Portal Vein Occlusion Research Articles

Meta-analysis of associating liver partition with portal vein ligation and portal vein occlusion for two-stage hepatectomy.

Discussion is ongoing regarding whether associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) or portal vein occlusion is better in staged hepatectomy. The aim of this study was to compare available strategies using a two-stage approach in extended hepatectomy. A literature search was performed in MEDLINE, Scopus, the Cochrane Library and Embase, and additional articles were identified by hand searching. Data from the international ALPPS registry were extracted. Clinical studies reporting volumetric changes, mortality, morbidity, feasibility of the second stage and tumour-free resection margins (R0) in two-stage hepatectomy were included. Ninety studies involving 4352 patients, including 320 from the ALPPS registry, met the inclusion criteria. Among these, nine studies (357 patients) reported on comparisons with other strategies. In the comparison of ALPPS versus portal vein embolization (PVE), ALPPS was associated with a greater increase in the future liver remnant (76 versus 37 per cent; P < 0·001) and more frequent completion of stage 2 (100 versus 77 per cent; P < 0·001). Compared with PVE, ALPPS had a trend towards higher morbidity (73 versus 59 per cent; P = 0·16) and mortality (14 versus 7 per cent; P = 0·19) after stage 2. In the non-comparative studies, complication rates were 39 per cent in the PVE group, 47 per cent in the portal vein ligation (PVL) group and 70 per cent in the ALPPS group. After stage 2, mortality rates were 5, 7 and 12 per cent respectively. ALPPS is associated with greater future liver remnant hypertrophy and a higher rate of completion of stage 2, but this may be at the price of greater morbidity and mortality.

Effect of Chelerythrine on Intestinal Cell Turnover following Intestinal Ischemia-Reperfusion Injury in a Rat Model.

Background Chelerythrine (CHE) is a benzophenanthridine alkaloid that is a potent, selective, and cell-permeable protein kinase C inhibitor. The purpose of the present study was to examine the effect of CHE on intestinal recovery and enterocyte turnover after intestinal ischemia-reperfusion (IR) injury in rats. Methods Male Sprague-Dawley rats were divided into four experimental groups: (1) sham rats underwent laparotomy, (2) sham-CHE rats underwent laparotomy and were treated with intraperitoneal CHE; (3) IR-rats underwent occlusion of both superior mesenteric artery and portal vein for 30 minutes followed by 48 hours of reperfusion, and (4) IR-CHE rats underwent IR and were treated with intraperitoneal CHE immediately before abdominal closure. Intestinal structural changes, Park injury score, enterocyte proliferation, and enterocyte apoptosis were determined 24 hours following IR. The expression of Bax, Bcl-2, p-ERK, and caspase-3 in the intestinal mucosa was determined using real Western blot and immunohistochemistry. Results Treatment with CHE resulted in a significant decrease in Park injury score in jejunum (threefold decrease) and ileum (twofold decrease), and parallel increase in mucosal weight in jejunum and ileum, villus height in jejunum and ileum, and crypt depth in ileum compared with IR animals. IR-CHE rats also experienced a significantly lower apoptotic index in jejunum and ileum, which was accompanied by a lower Bax/Bcl2 ratio compared with IR animals. Conclusions Treatment with CHE inhibits programmed cell death and prevents intestinal mucosal damage following intestinal IR in a rat.

Short Chemotherapy-Free Interval Improves Oncological Outcome in Patients Undergoing Two-Stage Hepatectomy for Colorectal Liver Metastases.

In patients undergoing two-stage hepatectomy (TSH) for colorectal liver metastases (CRLM), chemotherapy is discontinued before portal vein occlusion and restarted after curative resection. Long chemotherapy-free intervals (CFI) may lead to tumor progression and poor oncological outcomes. The aim of this study was to investigate the impact of the length of CFI on oncological outcome in patients undergoing TSH for CRLM. Overall, 74 patients suffering from bilobar CRLM who underwent ALPPS (associating liver partition with portal vein ligation for staged hepatectomy; n=43) or conventional TSH (n=31) at two tertiary centers were investigated. The impact of CFI on long-term outcomes was analyzed by univariable and multivariable analysis. Preoperative chemotherapy was administered in 91% (67/74) of patients, and chemotherapy was resumed postoperatively in 69% (44/64) of patients who completed TSH. The use of postoperative chemotherapy was significantly associated with improved mean overall survival (36±3 vs. 13±3months; p<0.001). Overall, the median CFI from surgery to postoperative chemotherapy was 16weeks (interquartile range 11-31) and was significantly shorter in the ALPPS group when compared with the conventional TSH group (10 vs. 21weeks; p<0.001). Multivariable analysis revealed a CFI≤10weeks as an independent factor associated with improved overall survival (p=0.006) and disease-free survival (p=0.010). A short CFI is associated with improved oncological outcome in patients undergoing TSH for CRLM. Decreased interstage intervals after ALPPS may facilitate the timely resumption of chemotherapy.

Ultrasonographic Study of Ascites with Clinicopathological Correlation

=50ml). Ultrasound performs better than CT in localizing asceitic fluid in relation to peritoneal spaces becauses it allows instant visualization in different planes. Ultrasound is also less hazardous in relation to CT. it involves minial patient‟s preparation and additionally is the least expensive of available imaging tests It can also be performed in very sick non ambulatory patients at beside. Diagnosis often requires fine needle percutaneous aspiration associated with cytopathological study. US guided fine needle aspiration is a simple and easy, cost effevtive and a useful procedure for obtaining ascitic fluid samples. Aetiophysiological Classification of Ascites A. Ascites not associated with peritoneal disease 1. Portal hypertension : A. Cirrhosis B. Hepatic congestion - C. C. F - Constrictive pericarditis - IVC obstruction - Hepatic vein obstruction (Budd-Chiari syndrome) C. Portal vein occlusion

Oncological Outcomes of Major Liver Resection Following Portal Vein Embolization: A Systematic Review and Meta-analysis.

Preoperative portal vein occlusion with either percutaneous portal vein embolization (PVE) or portal vein ligation is routinely used to induce liver hypertrophy prior to major liver resection in patients with hepatic malignancy. While this increases the future liver remnant, and hence the number of patients suitable for resection, recent evidence suggests that induction of liver hypertrophy preoperatively may promote tumor growth and increase recurrence rates. The aims of this current study were to evaluate the impact of PVE on hepatic recurrence rate and survival in patients with colorectal liver metastases (CRLM). The MEDLINE, EMBASE and Web of Science databases were searched to identify studies assessing the oncological outcomes of patients undergoing major liver resection for CRLM following PVE. Studies comparing patients undergoing one-stage liver resection with or without preoperative PVE were included. The primary outcome was postoperative hepatic recurrence (PHR), while secondary outcomes were 3- and 5-year overall survival (OS). Of the 2131 studies identified, six non-randomized studies (n=668) met the eligibility criteria, comparing outcomes of patients undergoing major liver resection with or without PVE (n=182 and n=486, respectively). No significant difference was observed in PHR (odds ratio [OR] 0.78; 95% confidence interval [CI] 0.42-1.44), 3-year OS (OR 0.80; 95% CI 0.56-1.14) or 5-year OS (OR 1.12; 95% CI 0.40-3.11). PVE does not have any adverse effect on PHR or OS in patients undergoing major liver resection for CRLM. Further studies based on individual patient data are needed to provide definitive answers.

Effects of Microwave Ablation on Arterial and Venous Vasculature after Treatment of Hepatocellular Carcinoma.

Purpose To characterize vessel occlusion rates and their role in local tumor progression in patients with hepatocellular carcinoma (HCC) who underwent microwave tumor ablation. Materials and Methods This institutional review board approved, HIPAA-compliant retrospective review included 95 patients (75 men and 20 women) with 124 primary HCCs who were treated at a single center between January 2011 and March 2014. Complete occlusion of the portal veins, hepatic veins, and hepatic arteries within and directly abutting the ablation zone was identified with postprocedure contrast material-enhanced computed tomography. For each vessel identified in the ablation zone, its size and antenna spacing were recorded and correlated with vascular occlusion with logistic regression analysis. Local tumor progression rates were then compared between patent and occluded vessels for each vessel type with Fisher exact test. Results Occlusion was identified in 39.7% of portal veins (29 of 73), 15.0% of hepatic veins (six of 40), and 14.2% of hepatic arteries (10 of 70) encompassed within the ablation zone. Hepatic vein occlusion was significantly correlated with a smaller vessel size (P = .036) and vessel-antenna spacing (P = .006). Portal vein occlusion was only significantly correlated with a smaller vessel size (P = .001), particularly in vessels that were less than 3 mm in diameter. Local tumor progression rates were significantly correlated with patent hepatic arteries within the ablation zone (P = .02) but not with patent hepatic (P = .57) or portal (P = .14) veins. Conclusion During microwave ablation of HCC, hepatic veins and arteries were resistant to vessel occlusion compared with portal veins, and only arterial patency within an ablation zone was related to local tumor progression. © RSNA, 2016.

Right Intrahepatic Cholangiocarcinoma

Intrahepatic cholangiocarcinoma (Klatskin tumor) is a rare fatal disease that originates from biliary epithelium. This tumor may arise anywhere within the biliary tree, intrahepatic bile ducts, or common bile ducts, and it accounts for approximately 2% of all reported cancers. A case is reported of an elderly male patient presenting with chronic occlusion of the right portal vein and diagnosed with intrahepatic cholangiocarcinoma. This report details the initial sonographic findings, the correlating follow-up imaging studies that were done, and patient management.

Interleukin-18 Binding Protein Pretreatment Attenuates Kidney Injury Induced by Hepatic Ischemia Reperfusion

ObjectiveAcute kidney injury (AKI) is a serious condition that can be induced by liver transplantation, major hepatic resection or prolonged portal vein occlusion. AKI can increase the frequency of postoperative complications. In the current study, we aimed to investigate whether interleukin-18 binding protein (IL-18BP) pretreatment has a protective effect against possible kidney injury following liver ischemia-reperfusion (IR) achieved by Pringle maneuver in an experimental rat model. Materials and MethodsA total of 24 male Wistar albino rats were included in this study. Animals were equally and randomly separated into 3 groups as follows: I, Sham group, II, IR group (1-hour ischemia and 4-hour reperfusion) and III, IR + IL-18BP group (50μg/kg IL-18BP was intraperitoneally administered 30 minutes before surgery). Blood, liver and kidney samples were collected for histopathological and biochemical (hepatic and renal function, nitric oxide, malondialdehyde and glutathione levels) analysis. In addition, proinflammatory cytokines including tumor necrosis factor α, IL-1β and IL-6 levels were measured in kidney tissues. ResultsIL-18BP has improved kidney functions in acute kidney damage, restored structural changes, exhibited anti-inflammatory effects by decreasing proinflammatory cytokines and regulated the oxidative stress parameters by antioxidant effect. ConclusionsCurrent study would be the first to evaluate the protective, antioxidant and anti-inflammatory effects of IL-18BP on renal damage induced by liver ischemia (1 hour) and reperfusion (4 hours). As a result, we have demonstrated that AKI may develop after hepatic IR with Pringle maneuver and IL-18BP pretreatment can attenuate this damage. By this way, complications related to liver IR could be minimized and also postoperative hospitalization durations, treatment costs and healing periods could be decreased.

Salvage ALPPS is safe and effective after failed portal vein occlusion in patients with bilobar colorectal liver metastases

Salvage ALPPS is safe and effective after failed portal vein occlusion in patients with bilobar colorectal liver metastases

The ALPPS as salvage procedure after unsuccessful portal vein occlusion. “Give then another chance…”

The ALPPS as salvage procedure after unsuccessful portal vein occlusion. “Give then another chance…”

Laparoscopic Pancreaticoduodenectomy with Reconstruction of the Portal Vein with the Parietal Peritoneum.

Laparoscopic pancreaticoduodenectomy (LPD) is increasingly used for resections of periampullary tumors, including pancreatic adenocarcinoma.1 LPD with venous resection-reconstruction (VRR) has already been performed with or without vascular graft.2 (,) 3 The parietal peritoneum (PP) was recently described for reconstruction of the mesenterico-portal vein, with excellent results.4 PATIENTS AND METHODS: Between April 2011 and May 2015, a total of 64 LPDs were performed in our department; however, only one patient underwent VRR. Compared with the open approach, full mobilization of the mesentery and right liver is not systematically carried out and, theoretically, vascular grafts may be more frequently needed with LPD. In this video, LPD for pancreatic adenocarcinoma with resection of the lateral right side of the portal vein (>25mm) was performed. Reconstruction was achieved rapidly, as a lateral patch, with the falciform ligament. Surgery lasted 360min, 60min of portal vein occlusion, 200ml of blood loss, and uneventful stay. Since 2010, the PP has been used as a lateral patch in 69 patients operated by open (n=68) or laparoscopic approach (n=1). Although handling and suturing can be difficult, no bleeding complications related to the PP were observed and the permeability rate was >95%. LPD is still restricted to selected centers, with conflicting results regarding safety; however, venous resection may be required. We feel that with the laparoscopic approach, vascular grafts are more frequently needed and the PP has many advantages compared with an open approach, including easy access, unlimited size, and rapid harvesting.

Liver regeneration after different degrees of portal vein ligation

BackgroundSelective portal vein ligation (PVL) is followed by ipsilateral atrophy and contralateral hypertrophy of the liver lobes. Although the atrophy-hypertrophy complex induced by PVL is a well-documented phenomenon, the effect of different degrees of extended portal vein occlusion on liver regeneration is not known. The aim of this study was to assess the effects of different degrees of portal occlusion on portal pressure and liver regeneration. Materials and methodsMale Wistar rats (n = 96; 220-250 g) were randomized into three groups and underwent 70%, 80%, or 90% portal vein ligation, respectively. The portal pressure was measured immediately and 24, 48, 72, 120, and 168 h after PVL (n = 6/group/time point). The hepatic lobes and the spleen were weighed, and liver regeneration ratio was calculated. Changes in liver histology and the mitotic activity were assessed on hematoxylin-eosin stained slides. ResultsHigher degree of portal occlusion triggered a stronger regenerative response (regeneration ratio of PVL 70%168h = 2.23 ± 0.13, PVL 80%168h = 3.11 ± 0.37, PVL 90%168h = 4.68 ± 0.48) PVL led to an immediate increase in portal pressure, the value of which changed proportionally to the mass of liver tissue deprived of portal perfusion (PVL 70%acute = 17 ± 2 mm Hg, PVL 80%acute = 19 ± 1 mm Hg, PVL 90%acute = 26 ± 4 mm Hg). Findings in histology showed necro-apoptotic lesions in the atrophic liver lobes and increased mitotic cell count in the hypertrophic lobes. The mitotic cell count of PVL 90% peaked earlier and at a significantly higher value than of PVL 70% and PVL 80% (PVL 9024h%: 96.0 ± 3.5 PVL 70%48h: 64.0 ± 2.1, PVL 80%48h: 56.3 ± 4.0). The mitotic index after 24 h showed a strong correlation with the acute portal hypertension. ConclusionsA higher degree of portal vein occlusion leads to a greater regenerative response, presumably triggered by the proportional increase in portal pressure, which supports the role of the so-called “blood-flow” theory of PVL-triggered liver regeneration.

Percutaneous Microwave Ablation Liver Partition and Portal Vein Embolization for Rapid Liver Regeneration: A Minimally Invasive First Step of ALPPS for Hepatocellular Carcinoma.

Percutaneous Microwave Ablation Liver Partition and Portal Vein Embolization for Rapid Liver Regeneration: A Minimally Invasive First Step of ALPPS for Hepatocellular Carcinoma.

Antioxidant, Antiapoptotic and Inflammatory Effects of Interleukin-18 Binding Protein on Kidney Damage Induced by Hepatic Ischemia Reperfusion

ObjectiveAcute kidney injury (AKI) is a serious condition that can be induced by liver transplantation, major hepatic resection or prolonged portal vein occlusion. The AKI can increase the frequency of postoperative complications. In the current study, we aimed to investigate whether interleukin-18 binding protein (IL-18BP) pretreatment has a protective effect against possible kidney injury–mediated liver ischemia-reperfusion (IR) achieved by Pringle maneuver in an experimental rat model. Materials and MethodsA total of 21 Wistar albino rats were included in this study. Animals were equally and randomly separated into 3 groups as follows: Sham (n = 7), IR group (n = 7) and IR + IL-18BP group (n = 7). Serum aspartate transaminase, alanine aminotransaminase and lactate dehydrogenase enzyme activities and serum urea and creatinine levels were determined. Tumor necrosis factor-α, IL-6, IL-1β, interferon gamma, total oxidant status, total antioxidant status and oxidative stress index were measured in kidney tissue homogenate samples. Histopathological examination and immunohistochemical Caspase-3 staining were applied to examine the general morphologic structure and apoptosis. ResultsRenal total oxidant status; oxidative stress index; IL-18 levels; serum aspartate transaminase, alanine aminotransaminase and lactate dehydrogenase activities and creatinine levels were significantly lower in IR + IL-18BP group, when compared with the IR group. Beside this, total antioxidant status levels were remarkably higher in IR + IL-18BP group, when compared with the IR group. The caspase-3 expression degree in IR group was remarkably higher than other groups. ConclusionsIt has been demonstrated that IL-18BP pretreatment may have inflammatory, antioxidant and antiapoptotic effects against AKI induced by hepatic IR.

Liver-fat and liver-function indices derived from Gd-EOB-DTPA-enhanced liver MRI for prediction of future liver remnant growth after portal vein occlusion

ObjectivesTo evaluate the use of Gd-EOB-DTPA-enhanced magnetic resonance imaging (MRI)-derived fat- and liver function-measurements for prediction of future liver remnant (FLR) growth after portal vein occlusion (PVO) in patients scheduled for major liver resection. MethodsForty-five patients (age, 59±13.9y) who underwent Gd-EOB-DTPA-enhanced liver MRI within 24±18days prior to PVO were included in this study. Fat-Signal-Fraction (FSF), relative liver enhancement (RLE) and corrected liver-to-spleen ratio (corrLSR) of the FLR were calculated from in- and out-of-phase (n=42) as well as from unenhanced T1-weighted, and hepatocyte-phase images (n=35), respectively. Kinetic growth rate (KGR, volume increase/week) of the FLR after PVO was the primary endpoint. Receiver operating characteristics analysis was used to determine cutoff values for prediction of impaired FLR-growth. ResultsFSF (%) showed significant inverse correlation with KGR (r=−0.41, p=0.008), whereas no significant correlation was found with RLE and corrLSR. FSF was significantly higher in patients with impaired FLR-growth than in those with normal growth (%FSF, 8.1±9.3 vs. 3.0±5.9, p=0.02). ROC-analysis revealed a cutoff-FSF of 4.9% for identification of patients with impaired FLR-growth with a specificity of 82% and sensitivity of 47% (AUC 0.71 [95%CI:0.54–0.87]). Patients with impaired FLR-growth according to the FSF-cutoff showed a tendency towards higher postoperative complication rates (posthepatectomy liver failure in 50% vs. 19%). ConclusionsLiver fat-content, but not liver function derived from Gd-EOB-DTPA-enhanced MRI is a predictor of FLR-growth after PVO. Thus, liver MRI could help in identifying patients at risk for insufficient FLR-growth, who may need re-evaluation of the therapeutic strategy.

Associating liver partition and portal vein ligation for staged hepatectomy in patients with colorectal liver metastases – Intermediate oncological results

BackgroundColorectal liver metastases (CRLM) not amenable for resection have grave prognosis. One limiting factor for surgery is a small future liver remnant (FLR). Early data suggests that associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) effectively increases the volume of the FLR allowing for resection in a larger fraction of patients than conventional two-stage hepatectomy (TSH) with portal vein occlusion (PVO). Oncological results of the treatment are lacking. The aim of this study was to assess the intermediate oncological outcomes after ALPPS in patients with CRLM. Material and methodsRetrospective analysis of all patients with CRLM operated with ALPPS at the participating centres between December 2012 and May 2014. ResultsTwenty-three patients (16 male, 7 female), age 67 years (28–80) were operated for 6.5 (1–38) metastases of which the largest was 40 mm (14–130). Six (27.3%) patients had extra-hepatic metastases, 16 (72.7%) synchronous presentation. All patients received chemotherapy, 6 cycles (3–25) preoperatively and 16 (70%) postoperatively. Ten patients (43%) were rescue ALPPS after failed PVO. Severe complications occurred in 13.6% and one (4.5%) patient died within 90 days of surgery. After a median follow-up of 22.5 months from surgery and 33.5 months from diagnosis of liver metastases estimated 2 year overall survival was 59% (from surgery) and 73% (from diagnosis). Liver only recurrences (n = 8), were treated with reresection/ablation (n = 7) while lung recurrences were treated with chemotherapy. ConclusionThe overall survival, rate of severe complications and perioperative mortality associated with ALPPS for patients with CRLM is comparable to TSH.

Transjugular intrahepatic portosystemic shunt using transsplenic access with balloon-assisted puncture technique in a patient with chronic and complete occlusion of portal vein

Transjugular intrahepatic portosystemic shunt using transsplenic access with balloon-assisted puncture technique in a patient with chronic and complete occlusion of portal vein

Effect of taurine on intestinal recovery following intestinal ischemia-reperfusion injury in a rat.

Taurine (TAU) is a sulfur-containing amino acid that is involved in a diverse array of biological and physiological functions, including bile salt conjugation, osmoregulation, membrane stabilization, calcium modulation, anti-oxidation, and immunomodulation. Several studies have established that treatment with TAU significantly protects cerebral, cardiac and testicular injury from ischemia-reperfusion (IR). The purpose of the present study was to examine the effect of TAU on intestinal recovery and enterocyte turnover after intestinal IR injury in rats. Male Sprague-Dawley rats were divided into four experimental groups: (1) Sham rats that underwent laparotomy, (2) Sham-TAU rats that underwent laparotomy and were treated with intraperitoneal (IP) TAU (250mg/kg); (3) IR-rats that underwent occlusion of both superior mesenteric artery and portal vein for 30min followed by 48h of reperfusion, and (4) IR-TAU rats that underwent IR and were treated with IP TAU (250mg/kg) immediately before abdominal closure. Intestinal structural changes, Park's injury score, enterocyte proliferation and enterocyte apoptosis were determined 24h following IR. The expression of Bax, Bcl-2, p-ERK and caspase-3 in the intestinal mucosa was determined using Western blot and immunohistochemistry. Treatment with TAU resulted in a significant decrease in Park's injury score compared to IR animals. IR-TAU rats also demonstrated a significant increase in mucosal weight in jejunum and ileum, villus height in jejunum and ileum and crypt depth in ileum compared to IR animals. IR-TAU rats also experienced significantly lower apoptotic indices in jejunum and ileum which was accompanied by a higher Bcl-2/Bax ratio compared to IR animals. Treatment with taurine prevents gut mucosal damage and inhibits intestinal epithelial cell apoptosis following intestinal IR in a rat.

Melatonin prevents lung injury induced by hepatic ischemia–reperfusion through anti-inflammatory and anti-apoptosis effects

Melatonin is a free radical scavenger and broad-spectrum antioxidant with immunomodulatory effects. The objective of the study is to investigate the effects of melatonin in hepatic ischemia/reperfusion (I/R) induced lung injury and explore its underlying mechanisms. Hepatic I/R injury was induced via portal vein and hepatic artery occlusion for 30min followed by 3-h reperfusion. Male Sprague–Dawley rats were divided into three groups: sham, I/R+ Vehicle and I/R+melatonin. Melatonin (10mg/kg) or vehicle was injected intravenously 15min before ischemia and 10min before reperfusion. The histology of the liver and lung, plasma aminotransferase and cytokine secretion, and apoptosis in the lung were evaluated. The phosphorylation of JNK, p38, and NF-ƙB and Nrf2 nuclear translocation in the lung was examined by Western blotting. We found that melatonin administration significantly attenuated hepatic I/R induced lung injury in rats. Melatonin inhibited the pro-inflammatory responses and enhanced antioxidative responses. Melatonin alleviated pathological changes of the lung and liver, and inhibited apoptosis of cells in the lung. Phosphorylation of JNK, p38 and NF-ƙB and Nrf2 nuclear translocation was increased significantly in the lung by hepatic I/R. Melatonin administration inhibited the activation of JNK, p38, and NF-ƙB, however, melatonin further enhanced Nrf2 activation. We conclude that melatonin exerts a protective effect in hepatic I/R induced lung injury by attenuating the pro-inflammatory responses, inhibiting cell apoptosis, which was mediated in part through JNK, p38 MAPK, NF-ƙB and Nrf2 signaling pathways. Melatonin may be a promising therapeutic strategy for hepatic I/R induced lung injury.

Advanced Combined Hepatocellular Carcinoma and Cholangiocarcinoma (cHCC-CC) in a Patient With Alcoholism and Chronic Hepatitis C

Introduction: A combined hepatocellular and cholangiocarcinoma (cHCC-CC) is rare subtype of primary liver cancer accounting for 0.87% of primary liver tumors. It is a distinct type of primary liver cancer with aggressive behavior, which is morphologically and phenotypically intermediate between HCC and CC. Although few studies have shown the increased occurrence of cHCC-CC in chronic hepatitis B patients, there is a lack of association with chronic hepatitis reported in US studies. We present a patient with advanced cHCC-CC and history of alcoholism and chronic hepatitis C(CHC). Case: A 64-year-old man with history of alcohol abuse and CHC, treatment naive, was referred to hepatology for jaundice for 2 weeks (blood work in table 1). Ultrasound of the abdomen showed a 6.6cm mass in left hepatic lobe extending to the hilum causing intrahepatic ductal dilatation(IHD), a 5.5cm mass in right hepatic lobe and scattered small liver lesions. MRI of the abdomen with Eovist revealed an 8.6cm mass in segment 4 extending to the hilum resulting in right(RT) and left (LT) IHD dilation and a 6cm mass in posterior right hepatic lobe. There were also smaller satellite nodules in both lobes, occlusion of the main portal vein with extensive cavernous transformation, and thrombus within the RT and LT intrahepatic portal veins. Liver was non-nodular while enhancement suggested CC. Liver biopsy showed CK7 positive, poorly differentiated CC with rare glandular architecture(Image 1). It also showed poorly differentiated HCC with giant cell features consistent with cHCC-CC (Image 2,3). Jaundice worsened and total bilirubin(TB) trended up to 30. A biliary drain was placed and TB decreased to 18. After the drain was capped 5 days later, he developed acute renal failure, leukocytosis and encephalopathy. Antibiotics, rifaximin, and albumin were given and his renal function and mental status improved. Palliative care was consulted for advanced cHCC-CC and the patient was discharged to home hospice. Conclusion: The diagnosis and treatment of cHCC-CC can be challenging due to clinical, imaging and histological features that overlap with pure HCC and CC. Our patient, although did not have ascites, had advanced stage disease with satellite lesions, multiple tumors, biliary, vascular and regional lymph node involvement. Further studies are needed to evaluate the risk of CHC in development of cHCC-CC. This may ultimately help us to screen for early disease and to improve prognosis.Table 1: LabsFigure 1Figure 2Figure 3