J Liver Cancer.  2023 Mar;23(1):206-212. 10.17998/jlc.2023.02.09.

A case of successful surgical treatment for peritoneal seeding of hepatocellular carcinoma after radiotherapy and atezolizumab plus bevacizumab combination treatment

• Cho Y
• Kim BH
• Kim TH
• Koh YH
• Park JW

• KMID: 2540833
• DOI: http://doi.org/10.17998/jlc.2023.02.09

Abstract

Peritoneal seeding of hepatocellular carcinoma (HCC) is incurable and has poor prognosis. A 68-year-old man underwent surgical resection for a 3.5 cm single nodular HCC at the tip of segment 3 and transarterial chemoembolization for a 1.5 cm-sized recurrent HCC at the tip of segment 6. 3 months later, an increasing 1 cm pelvic nodule on the rectovesical pouch warranted radiotherapy. Although it stabilized, a new 2.7 cm-sized peritoneal nodule in the right upper quadrant (RUQ) omentum appeared 3.5 years after radiotherapy. Hence, omental mass and small bowel mesentery mass excision were performed. 3 years later, recurrent peritoneal metastases in the RUQ omentum and rectovesical pouch progressed. 33 cycles of atezolizumab and bevacizumab treatment elicited stable disease response. Finally, laparoscopic left pelvic peritonectomy was performed without tumor recurrence. Herein, we present a case of HCC with peritoneal seeding that was successfully treated with surgery after radiotherapy and systemic therapy, leading to complete remission.

Keyword

Hepatocellular carcinoma; Peritoneal seeding; Atezolizumab; Bevacizumab; Radiotherapy

Figure

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  Figure 1. Initial and follow-up liver dynamic computed tomography (CT) imaging findings. (A) Arterial and (B) portal phase on July 2012, 3.5 cm single nodular hepatocellular carcinoma (HCC) on S3 (red arrow). (C) Arterial phase, before transarterial chemoembolization (TACE) on May 2014, 1.5 cm recurred HCC on S6 (red arrow). (D) Lipiodol uptake (red arrow) on non-contrast CT after TACE on July 2014.

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  Figure 2. Follow-up liver dynamic computed tomography (CT) imaging findings before and after radiotherapy transarterial chemoembolization. (A) Liver dynamic CT, arterial phase, before radiotherapy on October 2014, 1 cm nodule on the rectovesical pough (red arrow). (B) Liver dynamic CT, arterial phase, 5 mm nodule (red arrow) after radiotherapy on June 2015.

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  Figure 3. Follow-up liver dynamic computed tomography (CT) and positron emission tomography (PET)/CT imaging findings on May 2017: the progression of peritoneal metastases and omental metastatic mass of hepatocellular carcinoma after surgical resection on June 2017. (A) Liver dynamic CT, arterial phase, right upper quadrant area on abdominal cavity (red arrow). (B) Liver dynamic CT, arterial phase, rectovesical pouch (red arrow). (C) PET/CT, 2.8 cm sized nodule on right upper quadrant area on abdominal cavity. (D) PET/CT, 1.97 cm sized nodule on the rectovesical pouch. (E) Mass on right upper quadrant area on abdominal cavity. (F) Mass on the rectovesical pouch.

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  Figure 4. Follow-up liver dynamic computed tomography (CT) imaging findings before and after systemic therapy: the recurrence of peritoneal metastases. (A) Liver dynamic CT, arterial phase, right upper quadrant area on abdominal cavity (yellow line) on June 2020. (B) Liver dynamic CT, arterial phase, rectovesical pouch (yellow line) on June 2020. (C) Liver dynamic CT, arterial phase, right upper quadrant area on abdominal cavity (red arrow) on June 2021 after 33 cycles of atezolizumab and bevacizumab combination therapy. (D) Liver dynamic CT, arterial phase, rectovesical pouch (red arrow) on June 2021 after 33 cycles of atezolizumab and bevacizumab combination therapy.

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  Figure 5. Omental metastatic mass of hepatocellular carcinoma after left pelvic peritonectomy on July 2022.

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  Figure 6. Clinical course of the patient with alpha-fetoprotein (AFP) and prothrombin induced by vitamin K absence (PIVKA-II). TACE, transarterial chemoembolization.

Reference

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