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A 38-year-old man underwent right hepatectomy for a huge hepatocellular carcinoma(HCC)in the right hepatic lobe. Four months later, recurrent and metastatic disease were observed in the remnant liver and right lung, respectively. We performed a hepatectomy for the recurrent lesion because transcatheter arterial chemoembolization (TACE) was not effective. After surgery, we initiated sorafenib treatment for the lung metastases. One year later, the lung metastases worsened and metastases were observed in the mediastinal lymph nodes, and both metastatic lesions were resected. Seven months later, para-aortic lymph nodal metastasis was observed and dissected. Three months later, metastasis to the supraclavicular lymph node was observed. We performed particle radiation therapy and a complete response was achieved. One year later, metastases in both lungs were observed and resected. Despite continued sorafenib administration throughout the clinical course, a metastasis to the left adrenal gland was observed. This lesion was extirpated because no other recurrent lesions were detected. At 4 years and 6 months after the first operation, no other recurrences have occurred. Currently, sorafenib is the initial drug of choice for HCC with extrahepatic metastases. It is possible to improve the prognosis of patients with HCC and extrahepatic metastases by applying surgical treatment during the course of sorafenib administration.

The patient was a 79-year-old man diagnosed with a single 9.3-cm hepatocellular carcinoma (HCC) in the medial segment of the liver, and left iliac bone metastasis. Initially, the patient was treated with a hepatic arterial infusion of low-dose FP (cisplatin/5-fluorouracil) at another hospital. Here, the patient received particle therapy for the left iliac bone metastasis at a total dose of 52.8 Gy in 4 fractions. Subsequently, he underwent medial segmentectomy of the liver to treat the primary HCC. Eleven months later, the first intrahepatic recurrence occurred, and the tumor was treated with percutaneous radiofrequency ablation (RFA). A second intrahepatic recurrence was detected 39 months later, which was also treated with percutaneous RFA. The patient remains well, with no evidence of tumor recurrence.

Recently, the indications for particle beam therapy have been expanded to include metastatic liver tumors. However, its adverse effects on the treated liver are unclear, and the possibility of local recurrence after treatment should not be ignored. A 65-year-old man with advanced rectal carcinoma underwent low anterior resection. Resectable metastatic liver tumors were detected after adjuvant chemotherapy; however, he opted to undergo particle beam therapy. Nine months after treatment, a local recurrence was detected around the treated area, and central bisegmentectomy of the liver was performed as a salvage operation. The operation was technically complicated owing to severe adhesions and inflammatory changes in the liver parenchyma around the treated area. Pathological examination revealed advanced liver fibrosis at the treated area, in contrast with normal parenchyma in the untreated area. Although the procedure requires advanced surgical techniques, salvage surgery is a feasible option for recurrent liver tumors after particle beam therapy.

We report a case of multiple bilobar hepatocellular carcinoma( HCC) that was successfully treated with a multidisciplinary treatment including preoperative percutaneous isolated hepatic perfusion and hepatectomy. The patient was a 61- year-old man who was detected as having HCC mainly in segment 4 and 8 of the liver and multiple bilobar intrahepatic metastasis during follow-up evaluation for chronic hepatitis B. Curative resection was difficult because the patient had insufficient liver function and because of the location of the tumor. Hence, we performed preoperative percutaneous isolated hepatic perfusion (PIHP) to control the multiple HCC. Seven weeks after the PIHP, the tumor size had reduced, and therefore we performed an extended left hepatic lobectomy. In addition to these treatment modalities, we performed transcatheter arterial chemoembolization (TACE) 3 times owing to recurrent HCC in the right liver lobe. Considering that HCC in segment 8 can be treated with TACE, we performed partial hepatectomy. As of the last follow-up visit, the patient was alive without disease recurrence. Thus, preoperative PIHP may improve the resectability rate in patients with multiple bilobar HCC for which curative resection is difficult to perform.

We report a case of postoperative liver metastasis arising from pancreatic carcinoma treated with a novel procedure that we developed-percutaneous isolated hepatic perfusion (PIHP). A 69-year-old man diagnosed with pancreatic body cancer(pT3, pN0, pStage III) was treated using distal pancreatectomy and adjuvant therapy with gemcitabine(GEM). Six months later, a metastasis to the medial segment of the liver was found using computer tomography(CT). The patient was treated by chemotherapy with S-1, but the liver metastasis grew, and we therefore employed PIHP as the third-line therapy, using 80 mg doxorubicin (DXR) and 62 mg mitomycin C (MMC). Six weeks after PIHP, the tumor marker carbohydrate antigen 19-9( CA19-9) had decreased from 44,469 to 4,268 U/mL, and the carcinoembryonic antigen(CEA) level decreased from 28.8 to 5.4 U/mL. Although the size of the carcinoma remained the same on CT, some cells had liquefied as a result of necrosis. However, the patient died about 1 year after PIHP due to the growth of liver metastasis, peritoneal metastasis, and local recurrence, reflected by a progressively increasing level of tumor marker. In this case, PIHP seemed to be ineffective due to local recurrence and peritoneal metastasis as well as early enlargement of liver metastasis. However, the reduction in tumor marker levels and the observed tumor necrosis, suggest that PIHP is a potentially effective and promising treatment for liver metastasis arising from pancreatic carcinoma.

We report a case of bilobar multiple hepatocellular carcinoma (HCC) successfully treated by preoperative percutaneous isolated hepatic perfusion(PIHP) and subsequent hepatectomy. A 77-year-old man with elevated serum PIVKA-II level and hepatomas was referred to our hospital. Abdominal dynamic computed tomography and gadoxetate disodium-enhanced magnetic resonance imaging demonstrated advanced HCCs: 11 tumors with a maximum tumor size of 4.8 cm diameter in the right lobe, and 1 tumor of 3.6 cm diameter in the left lobe. Curative resection was impossible due to insufficient liver function and due to the locations of the tumors. Therefore, we performed preoperative PIHP in order to control the multiple HCCs in the right lobe. This resulted in normalization of serum PIVKA-II level and complete necrosis of all tumors in the right lobe, as observed on dynamic computed tomography after 4 weeks of PIHP. Then, at 7 weeks after PIHP, we performed extended left lobectomy for residual tumor in the left lobe. Finally, complete remission was thought to have been achieved. The patient is alive 6 months after PIHP, without recurrence.