be bland, and therefore, he was anticoagulated. The IVC lesion enlarged on subsequent imaging; biopsy showed metastatic HCC. Repeat CT and angiography were negative for intrahepatic lesions. Resection of the IVC with patch reconstruction was performed in August 2018; pathology revealed metastatic HCC with negative margins. Adjuvantly, Lenvatinib was started. CT at one year demonstrated no disease recurrence.
Conclusion:
HCC with major vascular TT generally confers poor prognosis. Metastasis in the IVC is generally by direct extension or via a major hepatic vein. Our patient remains disease-free at one year after resection of an IVC metastasis from an accessory vein and adjuvant Lenvatinib. Further investigation into effective treatment modalities is needed; however, surgical resection in appropriate patients seems to achieve good outcomes in this rare presentation.