A 66-year-old male with a history of Hepatitis C treated in 2009 with Ledipasvir/Sofosbuvir (Harvoni®) initially presented to the Medical Oncology team in Hackensack University Medical Center, NJ with abdominal discomfort and distention for 4–5 months associated with an approximate 15 pounds of weight loss. He underwent CT scan of the abdomen with contrast and was found to have a large 15.0 × 11.0 × 13.0 cm heterogenous mass attached to the left lobe of the liver, with compression of surrounding intra-abdominal contents including the stomach and transverse colon, as well as the abdominal wall [figure 1]. Subsequent percutaneous biopsy was performed, demonstrating hepatocellular carcinoma with extensive necrosis. He was then referred to the Surgical Oncology team for further workup and management. Follow up MRI demonstrated two additional satellite lesions consistent with multifocal hepatocellular carcinoma without evidence of invasion into surrounding vital structures. Surgical intervention was deemed necessary given the size of the mass and symptomology.
In the operating room, two large-bore intravenous catheters were placed but fluid was kept at a low rate along with placement of a foley catheter. A laparotomy was performed; making a midline sub-xiphoid incision, which was extended down to the pubic symphysis due to the shear size of the tumor [figure 2]. Multiple friable blood vessels were noted at the umbilicus. The omentum as then resected, freeing the anterior abdominal wall. The transverse colon was then carefully separated away from the tumor using an Echelon Endo-GIA stapler with a white load. The transverse colon and its mesentery were preserved and protected from the dense mass. It was also noted that the distal stomach was adhered to the mass along the greater curvature. A sleeve gastrectomy was completed using 60 mm stapler, requiring three firings for completion.
At this time, the retroperitoneal attachment to the duodenum was carefully dissected, followed by separation of the pancreatic head using Endo-GIA white load stapler. This allowed the tumor to be separated from the retroperitoneum and lifted out of the abdomen. A Pringle maneuver was performed using a vascular clamp, and the satellite lesions were transected using parenchymal ablation using the NeuWave Microwave Ablation system. The midline laparotomy was closed in the usual fashion.
On gross inspection, the resected specimen was a 21.0 × 20.0 × 10.7 cm, tan-yellow mass weighing 1948 grams (Fig. 2). The tumor is partially adhered to a portion of the stomach and surrounded by adjacent background liver. Microscopically, the tumor shows solid and trabecular growth pattern with round nucleus, prominent nucleoli, abundant cytoplasm and distinct cell border typical for hepatocellular carcinoma (Fig. 3). Mitotic figures are frequent and tumor necrosis is also seen. Multiple satellite nodules are seen adjacent to the main tumor and extensive small vessel invasion is present (Fig. 4). The tumor also invades into the gastric wall. The background non-tumor liver shows well-formed cirrhotic liver with mild to moderate activity. The attached portion of the stomach demonstrated negative margins (R0). The specimen from the partial hepatectomy, which was the satellite lesion of segment 3, demonstrated a similar pattern.
Post-operative course was significant for urinary retention after failure of trial of void. Given his history of benign prostate hyperplasia (BPH), a foley catheter was reinserted and tamsulosin was added to his regimen. He successfully passed his second trial of void. On post-operative day 2 (POD2), the patient developed nausea and an episode of vomiting, with obstructive series demonstrating ileus. A nasogastric tube was placed and was ultimately removed on POD7 after ileus resided. On POD5, he developed serosanguineous drainage from his incision site after a bout of heavy coughing. A Prevena VAC was placed but was discontinued one week later when the output was reduced to zero, and he was discharged from the hospital later in the day.