The patient was a 32-year-old woman who was 37-week pregnant (third time) and was admitted to the Bach Mai Hospital (Hanoi, Vietnam) due to epigastric pain, chest pain, and difficulty of breathing. Physical examination showed that the size of the uterus was appropriate for a gestational age of 37 weeks, with normal fetal heartbeat and no contractions. Additionally, a non-mobile, painless, 20-cm tumor was detected in the left liver, which was present since the previous year (<3 cm) but was not treated due to the patient's unwary of the importance of early treatment and poor economic conditions.
Blood tests showed an increase in total alpha-fetoprotein (AFP) of 1085 ng/mL, and other indicators were present at normal levels (AFP, L3 0.3%; Prothrombin induced by the absence of vitamin K or antagonist-II (PIVKA-II) 32 mAU/mL; red blood cells 3.76 T/L; white blood cells 9.6 g/L; platelet count, 184 g/L; prothrombin, 109% urea 3.2 mmol/L; creatinine, 51 mumol/L; total protein, 69.1 g/L; albumin, 35.4 g/L; total bilirubin, 9.6 mumol/L; serum AST, 35 U/L; serum ALT, 11 U/L). Magnetic resonance imaging (MRI) indicated that a large tumor (12 x 14 x 18 mm) in the left liver, with organ signals increased for T2-weighted (Figure 1) and decreased for T1-weighted (Figures 2 and 3). The mass had a lobe, developed along a downward pattern, and did not invade the portal vein. However, it compressed the lower part of the uterus, gallbladder, and pancreas. There was no free abdominal fluid, and the right liver did not show any tumors.
Fetal ultrasound showed a fetal heart of 127 times/minute, bipolar diameter of 92 mm, femoral length of 70 mm, head-to-toe length of 48.5 mm, head circumference of 329 mm, waist circumference of 328 mm, and fetal weight of 3287 g. The amniotic fluid was normal, the placenta was attached to the back of the uterus, and there were no fetal or uterine abnormalities noted.
This case was consulted by related specialists of surgery, obstetrics, resuscitation, radiology, nuclear medicine, oncology, pathology, pediatrics, and gastroenterology. As discussed, the expected surgical methods for this patient were a cesarean section, hysterectomy if the uterus had a poor contraction, and left hepatectomy. These were performed consecutively.
The middle linear alba below the navel was opened to deliver the neonate, weighing 3100 g. As for the mother, because the uterus was bleeding and contracting poorly, partial hysterectomy was performed. Subsequently, the surgical team extended the abdominal incision to the sternum. The abdomen was dry with no signs of metastasis to the peritoneum, and the right liver was soft with a pink color. The large tumor developed in the left liver lobe, encroaching on the inferior part of segment IV, with downward convex development which compressed the stomach and the transverse colon. Complete hepatic pedicle control was performed once in 15 min. A left hepatectomy including the inferior segments II, III, and IV was performed according to the Ton That Tung method. The liver veins and left liver pedicles were resected with a blood vessel stapler of 35 mm. The total weight of the resected tumor was 3000 g. Due to the 350 mL blood loss during the hepatectomy, 700 mL of red blood cells and 250 mL of fresh plasma was transfused during surgery. The surgery was performed safely and without any complications within 120 minutes in June 2020.
Postoperatively, the patient was awake and was able to ingest liquid food after 48 hours. Her skin and mucosa remained pink, the abdomen was soft, and the incision was dry and clean. Douglas drainage was withdrawn on the third postoperative day, and subhepatic drainage was removed on the fifth postoperative day. Blood tests on the first, third, and fifth postoperative days showed normal results. Biochemical and hematology tests on the third and fifth postoperative days were also within the normal ranges. The patient was discharged from the hospital after 10 days. One month after surgery, the patient received six courses of chemotherapy (one course lasted 3 weeks). Six months after surgery, chemotherapy was completed, and the patient was completely healthy.
The patient's patho-biological characteristics showed that the left liver had dimensions of 20 x 16 x 12 mm, and a tumor (16 x 13 x 12 mm) approximately 1 cm from the liver section. The cross-section was soft and gray, and the necrosis was wide at 70%. The tumor structure consisted of a polyhedron and elongated rhombohedral cells with coarse chromatin and multiple monstrous nuclei. Tumor cells were in clumps or rafts and separated by thin-walled blood vessels. Invasive vascular injury was not observed. The remaining resected areas of the liver did not contain any more of the tumor (Figure 4). Immunohistochemical staining showed positive CD34 (Figure 5), negative CD117, negative Dog-1, negative glypican, positive CK (Figure 6), and CD99 (Figure 7).