Hepatocellular carcinoma with extension to the diaphragm, falciform ligament, rectus abdominis and paraumbilical vein
R Kaur1,* MBBS, FRCR,
BJJ Abdullah1, MBBS, FRCR,
V Rajasingam2, MBBS, FRCS
1 Department of Biomedical Imaging, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
2 Department of Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
Hepatocellular carcinoma is the most common primary tumour
of the liver. The most common extrahepatic metastatic sites are the lung, lymph
nodes, bones and adrenal glands. All forms of HCC demonstrate a tendency for
vascular invasion, producing extensive intrahepatic metastases and,
occasionally, portal vein or inferior vena cava extension with spread into the
right atrium in extreme cases. Tumour spread of abdominal diseases via hepatic
ligaments has also been previously reported. We report a rare case of
hepatocellular carcinoma with extension into the falciform ligament, overlying
rectus sheath and adjacent diaphragm with concomitant infiltration into the
recanalised paraumbilical vein. � 2008 Biomedical Imaging and Intervention
Journal. All rights reserved.
Keywords: Hepatocellular carcinoma, metastases, computed
A 73 year-old male presented to our centre with a painful
swelling in the epigastric region which progressively increased in size over 1
month, alongside loss of appetite and fever with chills. He was an alcoholic,
diabetic and also suffered from ischaemic heart disease. There was no history
of hepatitis or prior blood transfusion. Physical examination revealed a firm,
well-defined erythematous but smooth-surfaced epigastric mass measuring 8�7 cm.
Spider naevi was noted on the legs and jaundice in the left sclera (right eye
Pertinent laboratory values were as follows: white blood
cell count 10.1�109 /L (normal 4-11); haemoglobin 103.0 g/L
(normal 130.0-180.0); haematocrit 0.34 (normal 0.4-0.5); total protein 54 g/L
(normal 64-82); albumin 24 g/L (normal 35-50); total bilirubin 8 μmol/L
(normal 3-17); ALT 77 IU/L (normal 30-65); AST 83 IU/L (normal
15-37); α-fetoprotein 9 IU/L; Hepatitis B and C profile was negative
and coagulation profile was normal.
An ultrasound examination revealed an ill-defined
hypoechoic mass measuring 5.7�7.4 cm in the left lobe of the liver. The biliary
ducts, gallbladder, pancreas and spleen were normal. Vascular channels ie. inferior
vena cava, portal and hepatic veins were also patent. A provisional diagnosis
of liver tumour was made. Subsequently a CT scan revealed an exophytic mass
arising from an atrophic left lobe of the liver with surrounding inflammatory
changes and extension into the overlying anterior abdominal wall (Figure 1)
with maximum enhancement during the delayed arterial phase (scan delay 35 s).
The fat plane between the tumour mass and the rectus sheath was obliterated and
the tumour extended superiorly from the level of the right ventricle to the
fundus of the stomach inferiorly. It measured 7.2�8.0�5.1 cm. The tumour
was also noted to extend into the recanalised paraumbilical vein (Figure 2). Liver
was nodular in outline and the left lobe was atrophic in keeping with
cirrhosis. Spleen and portal vein was normal. There were no peritoneal
seedlings, lymphadenopathy, lung nodules or bony lesions to suggest metastases.
Liver biopsy revealed a well-differentiated hepatocellular
carcinoma. Patient underwent a wedge resection of segment 2.
Intraoperative findings revealed an 8 cm nodular exophytic tumour arising
from segment 2 of the liver with extension to the anterior abdominal wall
and undersurface of the left hemidiafragm. The surface of the liver was nodular
in appearance. Patient also underwent a cholecystectomy and excision of the
infiltrated left diaphragm.At histopathology the specimen showed a tumour composed
of nodules of malignant cells in sheets with moderate vascularity. The cells
appeared hepatoid and displayed large irregular hyperchromatic vesicular nuclei
and prominent nucleoli. Fibrous septa separated the tumour nodules and there
was a thin capsule around the tumour. The adjacent hepatic tissue showed portal
tract infiltration by chronic inflammatory cells. Special stains showed that
immunohistochemistry for HBV was negative. The diaphragmatic specimen
consisting of skeletal fibres showed nodules of malignant cells similar to that
described in the liver specimen. There was no gallbladder invasion.
The most important risk factor for the development of
hepatocellular carcinoma (HCC) appears to be chronic hepatitis B or C viral
infection . Liver cirrhosis has also been identified in over 70% of HCC
patients in the Western countries and has been identified as a predisposing
Many different treatment options are available depending
on the staging of this aggressive tumour . The commonest extrahepatic
metastatic sites are the lung, lymph nodes, bones and adrenal glands [2,3].
Less common metastatic sites include the brain, bladder, gastrointestinal
tract, diaphragm, seminal vesicles and pancreas . All forms of HCC
demonstrate a tendency for vascular invasion, producing extensive intrahepatic
metastases and, occasionally, portal vein or inferior vena cava extension with
spread into the right atrium in extreme cases . Although these vessels were
intact in our patient, vascular invasion was demonstrated by the presence of
tumour within the recanalised paraumbilical vein.
Kim et al. and Mori et al. [5,6] have previously reported
cases of HCC extending into rectus abdominis via ligamentum teres. Meyers et
al. [7,8] initially established the concept of tumour spread of abdominal
diseases via hepatic ligaments.
Radiologically, disease processes, such as fluid
collections within and obliterating the perihepatic-ligamentous fat or focal
collections near the ligamentous attachments suggests ligamentous spread.
Concommitantly there may be continous spread, also suggesting ligamentum
continuity on CT scans or sonograms . Ligamentous spread of the tumour was
clearly demonstrated by the presence of sorrounding inflammatory changes,
extension into the overlying anterior abdominal wall and obliteration of the
fat plane between the tumour mass and rectus sheath. Unfortunately these
findings were not well appreciated on ultrasound examination.
We therefore postulate the extension into the anterior abdominal
wall may have occurred by direct extension of the exophytic tumour component
into the paraumbilical vein within the round ligament and rectus via the
falciform ligament. In addition, this patient had no history of having
undergone a liver biopsy prior to discovery of the tumour mass, excluding
tumour seeding along a previous biopsy tract.
Although the HPE specimen analysis did not reveal evidence
of fibrosis or cirrhosis of the liver parenchyma adjacent to the tumour, a thin
capsule was found around the tumour and the nodular surface of the liver was
confirmed macroscopically during surgery.
A curative surgical approach with wedge resection of
segment 2 of the liver was performed as the tumour was found to be
confined to segment 2 with no evidence of metastases. The patient was
subsequently followed up clinically at 3-monthly intervals with 6-monthly
follow-up CT scans. A year after the operation, the patient developed tumour
recurrence at the operative scar site on the anterior abdominal wall. He
underwent a single cycle of radiotheraphy and subsequently chemotheraphy;
however the tumour failed to respond favourably. The tumour demonstrated a slow
growth pattern and currently measures approximately 3�4 cm. The patient is
currently being managed conservatively and is otherwise well.
Figure 1 Scan performed in the late arterial phase demonstrating HCC (arrows) arising from liver with surrounding inflammatory changes, obliteration of the fat plane between the tumour mass and rectus sheath with extension into the overlying anterior abdominal wall.
Figure 2 Scan performed in the late arterial phase demonstrating tumour infiltration into the recanalised paraumbilical vein (arrow).
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Mori H, Aikawa H, Hirao K et al. Exophytic spread of hepatobiliary disease via perihepatic ligaments: demonstration with CT and US. Radiology 1989; 172(1):41-6.
Meyers MA. Dynamic radiology of the abdomen: normal and pathologic anatomy. 3rd edition. New York: Springer, 1988: 27-178.
Meyers MA, Oliphant M, Berne AS et al. The peritoneal ligaments and mesenteries: pathways of intraabdominal spread of disease. Radiology 1987; 163(3):593-604.
|Received 1 May 2008; received in revised form 12 August 2008, accepted 3 September 2008
Correspondence: Department of Biomedical Imaging, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia. Tel.: +603-79492069; Fax: +603-79581973; E-mail: firstname.lastname@example.org (Ranjit Kaur).
Please cite as: Kaur R, Abdullah BJJ, Rajasingam V,
Hepatocellular carcinoma with extension to the diaphragm, falciform ligament, rectus abdominis and paraumbilical vein, Biomed Imaging Interv J 2008; 4(4):e37