Isolated hepatic metastasis with hepatic venous invasion and tumor thrombus in right atrium.

Abstract

A 78-year-old man was transferred to our hospital for detailed examination and treatment of sudden-onset and rapidly increasing general edema. Routine blood counts and laboratory test results were normal. His medical history included chronic heart failure over a very long period under medical treatment and a sigmoidectomy for 4-cm sigmoid colon cancer carried out 3 years previously. At that time, an isolated small (about 2 cm) liver metastasis (segment 4) was also detected. Simultaneous segmentectomy and sigmoidectomy was initially considered, but the patient’s cardiac problem prevented it, and ultrasound (US)-guided radio-frequency ablation (RFA) was selected as the most appropriate treatment for the hepatic metastasis. During the following three years, the patient visited the outpatient clinic regularly, and several whole-body computed tomography (CT) studies at intervals of 6 months showed no abnormalities. They also showed the treated hepatic metastasis to be completely necrosed (Fig. 1). The patient was symptom-free for a long time, but very recently he suddenly became edematous. Abdominal US performed in our hospital using a Toshiba Aplio XG unit (Tokyo, Japan) revealed an approximately 6 9 5-cm irregular and ill-margined slightly hypoechoic tumor in S4, which extended posteriorly and directly invaded the left, middle, and right hepatic veins. The left and middle hepatic veins were completely occluded and were not recognized on B-mode US, and the right hepatic venous lumen was partially recognized. The tumor extended towards the right atrium, and a huge tumor thrombus was found there (Fig. 2). The intrahepatic and extrahepatic portal system was normal, but a large amount of ascites was also present throughout the whole abdominal cavity. Contrast-enhanced US using Sonazoid solution (GE Health Care), performed to observe blood flow in the liver, provided more detailed information about the hemodynamics of the lesion and the surrounding hepatic veins (mechanical index *0.25). Soon R. Satoyoshi (&) H. Kotanagi Department of Surgery, Akita Red Cross Hospital, 222-1 Kamikitade Saruta, Nawashirosawa, Akita 010-1495, Japan e-mail: rika-s@alto.ocn.ne.jp