Hepatocellular Carcinoma With Budd–Chiari Syndrome and Obstructive Jaundice: A Therapeutic Challenge

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To the Editor:
A 64-year-old man had a history of hepatitis B and cirrhosis, presented with notable ascites and extensive edema involving the trunk and bilateral lower extremities, was referred to our unit in July 2004. Computed tomography (CT) showed hepatomegalia with a large mass involving most of the right lobe of the liver and invading into the right hepatic vein and inferior vena cava (IVC). The laboratory findings were as follows: aspartate transaminase 91 U/L; alanine aminotransferase 76 U/L; total bilirubin 47 μmol/L; albumin 3.6 g/dL; alpha-fetoprotein (AFP) 276 ng/mL.
After a multidisciplinary review and written informed consent was obtained, recanalization via an endovascular approach was attempted. Digital subtraction angiography (Shimadzu, Miyazaki, Japan) revealed the complete obstruction of the hepatic segment of the IVC and outflow stenosis of the right hepatic vein. Two self-expandable nitinol stents (Bard) were deployed into the IVC and a balloon-expandable metallic stent (Boston Scientific) was placed into the right hepatic vein. The patient's performance status improved markedly a week later. Therefore, the second step of treatment plan was performed.
Common hepatic arterial angiography showed a huge hypervascular right hepatic tumor invading into the IVC and right hepatic vein. A standard transarterial chemoembolization (TACE) was performed1 (Figure 1). The residual tumor was treated by another 2 courses at 5 and 17 weeks after the first TACE. The AFP level reached normal gradually.
In May 2007, the patient came again because of the abnormal AFP level and CT imaging. Arteriography showed multifocal hypervascular hepatocellular carcinomas (HCCs) emerged in the liver. After another 2 courses of TACE alone, these tumors were well-controlled again (Figure 2). The similar diagnosis and treatment courses occurred in subsequent December 2008, June 2011, and August 2012, respectively.
In September 2014, the patient presented moderately advanced physical sign of jaundice. CT scans showed a hypovascular hepatic tumor in the hepatic hilar region. The nodule in the duodenum was proved as the metastasis from HCC by endoscopic biopsy and immunohistochemistry.
Patient's sign of jaundice improved substantially within 10 days after percutaneous transhepatic cholangial drainage. Two courses of TACE were performed subsequently. After the external biliary drainage was converted to internal–external biliary drainage, however, the patient gave up treating for his deteriorative functional status and economic consideration and expired 5 months later, for a total survival of 10 years 11 months.
Most of HCCs are hypervascular tumor with a strong tendency to invade the venous system.1 Many randomized controlled trials have confirmed TACE as an acceptable treatment for most cases of unresectable HCCs.2–4 However, only few studies have reported the application of TACE on the treatment of HCC with IVC and/or hepatic vein invasion.1,5 Chung et al1 reported 62 such patients treated with TACE alone. The median overall survival was 10.9 months. Chern et al5 also reported 26 similar patients and the median survival was 13.5 months of the only 14 responders. No endovascular stenting before TACE was possible of the reason for these limited efficacy.

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