Metastatic lung tumor from hepatocellular carcinoma with tumor thrombus invasion in the pulmonary vein: a case report

doi:10.21203/rs.3.rs-2245492/v1

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Case Report

Metastatic lung tumor from hepatocellular carcinoma with tumor thrombus invasion in the pulmonary vein: a case report

https://doi.org/10.21203/rs.3.rs-2245492/v1

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Journal Publication

published 28 Apr, 2023

Read the published version in Journal of Cardiothoracic Surgery →

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Background

Metastatic lung tumor with a tumor thrombus in the peripheral pulmonary vein is very rare. We present a case of a metastatic lung tumor from hepatocellular carcinoma (HCC) with tumor thrombus invasion in the pulmonary vein that was diagnosed preoperatively and underwent complete resection by segmentectomy.

Case presentation

A 77-year-old man underwent laparoscopic lateral segment hepatectomy for HCC eight years ago. Protein induced by vitamin K absence or antagonist-II (PIVKA-II) remained elevated from two years ago. Contrast-enhanced chest computed-tomography (CT) showed a 27 mm nodule in the right apical segment (S1). He was pathologically diagnosed with a metastatic lung tumor from HCC via transbronchoscopic biopsy. We planned to perform right S1 segmentectomy. Before surgery, contrast-enhanced CT in the pulmonary vessels phase for three-dimensional reconstruction showed that the tumor extended into the adjusting peripheral pulmonary vein, and we diagnosed tumor thrombus invasion in V1a. The surgery was conducted under 3-port video-assisted thoracic surgery. First, V1 was ligated and cut. A1 and B1 were cut. The intersegmental plane was cut with mechanical staplers. Pathological examination revealed moderately-differentiated metastatic HCC with tumor thrombus invasions in many pulmonary veins, including V1a. No additional postoperative treatments were performed.

Conclusions

As malignant tumors tend to develop a tumor thrombus in the primary tumor, it might be necessary to perform contrast-enhanced CT in the pulmonary vessel phase to check for a tumor thrombus before the operation for metastatic lung tumors.

Hepatocellular carcinoma

metastatic lung tumor

tumor thrombus

segmentectomy

three-dimensional computed tomography

Recurrence after treatment for hepatocellular carcinoma (HCC) mostly occurs in the liver, and extrahepatic metastases are relatively rare, reported at 24% [1]. The most frequent extrahepatic metastasis is lung metastasis [2]. HCC has the tendency to infiltrate and form a tumor thrombus in the portal and hepatic veins; however, metastatic lung tumors from HCC with tumor thrombus invasion in the pulmonary vessels are rare [3, 4]. We report a case of a metastatic lung tumor from HCC with tumor thrombus invasion in the pulmonary vein that was diagnosed preoperatively and underwent complete resection by segmentectomy.

A 77-year-old man who was hepatitis B virus carrier underwent laparoscopic lateral segment hepatectomy for HCC eight years ago. The pathological findings revealed no vessel invasion. He visited the hospital regularly for follow-ups. Protein induced by vitamin K absence or antagonist-II (PIVKA-II) remained elevated from two years ago, but imaging tests for the liver revealed no metastasis. Contrast-enhanced chest computed tomography (CT) showed a 27 mm nodule with mediastinal pleural invasion in the right apical segment (S1) (Fig. 1). The patient was pathologically diagnosed with a metastatic lung tumor from HCC via transbronchoscopic biopsy. We planned to perform right S1 segmentectomy. Before surgery, contrast-enhanced CT in the pulmonary vessel phase for three-dimensional (3D) reconstruction showed that the tumor extended into the adjusting peripheral pulmonary vein, and we diagnosed tumor thrombus invasion in V1a (Fig. 2). The surgery was conducted under 3-port video-assisted thoracic surgery. The tumor had invaded the mediastinal pleura. The right superior pulmonary vein was exposed and V1 was ligated and cut. Subsequently, A1 and B1 were cut respectively using a mechanical stapler. The intersegmental plane was identified by an inflation-deflation line after air inflation to the right lung, and subsequently cut with mechanical staplers. Finally, an intraoperative pathological examination of the frozen section demonstrated a malignant negative margin in V1. The operative time was 185 min, and the operative blood loss was minimal. Postoperative air leak developed and was treated by thoracic drainage. The patient was discharged on postoperative day 14. Pathological examination revealed moderately-differentiated metastatic HCC with tumor thrombus invasion in many pulmonary veins, including V1a (Fig. 3). No additional postoperative additional treatments were performed. He has not shown the recurrence of HCC for 13 months.

Metastatic lung tumors from malignant tumors develop by hematogenous, lymphogenous, or aerogenous metastases. As lung cancer has a high tendency to metastasize lymphogenously, it is necessary to perform lobectomy with systematic lymph node dissection. In contrast, because most metastatic lung tumors are developed by hematogenous metastasis, there is no need for systematic lymph node dissection, and the operative method only aims to resect the tumor. It has been reported that an insufficient resection margin is related to margin relapse; therefore, it is important to have a sufficient resection margin [5]. For lung cancer, the optimal resection margin was reported as a margin distance greater than 20 mm or the maximum tumor diameter [6]. For metastatic lung tumors from colorectal cancer, the optimal resection margin was reported to be a margin distance greater than 10 mm [7]. Wedge resection is often performed for metastatic lung tumors; however, segmentectomy or lobectomy is sometimes performed when the resection margin is expected to be suboptimal by wedge resection and the tumor is localized in the central lung field. In our case, we decided to perform segmentectomy for the optimal resection margin.

Advanced lung cancer sometimes invades in the left atrium via the pulmonary vein [8, 9]. In metastatic lung tumors, there have been some reports of tumor thrombus in the pulmonary vein. Most of them were metastatic lung tumors from HCC, renal cell carcinoma (RCC), and sarcoma [4, 10–13]. These malignant tumors have been reported to develop a tumor thrombus in the great vessels, such as the inferior vena cava, in primary lesions [3]. Most of metastatic lung tumors with a tumor thrombus were greater than 5cm and invaded in the main pulmonary vein and the left atrium. Metastatic lung tumor < 3cm in size, with a tumor thrombus only in the peripheral pulmonary vein, as in our case, is very rare.

Lung tumors with a tumor thrombus in the pulmonary vein have the potential to cause embolism in the systemic circulation as cerebral infarction by disengaging the tumor thrombus [14, 15]. It has been reported that lung tumors invading the pulmonary vein were detected after the development of transient ischemic attacks and cerebral infarction [16]. Additionally, embolism in the systemic circulation can occur during or after surgery [17]. If a tumor thrombus in the pulmonary vein can not be diagnosed preoperatively, an operative procedure such as resection of the pulmonary parenchyma and shifting of the lung without ligation of the pulmonary vein may cause embolism in the systemic circulation. To avoid such a situation, a preoperative diagnosis of a tumor thrombus is necessary.

It is recommended to perform contrast-enhanced CT in the pulmonary vessel phase for 3D reconstruction to understand the anatomical features of the pulmonary vessels and bronchi before performing segmentectomy and lobectomy [18]. Nakahashi et al. reported that pulmonary venous tumor thrombus could be diagnosed by contrast-enhanced CT in the pulmonary venous phase; however, this was not by standard contrast-enhanced CT [4]. In our case, the tumor thrombus in V1a could not be diagnosed using the standard contrast-enhanced CT (Fig. 4). Without a preoperative diagnosis, an operative procedure without first ligation of V1 might cause embolism by a tumor thrombus during the operation. Malignant tumors tend to invade the vessels and develop a tumor thrombus, such as HCC, RCC, and sarcoma. It might be necessary to perform preoperative contrast-enhanced CT in the pulmonary vessel phase to check for a tumor thrombus when surgery for metastatic lung tumor is performed.

We report a case of a metastatic lung tumor from HCC with tumor thrombus invasion in the pulmonary vein that was diagnosed preoperatively and underwent complete resection by segmentectomy. Without a preoperative diagnosis of a tumor thrombus, it may cause embolism in the systemic circulation during an operation. As malignant tumors tend to develop a tumor thrombus in the primary tumor, it might be necessary to perform contrast-enhanced CT in the pulmonary vessel phase to check for a tumor thrombus before the operation for metastatic lung tumors.

HCC, hepatocellular carcinoma; PIVKA-II, protein induced by vitamin K absence or antagonist-II; 3D, three-dimensional; RCC, renal cell carcinoma

Ethics approval and consent to participate

Not applicable.

Consent for publication

Informed consent was obtained from the patient for the publication of this case report.

Availability of data and materials

Please contact the author for data requests.

Competing interests

The authors declare that they have no competing interests.

Funding

None declared.

Author’s contributions

KO was the main surgeon and drafted the manuscript. SO assisted with surgery and helped draft the manuscript. YI, SK, YT, TM, YY, MI, TY, ET, KM, and KO helped to care for the patient and drafted the manuscript. All authors have read and approved the final manuscript.

Acknowledgement

The authors thank Dr. Keisuke Kikuchi (Department of Pathology, Obihiro Kosei General Hospital).

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No competing interests reported.

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Journal Publication

published 28 Apr, 2023

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Editorial decision: Major revision
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You are reading this latest preprint version

Metastatic lung tumor from hepatocellular carcinoma with tumor thrombus invasion in the pulmonary vein: a case report

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Journal Publication

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Abstract

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Background

Case Presentation

Discussion

Conclusions

Abbreviations

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References

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Journal Publication

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