Hepatocellular Carcinoma Spreading Through the Round Ligament

Excerpt

A 70-year-old man with a previous past medical history significant for alcoholic cirrhosis was referred to our unit for the treatment of multifocal hepatocellular carcinoma (HCC). An abdominal magnetic resonance imaging (MRI) showed five nodules of HCC ranging from 2 to 5 cm in diameter involving the right and left liver lobes. Biologic data and clinical status classed the patients as Child-Pugh A 6. There was minimal portal hypertension with grade 1 oesophageal varices, no previous history of liver decompensation and serum alpha-fetoprotein was elevated at 50 μg/l (normal values < 13 μg/l). After multidisciplinary discussion, the patient was treated by sequential (right-liver first) transarterial chemoembolization (TACE) in order to downstage HCC. Following TACE, alpha-fetoprotein dropped within normal values and MRI showed complete tumoral necrosis. The patient was then followed up radiologically and clinically in outpatient clinic and liver transplantation (LT) work-up was considered after 1 year of clinical remission. Fourteen months after TACE, serum alpha-fetoprotein level increased to 56 μg/l and abdominal MRI showed a non hypervascularized recurrent noudule 1, 5 cm in size in the segment 4 inferior close to the segmental portal pedicle and 4, 5 cm exophytic nodule under the left liver lobe (Fig. 1). The abdominal examination found a round, mobile nodule on the epigastrium. Complete work-up did not found any recurrence into the chest and bone. In order to rule out the presence of a peritoneal implant, the patient underwent explorative laparoscopy which found HCC spreading through the round ligament (RL). The RL was excised and pathology confirmed HCC diffusion through the RL (Fig. 2). The patient was delisted from LT and treated by sorafenib®. The round ligament of the liver connects the umbilical portion of the left portal vein to the umbilicus. RL is a fibrous cord which originates from the involution of the umbilical vein which transfers oxygenated blood from the placenta into the growing foetus. Under increased intrahepatic pressures the round ligament reopens allowing a wide communication between the portal and systemic circulation such as seen in cirrhotic patients with portal hypertension. Tumoral spreading through the RL and umbilical metastases represents rare manifestations of digestive cancers. Spreading to the umbilicus can arise from cutaneous lymphatics by retrograde lymphatic flow, by direct peritoneal implantation from the anterior peritoneal surface and by arterial embolization from distant sites. The final localization of tumoral disease at the umbilicus is known as the sister Mary Joseph’s nodule.1 However because of his vascular structure, the RL can also be the source of tumoral diffusion directly from the liver. HCC has an elevated propensity toward diffusion through portal system into the same liver segment and toward the main portal branches.2 In the presence of portal hypertension and reopened umbilical vein, HCC invading a segmental branch of the umbilical left portal vein can spread through the RL such as in the present case.3 Considering the RL as a major branch of the portal system, invasion form HCC should be considered such as macrovascular invasion and precludes the performance of LT.

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