Too Big to Fail: Successful Resection of a Large Hepatocellular Carcinoma with Portal Tumor Thrombus

Excerpt

A 42-year-old man with a history of chronic hepatitis B, maintained on tenofovir, was evaluated for cough and shortness of breath. After initial evaluation in the outpatient setting demonstrated a large right-sided pleural effusion, he was seen at his local Emergency Department where CT and subsequent MR identified a large (22.2 cm) Liver Reporting and Data System (LI-RADS) 5 mass occupying the right hepatic lobe (Fig. 1) that exhibited arterial-phase hyperenhancement, washout, and an enhancing pseudo-capsule. An enhancing tumor thrombus was also visible within the right main portal vein. Further evaluation identified an alpha fetoprotein (AFP) of 34,000 and a history of unintentional 15 lbs weight loss over a period of months. As a result of the large mass, the patient required multiple drainages for recurrent pleural effusions. He was empirically started on anti-vascular endothelial growth factor (VEGF) therapy with lenvatinib and referred to interventional radiology for consideration of radioembolization, but this was deferred due to an elevated shunt fraction, with approximately 3.6% shunting to the lungs. The patient was then referred for consideration of resection. Other than hepatitis B, he had no other pertinent medical history.

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