Intrahepatic cholangiocarcinoma with a tumor thrombus extending from the inferior vena cava to the right atrium: a case report

Background Vascular invasion involving a tumor thrombus in the inferior vena cava and/or right atrium is an unfavorable prognostic factor after intrahepatic cholangiocarcinoma resection. We report an intrahepatic cholangiocarcinoma case with a tumor thrombus extending from the left hepatic vein via the inferior vena cava to the right atrium. Case presentation A 58-year-old man with epigastralgia was referred to our hospital after an emergent transcatheter arterial embolization was done following the radiological diagnosis of a ruptured hepatic tumor. The serum concentrations of carcinoembryonic antigen, carbohydrate 19-9, duke pancreatic monoclonal antigen type 2, and cytokeratin-19 fragments were elevated; meanwhile those of alfa-fetoprotein and des-γ-carboxy prothrombin were within normal ranges. A contrast-enhanced computed tomography scan showed a heterogeneously enhanced tumor, 13 cm in diameter, in the left lobe of the liver, enlarged lymph nodes along the lesser curvature of the stomach, and a tumor thrombus extending from the left hepatic vein via the inferior vena cava to the right atrium. We performed a left hemihepatectomy and tumor thrombectomy under total hepatic vascular exclusion to reduce the risk of sudden death. After dissection of the liver parenchyma along the left side of the middle hepatic vein, except for the left hepatic vein, the inferior vena cava just below the right atrium could be clamped by pulling down the left lobe of the liver toward the caudal side. The thrombus could be removed by incising the inferior vena cava under total hepatic vascular exclusion. Microscopic examination showed a tubular adenocarcinoma. Immunohistochemical staining was positive for cytokeratin-7, cytokeratin-19, and epithelial membrane antigen, but negative for arginase-1, glypican-3, and hepatocyte. The patient was pathologically diagnosed with an intrahepatic cholangiocarcinoma with a tumor thrombus in the inferior vena cava. Adjuvant chemotherapy with tegafur/gimeracil/oteracil was administered for 1 year. The patient remained in good health without cancer recurrence for over 4 years after the operation. Conclusion An aggressive surgical approach may be indicated for intrahepatic cholangiocarcinoma with a tumor thrombus in the inferior vena cava and/or right atrium to avoid the risk of impending death.

Hepatic vascular exclusion minimizes hemorrhage during isolated caudate lobectomy

Isolated caudate lobectomy is a challenging operation for hepatobiliary surgeons. Unexpected massive hemorrhage is one of the major concerns for successful operation. To address the issue of bleeding control and prophylaxis during isolated caudate lobectomy is necessary. Our aim was to summarize the application of hepatic vascular exclusion in the operation for decreasing blood loss. 26 cases of isolated caudate lobectomy were reviewed. All the operations were accomplished successfully with satisfactory average blood loss (325.38ml) and without major post operative complications. Hepatic vascular exclusion was resorted to in nearly four fifths of the cases. Pringle maneuver, portal vein exclusion, total hepatic vascular exclusion, selective total hepatic vascular exclusion and selective regional total hepatic vascular exclusion were applied selectively. Hepatic vascular exclusion decreased blood loss during isolated caudate lobectomy effectively. Fully mobilization of the liver facilitates hepatic vascular exclusion. Certain precautionary measures and effective remedy for unexpected bleeding are necessary. Isolated caudate lobectomy should be carried out by experienced hepatobiliary surgeons.