Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Operable synchronous ampullary carcinoma and hepatocellular carcinoma: a case report and review of the literature

Operable synchronous ampullary carcinoma and hepatocellular carcinoma: a case report and review... We report a rare case of synchronous double primary malignancies of the liver and ampulla. A 70-year-old white female was diagnosed with ampullary and hepatocellular carcinoma. The management and outcome of this rare case of synchron- ous double primary hepatic and periampullary malignancies, amenable to surgical resection is discussed. INTRODUCTION CASE REPORT Hepatocelllar carcinoma (HCC) is the third leading cause of A 70-year-old woman presented with right-sided abdominal cancer related death worldwide with an annual incidence pain, nausea, vomiting and fever. She had a history of diabetes, of at least 6 per 100 000 in 2010. The number of deaths per hypertension and hypercholesterolemia. She smoked 0.5 pack/ year due to HCC is virtually identical to the worldwide inci- day and denied alcohol abuse. There was no significant family dence, delineating the lethality of this disease [1]. Ampullary history. On admission her vital signs were within normal lim- adenocarcinomas are rare and account for 0.5% of gastrointes- its. On physical exam her sclera were anicteric. Her abdomen tinal malignancies [2]. The etiology of ampullary cancers is was soft, non-tender, non-distended with no palpable masses. unknown. Only one case of synchronous HCC and pancreatic Labarotory studies revealed: Alk Phos 126 IU/L, total bilirubin cancer has been reported in the literature [3]. Furthermore, 2.0 mg/dL, AST 63 IU/L, ALT 58 IU/L, tumor markers showed AFP there are no reports of resected synchronous HCC and peri- 226 ng/mL (normal 0.0–8), CA 19-9 959 unit/mL (normal 0–35) ampullary carcinomas. We herein report the first case of and carcinoembryonic antigen (CEA) 3.9 ng/mL (normal 0–3). simultaneous resection of synchronous hepatocellular and Hepatitis C antibody was reactive and Hepatitis B core AB nega- ampullary carcinomas. tive. CAT-scan of the abdomen revealed a 1.3 cm mass in the Received: June 19, 2017. Accepted: August 28, 2017 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2017. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 1 2 M. Davidson et al. Figure 2: Tumor cells in cell block (FNA specimen) are positive for hepatocyte specific antigen (a) and alphafetoprotein (b) (magnification ×40). Figure 1: (a) CT scan of the abdomen showing pancreatic mass, solid arrow. (b) MRI of the abdomen showing segment six hepatic lesion, solid arrow. was then performed. She was discharged home on post-operative Day 6. Pathology revealed a 6 cm poorly differentiated hepatocel- lular carcinoma (Fig. 3) and a 1 cm intra-ampullary carcinoma head of the pancreas with intrahepatic and extrahepatic ductal extending into proximal stomach and distal bile duct. dilatation (Fig. 1a). MRI of the abdomen showed a 3.7 cm mass in segment VI of the liver (Fig. 1b). ERCP with bile duct brush- ings was performed and consistent with malignancy. EUS DISCUSSION demonstrated a 2.6 cm mass in the head of the pancreas with portal vein involvement. Ultrasound guided biopsy of the liver Synchronous malignancies are defined as those that present was consistent with HCC. (Fig. 2). Routine staging CT scan of simultaneously or within a 6-month period of each other. The the chest showed a prominent 2.1 cm pre-tracheal lymph node. diagnosis of synchronous malignancies of hepato-pancreatico- Endobronchial ultrasound guided-fine needle aspiration (FNA) biliary origin is rare. Operable primary ampullary and liver can- of this lymph node showed no evidence of malignant cells. cer is even less common. Given the concern for portal vein involvement on EUS the pan- Differentiating ampullary carcinoma from other periampul- creatic head lesion was deemed borderline resectable and a lary malignancies may be clinically as well as pathologically neoadjuvant approach was preferred. Prior to initiation of chemo- difficult. Ampullary cancers are uncommon and account for therapyastaging laparoscopyand liver biopsy was performed. At 15–25% of cancers in the periampullary region. Overall, 5-year operation there was no evidence of peritoneal carcinomatosis, survival after resection of ampullary cancer is superior to that of metastatic disease or gross liver cirrhosis. On final pathology the pancreatic cancer (43.3 vs 7–27%, respectively) [4, 5]. Pancreatic liver lesion stained positive for alphafetoprotein (AFP) and hepato- head adenocarcinoma is however much more common and cyte specific antigen (HSA) supporting the diagnosis of a primary more likely to present with metastatic disease. hepatocellular carcinoma. The uninvolved liver had no evidence Hepatic lesions in the setting of a peripancreatic adenocarcin- of cirrhosis. The patient received neoadjuvant FOLFIRINOX fol- oma is metastatic until proven otherwise. While hepatocelluar lowed by re-imaging. Repeat CT scan showed no evidence of dis- carcinoma is the most common primary cancer of the liver it is ease progression. Pancreaticoduodenectomy with synchronous usually found in the setting of liver cirrhosis, chronic hepatitis B liver resection was offered. A classic Whipple procedure was or C infection or non-alcoholic fatty liver disease. Even though performed with a duct to mucosal pancreatico-jejunostomy. A our patient was infected with hepatitis C, her hepatocellular parenchyma-sparing segment VI non-anatomic liver resection carcinoma developed in a non-cirrhotic liver. The incidence of Operable synchronous ampullary carcinoma and hepatocellular carcinoma 3 Care should be taken to rule out metastatic disease in patients with synchronous malignancies particularly when one of the lesions is hepatic. In this case the possibility of synchronous intra and extrahepatic biliary tumors was not considered given the radiographic characteristics of the hepatic lesion. The MRI revealed a hyperintense lesion, heterogeneous enhancement with central washout and delayed capsular enhancement, consistent with primary hepatocellular carcinoma. Preoperative biopsy of the hepatic lesion stained positive for AFP and HSA supporting the diagnosis of a primary hepatocel- lular carcinoma. Synchronous ampullary and hepatocellular carcinoma has not been reported in the literature previously. There have been reports of synchronous unresectable pancreatic and hepatocel- lular carcinomas [3]. We believe this is the first report of syn- chronous resectable ampullary and hepatocellular carcinomas. The patient has recovered well from surgery. She has com- pleted adjuvant chemotherapy as well as sofosbuvir and dacla- tivir for hepatitis C. At 1 year after diagnosis she is without evidence of recurrent disease. CONFLICT OF INTEREST STATEMENT None declared. REFERENCES 1. Parkin D, Bray F, Ferlay J, Pisani P. Global cancer statistics, 2002. CA Cancer J Clin 2005;55:74–108. 2. Albores-Saavedra J, Schwartz AM, Batich K, Henson DE. Cancers of the ampulla of vater: demographics, morph- ology, and survival based on 5,625 cases from the SEER pro- gram. J Surg Oncol 2009;100:598–605. Figure 3: Adenocarcinoma with foamy cytoplasm invading dense stromal tissue 3. Yadav Y, Dipanjan P, Yashwant P, Chhagan B. A rare case (a). Tumor cells are positive for hepatocyte specific antigen (b) (magnification ×40). report: carcinoma pancreas with hepatocellular carcinoma. Indian J Palliat Care 2014;20:53–6. 4. Qiao Q, Zhao Y, Ye M. Carcinoma of the ampulla of vater: factors influencing long-term survival of 127 patients with non-cirrhotic hepatocellular carcinomas in western countries resection. World J Surg 2007;31:137–43. canbe ashigh as19% [6]. 5. Garcea G, Dennison AR, Pattenden CJ. Survival following HCC developing in a non-cirrhotic patient with chronic curative resection for pancreatic ductal adenocarcinoma. A hepatitis C infection has been reported but is very rare [7]. The systematic review of the literature. JOP 2008;9:99–132. hepatitis C virus may generate gene products with carcinogenic 6. van Meer S, van Erpecum KJ, Sprengers D. Hepatocellular potential. Accelerated liver fibrosis without frank cirrhosis has carcinoma in cirrhotic versus noncirrhotic livers: results also been implicated in non-cirrhotic HCC [8]. from a large cohort in the Netherlands. Eur J Gastroenterol In appropriate patients, surgical options for managing hepa- Hepatol 2016;28:352–9. tocellular carcinoma include resection or liver transplantation 7.. De Mitri MS, Poussin K, Baccarini P, Pontisso P, D’Errico A, depending on size, number and location of the tumors. Resection Simon N, et al. HCV-associated liver cancer without cirrho- of a solitary hepatocellular carcinoma in a non-cirrhotic patient is sis. Lancet 1995;345:413–5. associated with the best long term treatment results with a 5- 8. Nash KL, Woodall T, Brown ASM, Davies SE, Graeme AJM. year survival of 44–58%, significantly higher than the survival in Hepatocellular carcinoma in patients with chronic hepatitis thepresenceof cirrhosis 23–48% [9]. Recent studies have reported C virus infection without cirrhosis. World J Gastroenterol decreased local recurrence and increased time to recurrence 2010;16:4061–65. with anatomic resection compared to non-anatomic for HCC. 9. Gaddikeri S, McNeeley M, Wang C, Bhargava P, Dighe M, However, impact on overall survival has not been demon- Yeh M, et al. Hepatocellular carcinoma in the noncirrhotic strated [10]. This patient presented with two relatively aggres- liver. AJR Am J Roentgenol 2014;203:34–47. sive malignancies. An anatomic liver resection may not have 10. Feng X, Su Y, Zheng S, Xia F, Ma K, Li X, et al. A double impacted her overall survival but could have potentially added blinded prospective randomized trial comparing the effect time and morbidity to the operation and therefore a non- of anatomic versus non-anatomic resection on hepatocellu- anatomic liver resection was performed. lar carcinoma recurrence. HPB (Oxford) 2017;19:667–74. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Operable synchronous ampullary carcinoma and hepatocellular carcinoma: a case report and review of the literature

Download PDF
3 pages

Loading next page...
 
/lp/oxford-university-press/operable-synchronous-ampullary-carcinoma-and-hepatocellular-carcinoma-jrLzfAJPQr

References (12)

Publisher
Oxford University Press
Copyright
Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2017.
eISSN
2042-8812
DOI
10.1093/jscr/rjx182
Publisher site
See Article on Publisher Site

Abstract

We report a rare case of synchronous double primary malignancies of the liver and ampulla. A 70-year-old white female was diagnosed with ampullary and hepatocellular carcinoma. The management and outcome of this rare case of synchron- ous double primary hepatic and periampullary malignancies, amenable to surgical resection is discussed. INTRODUCTION CASE REPORT Hepatocelllar carcinoma (HCC) is the third leading cause of A 70-year-old woman presented with right-sided abdominal cancer related death worldwide with an annual incidence pain, nausea, vomiting and fever. She had a history of diabetes, of at least 6 per 100 000 in 2010. The number of deaths per hypertension and hypercholesterolemia. She smoked 0.5 pack/ year due to HCC is virtually identical to the worldwide inci- day and denied alcohol abuse. There was no significant family dence, delineating the lethality of this disease [1]. Ampullary history. On admission her vital signs were within normal lim- adenocarcinomas are rare and account for 0.5% of gastrointes- its. On physical exam her sclera were anicteric. Her abdomen tinal malignancies [2]. The etiology of ampullary cancers is was soft, non-tender, non-distended with no palpable masses. unknown. Only one case of synchronous HCC and pancreatic Labarotory studies revealed: Alk Phos 126 IU/L, total bilirubin cancer has been reported in the literature [3]. Furthermore, 2.0 mg/dL, AST 63 IU/L, ALT 58 IU/L, tumor markers showed AFP there are no reports of resected synchronous HCC and peri- 226 ng/mL (normal 0.0–8), CA 19-9 959 unit/mL (normal 0–35) ampullary carcinomas. We herein report the first case of and carcinoembryonic antigen (CEA) 3.9 ng/mL (normal 0–3). simultaneous resection of synchronous hepatocellular and Hepatitis C antibody was reactive and Hepatitis B core AB nega- ampullary carcinomas. tive. CAT-scan of the abdomen revealed a 1.3 cm mass in the Received: June 19, 2017. Accepted: August 28, 2017 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2017. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 1 2 M. Davidson et al. Figure 2: Tumor cells in cell block (FNA specimen) are positive for hepatocyte specific antigen (a) and alphafetoprotein (b) (magnification ×40). Figure 1: (a) CT scan of the abdomen showing pancreatic mass, solid arrow. (b) MRI of the abdomen showing segment six hepatic lesion, solid arrow. was then performed. She was discharged home on post-operative Day 6. Pathology revealed a 6 cm poorly differentiated hepatocel- lular carcinoma (Fig. 3) and a 1 cm intra-ampullary carcinoma head of the pancreas with intrahepatic and extrahepatic ductal extending into proximal stomach and distal bile duct. dilatation (Fig. 1a). MRI of the abdomen showed a 3.7 cm mass in segment VI of the liver (Fig. 1b). ERCP with bile duct brush- ings was performed and consistent with malignancy. EUS DISCUSSION demonstrated a 2.6 cm mass in the head of the pancreas with portal vein involvement. Ultrasound guided biopsy of the liver Synchronous malignancies are defined as those that present was consistent with HCC. (Fig. 2). Routine staging CT scan of simultaneously or within a 6-month period of each other. The the chest showed a prominent 2.1 cm pre-tracheal lymph node. diagnosis of synchronous malignancies of hepato-pancreatico- Endobronchial ultrasound guided-fine needle aspiration (FNA) biliary origin is rare. Operable primary ampullary and liver can- of this lymph node showed no evidence of malignant cells. cer is even less common. Given the concern for portal vein involvement on EUS the pan- Differentiating ampullary carcinoma from other periampul- creatic head lesion was deemed borderline resectable and a lary malignancies may be clinically as well as pathologically neoadjuvant approach was preferred. Prior to initiation of chemo- difficult. Ampullary cancers are uncommon and account for therapyastaging laparoscopyand liver biopsy was performed. At 15–25% of cancers in the periampullary region. Overall, 5-year operation there was no evidence of peritoneal carcinomatosis, survival after resection of ampullary cancer is superior to that of metastatic disease or gross liver cirrhosis. On final pathology the pancreatic cancer (43.3 vs 7–27%, respectively) [4, 5]. Pancreatic liver lesion stained positive for alphafetoprotein (AFP) and hepato- head adenocarcinoma is however much more common and cyte specific antigen (HSA) supporting the diagnosis of a primary more likely to present with metastatic disease. hepatocellular carcinoma. The uninvolved liver had no evidence Hepatic lesions in the setting of a peripancreatic adenocarcin- of cirrhosis. The patient received neoadjuvant FOLFIRINOX fol- oma is metastatic until proven otherwise. While hepatocelluar lowed by re-imaging. Repeat CT scan showed no evidence of dis- carcinoma is the most common primary cancer of the liver it is ease progression. Pancreaticoduodenectomy with synchronous usually found in the setting of liver cirrhosis, chronic hepatitis B liver resection was offered. A classic Whipple procedure was or C infection or non-alcoholic fatty liver disease. Even though performed with a duct to mucosal pancreatico-jejunostomy. A our patient was infected with hepatitis C, her hepatocellular parenchyma-sparing segment VI non-anatomic liver resection carcinoma developed in a non-cirrhotic liver. The incidence of Operable synchronous ampullary carcinoma and hepatocellular carcinoma 3 Care should be taken to rule out metastatic disease in patients with synchronous malignancies particularly when one of the lesions is hepatic. In this case the possibility of synchronous intra and extrahepatic biliary tumors was not considered given the radiographic characteristics of the hepatic lesion. The MRI revealed a hyperintense lesion, heterogeneous enhancement with central washout and delayed capsular enhancement, consistent with primary hepatocellular carcinoma. Preoperative biopsy of the hepatic lesion stained positive for AFP and HSA supporting the diagnosis of a primary hepatocel- lular carcinoma. Synchronous ampullary and hepatocellular carcinoma has not been reported in the literature previously. There have been reports of synchronous unresectable pancreatic and hepatocel- lular carcinomas [3]. We believe this is the first report of syn- chronous resectable ampullary and hepatocellular carcinomas. The patient has recovered well from surgery. She has com- pleted adjuvant chemotherapy as well as sofosbuvir and dacla- tivir for hepatitis C. At 1 year after diagnosis she is without evidence of recurrent disease. CONFLICT OF INTEREST STATEMENT None declared. REFERENCES 1. Parkin D, Bray F, Ferlay J, Pisani P. Global cancer statistics, 2002. CA Cancer J Clin 2005;55:74–108. 2. Albores-Saavedra J, Schwartz AM, Batich K, Henson DE. Cancers of the ampulla of vater: demographics, morph- ology, and survival based on 5,625 cases from the SEER pro- gram. J Surg Oncol 2009;100:598–605. Figure 3: Adenocarcinoma with foamy cytoplasm invading dense stromal tissue 3. Yadav Y, Dipanjan P, Yashwant P, Chhagan B. A rare case (a). Tumor cells are positive for hepatocyte specific antigen (b) (magnification ×40). report: carcinoma pancreas with hepatocellular carcinoma. Indian J Palliat Care 2014;20:53–6. 4. Qiao Q, Zhao Y, Ye M. Carcinoma of the ampulla of vater: factors influencing long-term survival of 127 patients with non-cirrhotic hepatocellular carcinomas in western countries resection. World J Surg 2007;31:137–43. canbe ashigh as19% [6]. 5. Garcea G, Dennison AR, Pattenden CJ. Survival following HCC developing in a non-cirrhotic patient with chronic curative resection for pancreatic ductal adenocarcinoma. A hepatitis C infection has been reported but is very rare [7]. The systematic review of the literature. JOP 2008;9:99–132. hepatitis C virus may generate gene products with carcinogenic 6. van Meer S, van Erpecum KJ, Sprengers D. Hepatocellular potential. Accelerated liver fibrosis without frank cirrhosis has carcinoma in cirrhotic versus noncirrhotic livers: results also been implicated in non-cirrhotic HCC [8]. from a large cohort in the Netherlands. Eur J Gastroenterol In appropriate patients, surgical options for managing hepa- Hepatol 2016;28:352–9. tocellular carcinoma include resection or liver transplantation 7.. De Mitri MS, Poussin K, Baccarini P, Pontisso P, D’Errico A, depending on size, number and location of the tumors. Resection Simon N, et al. HCV-associated liver cancer without cirrho- of a solitary hepatocellular carcinoma in a non-cirrhotic patient is sis. Lancet 1995;345:413–5. associated with the best long term treatment results with a 5- 8. Nash KL, Woodall T, Brown ASM, Davies SE, Graeme AJM. year survival of 44–58%, significantly higher than the survival in Hepatocellular carcinoma in patients with chronic hepatitis thepresenceof cirrhosis 23–48% [9]. Recent studies have reported C virus infection without cirrhosis. World J Gastroenterol decreased local recurrence and increased time to recurrence 2010;16:4061–65. with anatomic resection compared to non-anatomic for HCC. 9. Gaddikeri S, McNeeley M, Wang C, Bhargava P, Dighe M, However, impact on overall survival has not been demon- Yeh M, et al. Hepatocellular carcinoma in the noncirrhotic strated [10]. This patient presented with two relatively aggres- liver. AJR Am J Roentgenol 2014;203:34–47. sive malignancies. An anatomic liver resection may not have 10. Feng X, Su Y, Zheng S, Xia F, Ma K, Li X, et al. A double impacted her overall survival but could have potentially added blinded prospective randomized trial comparing the effect time and morbidity to the operation and therefore a non- of anatomic versus non-anatomic resection on hepatocellu- anatomic liver resection was performed. lar carcinoma recurrence. HPB (Oxford) 2017;19:667–74.

Journal

Journal of Surgical Case Reports – Oxford University Press

Published: Sep 21, 2017

There are no references for this article.