case_images: PMC2798618_01
case_images: Preoperative findings. CT shows a heterogenous mass ((a)-(c), arrow), 9 cm in diameter adjacent to the remnant liver (a), displacing the IVC (b) and the pericardium (c). Angiography shows that the remnant liver is supplied by the left hepatic artery (d). Selective angiograms show a hypervascular tumor supplied from the descending branch of the inferior phrenic artery (IPA) (e) and the phrenic branch of the internal mammary artery (IMA) (f).
case_images: JO2009-231854.001.jpg
case_images: PMC2798618_01_JO2009-231854.001.jpg
case_images: fig1
case_images: Computed tomography (CT) revealed a heterogenous mass, 9 x 7 cm in diameter, in the remnant liver (Figure 1(a)). The mass had expanded to the adjacent organs, inferior vena cava (IVC) (Figure 1(b)) and the pericardium (Figure 1(c)), indicating a diagnosis of intrahepatic recurrence from HCC. Angiography revealed that the remnant liver was supplied by left hepatic artery with no tumor stain (Figure 1(d)). Because selective angiograms showed a hypervascular tumor supplied from the descending branch of the inferior phrenic artery (IPA) (Figure 1(e)) and the phrenic branch of the internal mammary artery (IMA) (Figure 1(f)), transcatheter arterial embolization (TAE) was selected first.
case_images: Images and schematic presentations of operative findings and procedures. By opening the pericardium, the tumor was found to be located between the remnant liver and the heart, and the diaphragm was displaced to the upper side ((a), (b)). Due to a median sternotomy with opening of the pericardium, the tumor was pulled to the right (c). The pericardium was divided from the dorsal aspect of the tumor to the left wall of the IVC (d). A complete resection can be achieved (e). Defects of the diaphragm and the pericardium were repaired ((f)-(h)).
case_images: JO2009-231854.002.jpg
case_images: PMC2798618_01_JO2009-231854.002.jpg
case_images: fig2
case_images: Because it was difficult to identify the whole aspect of the tumor from just the abdominal upper midline incision, an additional median sternotomy was carried out (Figures 2(a) and 2(b)). Since the adhesion on the central tendon was too complete to separate, the crus was ligated (Figure 2(c)). In the opened pericardial cavity, the pericardium was transected to expose the posterior side of the tumor from the IVC (Figure 2(d)), and following transection of the posterior parietal peritoneum, the specimen was removed (Figure 2(e)). The diaphragm was sutured and the defect in the pericardium was repaired using a composix mesh (Figures 2(f)-2(h)).
case_images: Resected specimen. The tumor is covered with the diaphragm at the cranial edge with no infiltration (a). The cut surface shows focal necrosis induced by preoperative TAE (b). The tumor is composed of moderately differentiated HCC with a thick trabecular pattern (c). The diaphragm is displaced with no infiltration to the muscular layer ((d), arrow).
case_images: JO2009-231854.003.jpg
case_images: PMC2798618_01_JO2009-231854.003.jpg
case_images: fig3
case_images: Macroscopically, the resected tumor, at 9.5 x 7.4 cm (Figure 3(a)), was covered with fibrous tissue (diaphragm) without evidence of infiltration and expansive necrosis was detected (Figure 3(b)). The tumor comprised moderately differentiated HCC showing a thick trabecular pattern and focal pseudogland formation (Figure 3(c)) and also the displaced muscular layer of the diaphragm was observed (Figure 3(d), arrow).