Extrahepatic Hepatocellular Carcinoma Research Articles

Body mass index above 24 is beneficial for the 6-month survival rate in hepatocellular carcinoma patients with extrahepatic metastases.

To investigate the effect of overweight status on the 6-month survival rate in patients with extrahepatic hepatocellular carcinoma (HCC). We retrospectively analyzed the records of 51 patients with hepatocellular carcinoma and extrahepatic metastases between 2007 and 2010 before treatment. The associations among overweight status (body mass index [BMI] >24 kg/m2), demographic variables, and survival outcome were analyzed by univariate and multivariate analysis. BMI>24 kg/m2 was significantly associated with the 6-month survival rate (p=0.042). Gender (p=0.149), Child Pugh classification (p=0.149), Okuda staging (p=0.093), and albumin concentration >3.5 mg/dL (p=0.082) showed marginal survival benefits in univariate analysis. Multivariate analysis confirmed that BMI >24 kg/m2 was an independent prognostic factor for the 6-month survival rate (p=0.03). BMI >24 kg/m2 was associated with an improved 6-month survival rate in patients with extrahepatic metastatic hepatocellular carcinoma.

Sorafenib and a novel immune therapy in lung metastasis from hepatocellular carcinoma following hepatectomy: A case report.

Sorafenib is the standard therapeutic strategy for recurrent hepatocellular carcinoma (HCC) following hepatectomy. However, only few patients truly benefit from this therapy. Thus, new strategies combined with sorafenib are urgently required. We herein present the case of a patient with hepatic and extrahepatic HCC recurrence following hepatectomy, who was treated by combined sorafenib, focused ultrasound knife and DRibbles-pulsed dendritic cell (DC) vaccine. Enzyme-Linked ImmunoSpot assay (ELISPOT) and intracellular staining (ICS) analysis were used to detect the secretion of interferon (IFN)-γ by T cells at different timepoints of the vaccine in order to evaluate the patient's specific T-cell response to SMMC-7721-derived DRibbles vaccine. The α-fetoprotein level decreased from 103,295 to 5 ng/ml and the patient displayed improved liver function, an Eastern Cooperative Oncology Group performance status score of 0, remission of liver metastases and disappearance of the lung metastases 8 months post-combination therapy. The computed tomography scan revealed the disappearance of liver metastases 2 years post-combination therapy. The ELISPOT data revealed a low antigen-specific T-cell response 4 weeks after the first vaccine cycle and the response decreased to nearly zero prior to the second cycle. However, high antigen-specific T-cell response was observed 2 weeks after the second vaccine cycle and did not decrease, even after 10 months, which was consistent with the result of the ICS analysis, which demonstrated that most of the secreted IFN-γ was produced by CD4+ T cells, whereas a low CD8+ T-cell response was observed (0.429 vs. 0.0665%, respectively). Our results demonstrated that antigen-specific T-cell response aimed to treat recurrent HCC may be induced through stimulation by the DC-DRibbles vaccine. The success of the treatment supports the combination of sorafenib, focused ultrasound knife and DC-DRibbles vaccine as a therapeutic strategy for patients with HCC recurrence following hepatectomy.

Survival after hepatectomy for colorectal metastases

recurrent tumors located in segment VII and VIII or extrahepatic location, such as a subdiaphragm, a transthoracic transdiaphragmatic approach via thoracoscopy is feasible. Since the technique has the advantage of better intrathoracic exposure avoiding severe adhesiolysis, liver mobilization and possible hepatic congestion. We report a case of extrahepatic metastatic hepatocellular carcinoma that was successfully resected by transthoracic thoracoscopic metastasectomy. Methods: A 68-year-old male patient who has undergone posterior sectinectomy with caudate lobectomy (S1,6,7) and cholecystectomy under a diagnosis of hepatocellular carcinoma at 3 years ago, was admitted to our hospital for further evaluation of extrahepatic metastatic tumor. On liver dynamic computed tomography revealed a welldefined mass of 3.5 cm in diameter, in right subphrenic space with invading diaphragm and rt. adrenal gland. The imaging findings suggested an extrahepatic hepatocellular carcinoma that metastasized to the diaphragm. LFT was normal and AFP revealed 94.14 ng/ml. Results: We performed transthoracic thoracoscopic metastasectomy for subdiaphragmatic metastases of HCC and partial diaphragmatic resection and repair. The operation time was 3 hour 30 minutes and blood loss was 100 ml. The patient started a diet POD1 day and discharged POD 11days due to chest tube. The postoperative course was uneventful, and the patient was discharged without any complications. Conclusions: Transthoracic thoracoscopic metastasectomy can be feasible even if the recurrent tumors located in segments VII and VIII or extrahepatic location, such as a diaphragm.

Can hepatocellular carcinoma (HCC) produce unconventional metastases? Four cases of extrahepatic HCC.

Extrahepatic spread of hepatocellular carcinoma (HCC) diagnosed during the clinical course of the disease is not frequent; however, with the prolonged survival of HCC patients, the incidence of extrahepatic metastases seems to be increasing. We present four unusual cases of extrahepatic metastasis from HCC: the first concerns a patient who underwent a liver transplantation for HCC with cirrhosis and three years later developed metastases in the lung and the left orbit; the second is that of a patient who developed an extraperitoneal pararectal metastasis; in the third case a large osteolytic lesion developed on the left iliac bone, and in the fourth case we found an isolated metastasis in the left mandible. These cases offer important information related to the unusual biology of isolated metastases from HCC after successful treatment of the primary cancer.

EUS-FNAで診断し得た肝細胞癌胃壁浸潤の1例

A 60-year-old man was transported to our hospital with hematemesis. Upon admission, emergency esophagogastroduodenoscopy revealed an elevated, submucosal lesion just below the gastroesophageal junction. The top of the lesion was ulcerated and this seemed to be the source of the bleeding. Laboratory data showed liver dysfunction and enhanced computed tomography revealed a massive tumor ranging from the cardia to the left hepatic lobe. Endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) of the tumor through the gastric wall revealed pathological hepatocellular carcinoma (HCC) and direct extrahepatic HCC invasion of the gastric wall was diagnosed. Extrahepatic HCC is rare among the types of primary liver cancer. EUS-FNA helped to achieve an accurate diagnosis. We believe that EUS-FNA is useful, not only for pancreatic cancer and submucosal tumors of the digestive tract, but also for extrahepatic hepatocellular carcinoma.

Molecular imaging and therapy targeting copper metabolism in hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide. Significant efforts have been devoted to identify new biomarkers for molecular imaging and targeted therapy of HCC. Copper is a nutritional metal required for the function of numerous enzymatic molecules in the metabolic pathways of human cells. Emerging evidence suggests that copper plays a role in cell proliferation and angiogenesis. Increased accumulation of copper ions was detected in tissue samples of HCC and many other cancers in humans. Altered copper metabolism is a new biomarker for molecular cancer imaging with position emission tomography (PET) using radioactive copper as a tracer. It has been reported that extrahepatic mouse hepatoma or HCC xenografts can be localized with PET using copper-64 chloride as a tracer, suggesting that copper metabolism is a new biomarker for the detection of HCC metastasis in areas of low physiological copper uptake. In addition to copper modulation therapy with copper chelators, short-interference RNA specific for human copper transporter 1 (hCtr1) may be used to suppress growth of HCC by blocking increased copper uptake mediated by hCtr1. Furthermore, altered copper metabolism is a promising target for radionuclide therapy of HCC using therapeutic copper radionuclides. Copper metabolism has potential as a new theranostic biomarker for molecular imaging as well as targeted therapy of HCC.

PIM1 regulates glycolysis and promotes tumor progression in hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is characteristically one of the most rapidly proliferating tumors which outgrows functional blood supply and results in regional oxygen deprivation. Overexpression of PIM1, a serine/threonine kinase, has been identified recently in human cancers. Knowledge on PIM1 in HCC is however, scarce. By immunohistochemical analysis on 56 human primary HCC samples, we observed overexpression of PIM1 in 39% of the cases. In two independent cohorts of paired primary and extra-hepatic metastatic HCC tissues, PIM1 expression was higher (p=0.002) in the extra-hepatic metastatic HCC tissues as compared with the corresponding primary HCCs. PIM1 was markedly up-regulated in multiple HCC cell lines in hypoxic condition (1% O2) versus normoxia (20% O2). Silencing of PIM1 suppressed HCC cell invasion in vitro as compared to non-target control, and decreased HCC cell proliferation in vitro and tumor growth and metastatic potential in vivo. Knockdown of PIM1 significantly reduced glucose uptake by HCC cells and was associated with decreased levels of p-AKT and key molecules in the glycolytic pathway. Taken together, PIM1 is up-regulated by hypoxia in HCC and promotes tumor growth and metastasis through facilitating cancer cell glycolysis. Targeting PIM1 may have potential role in the management of HCC.

Surgical treatment of intrahepatic cholangiocarcinoma in the USA.

Cholangiocarcinoma (CC) is a malignancy that arises from the epithelial cells of the biliary system (ductules as well as large ducts, and likely from progenitor cells, as well). Intrahepatic CC (ICC) is the second most common primary hepatic malignancy after hepatocellular carcinoma (HCC), and accounts for 10-15% of primary liver cancers. ICC differs from both extrahepatic and CC and HCC and has unique risk factors, histological features, genetic alterations and clinical outcomes. The natural history and results of surgical intervention are not well described as ICC is a relatively uncommon tumor, especially in the USA. This article reviews the literature relevant to the surgical management and outcome of patients with ICC in the USA.

Surgical treatment of extrahepatic recurrence of hepatocellular carcinoma.

The purpose of this study was to clarify the clinicopathological features of extrahepatic hepatocellular carcinoma (HCC) recurrence after hepatectomy in order to schedule optimal treatment strategies for better long-term outcomes. A cohort of 206 patients who had undergone curative hepatectomy for HCC was analysed; 133 patients had developed relapse. Among them, 101 patients had intrahepatic recurrence only (IHR), and 32 patients had extrahepatic recurrence (EHR). Clinicopathological and survival data were compared between the two groups. The overall survival rate after hepatectomy was better in the IHR than in the EHR group (p<0.0001). The recurrence-free interval after hepatectomy was significantly shorter in the EHR than in the IHR group (258 vs. 487 days, p<0.0043). Patients in the EHR group were more likely to have a high PIVKA II, a large tumour, and microscopic portal vein invasion when compared with patients in the IHR group. Microscopic portal vein invasion was the most important independent risk factor for EHR after hepatectomy (p=0.0295). Patients with more than two risk factors for EHR showed poor prognosis in comparison with patients without any risk factors (p<0.001). In the EHR group, patients who underwent repeated resection had significantly better survival than patients receiving only the best supportive care (539 vs. 133 days, p=0.0098). Furthermore, among EHR patients with concomitant IHR, patients with controllable IHR had significantly better survival than those with uncontrollable IHR (524 vs. 147 days, p=0.0131). EHR of HCC was associated with early recurrence, and risk factors for the occurrence of EHR included the presence of high PIVKA II, large tumours, and microscopic portal vein invasion. Resection of recurrent tumour and local control of concomitant IHR may improve the prognosis of EHR patients.

Accuracy of Imaging Study in Correlation to Pathology of Explanted Liver of Hepatocellular Carcinoma Cases.

Background: Living donor liver transplantation (LDLT) can provide life-saving therapy for many patients with hepatocellular carcinoma (HCC). Ultrasound (US), Multislice computed tomography (CT) and Positron emission tomography (PET) are used for pretransplant HCC evaluation. Objective: The objective of this study was to determine the accuracy of different imaging modalities in assessment of HCC patients for LDLT, in correlation with the histopathological study of the explanted liver. Also, to study the effectiveness of these imaging modalities to classify the potential recipients as regard the different selection criteria, and to assess their feasibility in evaluation of the effectiveness of pretransplant bridging procedures. Methods: From April 2003 to December 2013, 61 of 210 recipients underwent LDLT for HCC at National Liver Institute, Menofia University, Egypt. Imaging findings were correlated with histopathologic features of the explanted livers. Results: Sixty one patients of 210 underwent LDLT for HCC, 54 patients of them proved to be HCC in pathology of explanted liver. Sensitivity & specificity of US & CT scan for detection of HCC were (100%) and (95.5%) respectively. Sensitivity & specificity of PET scan were (44.8%), (50%) respectively. US overestimated numbers and sizes of HCCs by 13/54 (24.1%) and 14/54 (25.9%) respectively. CT overestimated numbers & sizes of HCCs by 14/54 (25.9%), and 12/54 (22.2%) respectively. Thirty nine (63.9%) patients were within imaging Milan, and 51(83.6%) patients were within imaging University of California, San Francisco (UCSF) criteria, but 35(64.8%) patients were within pathological Milan, and 40(74.1%) patients were within pathological UCSF criteria. Nineteen (35.2%) patients underwent pretransplant bridging therapy for HCC, and only 3 patients had complete ablation in pathology of explanted liver. Conclusion: US & CT scan have high sensitivity for detection of HCC, and PET scan has less sensitivity, but PET scan might be of particular value in excluding extrahepatic HCC extension. Fallacies of the imaging study due to overestimation and underestimation should be considered during scheduling according to selection criteria. CT has doubtful value in addressing the efficacy of bridging therapy for HCC.

Diagnostic accuracy of18F-methylcholine positron emission tomography/computed tomography for intra- and extrahepatic hepatocellular carcinoma

Diagnosis of hepatocellular carcinoma (HCC) primarily involves imaging. The aim of this study was to assess the accuracy of (18) F-fluorocholine ((18) F-FCH) positron emission tomography (PET) for detection of HCC and evaluation of extent of disease. Patients with HCC >1 cm were included between 2009 and July 2011, and follow-up closed in February 2013. Diagnosis was based on American Association for the Study of Liver Diseases criteria, and all patients underwent (18) F-FCH PET/computed tomography (CT) at baseline before treatment, 6 underwent a second PET/CT posttreatment, and 1 a third during follow-up. Whole-body PET and low-dose CT imaging were performed 15 minutes after (18) F-FCH injection. Evaluation of imaging was done with standardized uptake value (SUV) ratios: SUV maximum of the lesion divided by the SUV mean of surrounding tissue. Statistical analyses included descriptive analyses, receiver operating characteristic curve, McNemar's test, and Kaplan-Meier's test at 5% level of significance. Twenty-nine patients revealed 53 intrahepatic lesions. In 48 of 53 lesions, (18) F-FCH PET was positive (SUVratio , 1.95 ± 0.66; sensitivity, 88%; specificity, 100%). PET/CT showed uptake in 18 extrahepatic lesions and no uptake in 3 lesions affirmed non-HCC lesions; all lesions were confirmed with additional investigation (accuracy, 100%). In 17 of 29 patients, additional lesions were found on PET/CT imaging, with implications for treatment in 15 patients. Posttreatment PET/CT showed identical results, compared with standard treatment evaluation. This study shows additional value of (18) F-FCH PET/CT for patients with HCC. (18) F-FCH PET/CT has implications for staging, management, and treatment evaluation because of accurate assessment of extrahepatic disease.

Indicators of sorafenib efficacy in patients with advanced hepatocellular carcinoma.

To determine significant indicators for the efficacy of sorafenib in patients with advanced hepatocellular carcinoma (HCC). A total of 46 patients with Barcelona Clinic Liver Cancer stage C who received sorafenib for more than 30 d at the Iizuka Hospital from June 2009 to December 2012 were enrolled in this study. Multivariate and univariate analyses were performed to evaluate the associations of hepatic function according to Child-Pugh grade, location and size of the largest tumor and adverse events of sorafenib treatment, such as hand-foot syndrome (HFS), hypertension, diarrhea, and alopecia, with the efficacy of treatment, as measured by overall survival (OS) and time to progression (TTP). Patients included 39 men and 7 women whose ages ranged from 48 to 85 years (70.6 ± 9.6 years). HCC was classified according to etiology as follows: hepatitis C virus (n = 26), hepatitis B virus (n = 9), and other (n = 11). Liver function in patients was categorized as Child-Pugh grade A (n = 30) or B (n = 16). Tumors were categorized by size [< 5 cm (n = 33) or >5 cm (n = 13)] and the location of the largest tumor was used to categorize patients with intrahepatic (n = 28) or extrahepatic (n = 18) HCC. HFS, hypertension, diarrhea, and alopecia were present in 22 (47.8%), 19 (41.3%), 15 (32.6%) and 7 patients (15.2%), respectively. The median OS of all patients was 373 d and the median TTP was 112 d. The etiology of HCC did not correlate with the median OS and TPP. The median OS of patients with tumors < 5 cm was significantly longer than those with larger tumors (496 vs 245 d; HR = 0.19, 95%CI: 0.07-0.48; P < 0.01). According to the results of a multivariate analysis, the size of the largest tumor affected OS (HR = 0.22, 95%CI: 0.08-0.59; P < 0.01). The median TTP was significantly longer in patients with extrahepatic compared to intrahepatic major HCC (224 vs 98 d; HR = 0.32; 95%CI: 0.14-0.67; P < 0.01). The median TTP of patients with HFS was significantly longer than those without it (195 d vs 83 d; HR = 0.41, 95%CI: 0.20-0.82; P < 0.05), and the median TTP was significantly longer in patients with hypertension (195 d vs 84 d; HR = 0.43, 95%CI: 0.21-0.84; P < 0.05). According to the results of the multivariate analysis, extrahepatic major HCC (HR = 0.36, P < 0.01) and HFS (HR = 0.44, P < 0.05) prolonged TTP. Extrahepatic major HCC and HFS are associated with prolonged TTP and are useful indicators for judging the efficacy of sorafenib treatment.

Extrahepatic Metastases of Hepatocellular Carcinoma: A Spectrum of Imaging Findings

Hepatocellular carcinoma (HCC) is the most common primary tumour of the liver, responsible for significant morbidity and mortality worldwide. In the Western world, it primarily affects patients with cirrhosis, secondary to hepatitis C virus and alcoholism. In the rest of the world, HCC is closely associated with hepatitis B virus infections. Radiologists play a key role in accurately staging HCC, which has important implications for treatment planning. This pictorial review aims to describe the routes of HCC spread and the most frequent sites of metastases, to recognize extrahepatic HCC findings on computed tomography and magnetic resonance imaging, and to understand the implications of HCC staging on treatment planning.

Can hepatocellular carcinoma (HCC) give unconventional metastases? We report three cases of extrahepatic HCC that confirm this question

Can hepatocellular carcinoma (HCC) give unconventional metastases? We report three cases of extrahepatic HCC that confirm this question

Can Hepatocellular Carcinoma (HCC) Produce Unconventional Metastases? Four Cases of Extrahepatic HCC

Extrahepatic spread of hepatocellular carcinoma (HCC) diagnosed during the clinical course of the disease is not frequent; however, with the prolonged survival of HCC patients, the incidence of extrahepatic metastases seems to be increasing. We present four unusual cases of extrahepatic metastasis from HCC: the first concerns a patient who underwent a liver transplantation for HCC with cirrhosis and three years later developed metastases in the lung and the left orbit; the second is that of a patient who developed an extraperitoneal pararectal metastasis; in the third case a large osteolytic lesion developed on the left iliac bone, and in the fourth case we found an isolated metastasis in the left mandible. These cases offer important information related to the unusual biology of isolated metastases from HCC after successful treatment of the primary cancer.

Indocyanine green fluorescent imaging for detecting extrahepatic metastasis of hepatocellular carcinoma

Indocyanine green (ICG) fluorescent imaging has been used effectively to identify hepatocellular carcinoma (HCC) in intraoperative setting. However, whether extrahepatic metastatic lesions from HCC can also be detected by this imaging is unknown. This study was conducted on 17 patients with suspected extrahepatic HCC metastases in the lung (n=3), adrenal gland (n=1), lymph node (n=7), peritoneum (n=5) and both lymph node and peritoneum (n=1). ICG was administered intravenously at a dose of 0.5mg/kg prior to operation for liver function evaluation. Intraoperative ICG fluorescent imaging was performed with a near-infrared light camera system. The surgical specimens were also examined in all cases for the presence of ICG fluorescence. Of 28 lesions for which ICG fluorescence was examined intraoperatively, 24 lesions exhibited fluorescence and were proved to be HCC metastases pathologically. Five of them were newly identified by ICG fluorescent imaging. The other four lesions included two HCC metastases and two benign tumors. Of 33 suspicious metastatic lesions extirpated, 26 lesions emitting fluorescence from the specimen were all metastatic HCC. The other 7 lesions consisted of 6 benign tumors and one HCC metastasis. Accordingly, the positive predictive value of in vivo and ex vivo ICG fluorescent imaging were both 100%, while the negative predictive value of those methods were 50 and 86%, respectively. Extrahepatic metastases from HCC exhibited ICG fluorescence when illuminated by near-infrared light, indicating their capability to transport ICG. This imaging can be a useful tool for intraoperative detection of metastasis in HCC patients.

Hepatocellular Carcinoma in the Right Thigh without Primary Hepatic Lesion: A Case Report

Hepatocellular carcinoma (HCC) is the most common primary malignant tumor of the liver. HCC metastasizes to anywhere of the body through the blood directly or by lymphatic spread (1). However, a literature concerning lymph node metastasis is rare in HCC. There are some reports of primary extrahepatic HCC (2, 3). However, there is no report of HCC presenting as primary thigh mass or report of that metastasizes to the thigh. We experienced a case of pathologically proven HCC in the right thigh, just below the inguinal area, without intrahepatic lesion.

Protein induced by vitamin K absence or antagonist-II production is a strong predictive marker for extrahepatic metastases in early hepatocellular carcinoma: a prospective evaluation

BackgroundClinicians often experience extrahepatic metastases associated with hepatocellular carcinoma (HCC), even if no evidence of intrahepatic recurrence after treatment is observed. We investigated the pretreatment predictors of extrahepatic metastases in HCC patients.MethodsPatients diagnosed with HCC without evidence of extrahepatic metastases were prospectively enrolled. We evaluated the correlation between extrahepatic metastases and pretreatment clinical variables, including serum tumor markers.ResultsA total of 354 patients were included. Seventy-six patients (21%) had extrahepatic metastases during the observation period (median, 25.3 months; range, 0.6-51.3 months). Cox regression multivariate analysis showed that serum protein induced by vitamin K absence or antagonist-II (PIVKA-II) production levels, the intrahepatic tumor stage, platelet count, and portal vein thrombosis were independent risk factors for extrahepatic metastases. Patients with a PIVKA-II production ≥ 300 mAU/mL had a 2.7-fold (95% confidence interval; 1.5-4.8; P < 0.001) and 3.7-fold (95% confidence interval; 2.0-6.6; P < 0.001) increased risk for extrahepatic metastases after adjustment for stage, platelet count, alpha-fetoprotein ≥ 400 ng/mL, and portal vein thrombosis according to the AJCC and BCLC staging systems, respectively.ConclusionPIVKA-II production levels might be a good candidate predictive marker for extrahepatic HCC metastases, especially in patients with smaller and/or fewer tumors in the liver with in stages regardless of serum alpha-fetoprotein.

Clinical applications of positron emission tomography in hepatic tumors

Fluorodeoxyglucose (FDG), which allows the evaluation of glucose metabolism, is widely used for tumor diagnosis using positron emission tomography (PET). FDG-PET, which is used for the diagnosis of intrahepatic tumor lesions, shows high FDG accumulation in cholangiocellular carcinoma (CCC) and metastatic liver cancer. FDG-PET shows high FDG accumulation in moderately or poorly differentiated hepatocellular carcinoma (HCC) and is useful for the diagnosis of extrahepatic HCC metastases and recurrences. However, because the imaging method frequently shows low FDG accumulation in well-differentiated HCC, it is not very useful for that diagnosis. For the diagnosis of well-differentiated HCC, F-18 fluorocholine for evaluation of phospholipid metabolism and C-11 acetate for evaluation of free fatty acid metabolism are useful in the diagnosis of that HCC. It is expected that the combination of these PET agents will enhance the diagnostic performance of FDG-PET for HCC in the future. The problem of a lack of anatomical information is being resolved with the development of the use of PET in combination with computed tomography or magnetic resonance imaging. For the problem of low resolution, PET devices using semiconductors have been developed.

A Rare Case of Metastatic Hepatocellular Carcinoma to the Colon with Associated Paraneoplastic Syndrome

Purpose: Hepatocellular carcinoma (HCC) is an aggressive malignancy with poor prognosis that is associated with a 4-6 month mean survival. Early detection with surgical resection offers the best chance for long-term survival. There are rare cases of patients with extrahepatic HCC recurrences. We report an unusual case of extrahepatic HCC occurring 18 and 36 months following initial presentation. Results: A 79-year-old man presented with 1 month of persistent epigastric pain. An abdominal CT revealed a large (16.5 × 13.8 cm), lobulated mass in the left hepatic lobe. Hepatitis B and C serology were negative. An alpha feto-protein (AFP) was 123 ng/mL. A left hepatic lobectomy was performed. Pathology revealed a high grade hepatocellular carcinoma. Surveillance included serial AFPs (which had normalized) and regular CT scans. Sixteen months after hepatic resection, he had a gastric outlet obstruction. An abdominal CT revealed a large (8.4 × 8.1 cm) exophytic gastric mass. An AFP was 23 ng/mL. An EGD with EUS revealed a retrogastric mass with cystic components. FNA obtained necrotic tissue and tumor fragments consistent with metastatic HCC. A distal gastrectomy with roux gastrojejunostomy was performed. Pathology revealed a poorly differentiated carcinoma consistent with the primary HCC. He remained clinically stable for 18 months when an abdominal CT revealed a mid-transverse colon mass. A colonoscopy performed prior to the hepatic resection removed 5 diminutive tubular adenomas. A repeat colonoscopy revealed a partially obstructing, malignant appearing mass. Biopsies revealed a poorly differentiated carcinoma consistent with metastatic HCC. Additionally, biopsies of the nodular mucosa in the cecum revealed lamina propria, intraepithelial and muscularis mucosal eosinophils. The peripheral eosinophil count was 24%. A transverse colectomy with primary anastomosis was performed. The specimen was described as an eccentric fungating lesion involving the full thickness of the bowel with gross invasion of the pericolic fat. There were no other intra-abdominal masses or liver metastases. Conclusion: This is a rare case of extrahepatic HCC metastases occurring at 18 and 36 months following hepatic resection. Gastrointestinal involvement of HCC is highly unusual, occurring in 0.5-2% of cases. The most common site of GI involvement is the duodenum, followed by stomach and least often colon. The presumed mode of transmission is direct invasion of the GI tract. However, hematogenous spread to the colon has been speculated and is thought to have occurred in this patient. Awareness of the unusual occurrence of extrahepatic metastatic HCC is important to ensure adequate surveillance following primary resection.