In our case report, a 55-year-old male patient was admitted to our department for recurrent pain in the upper-middle abdomen, which had started 2 years earlier and was aggravated with jaundice for 3 days. The patient complained of pain and discomfort that often radiated to the back and was accompanied by nausea and vomiting. Three days before admission, the pain flared up again, chills and fever were accompanied, and jaundice followed. The patient's prior medical history is as follows. In 2009, he received right posterior sectionectomy for primary liver cancer. In 2015, he received TACE and radiofrequency ablation for the treatment of recurrent HCC. In the meantime he took Sorafenib for one year. (Figure 1). Physical examination showed that the patient had skin and scleral jaundice and tenderness in the right upper quadrant. Laboratory tests indicated the following: white blood cell count (WBC) 16.47 x 109/L, neutrophil ratio (NEUR) 94.9%; albumin (ALB) 37.1 g/L, total bilirubin (TB) 125.7 mumol/L, direct bilirubin (DB) 72.9 mumol/L, aspartate aminotransferase (AST) 111.5 U/L, alanine transferase (ALT) 355.8 U/L, gamma-glutamyltransferase (GGT) 289.1 U/L; serum alpha-fetoprotein (AFP) 401.23 ng/ml; prothrombin time (PT) 18.8 s, prothrombin time international normalized ratio (PT-INR) 1.64; procalcitonin (PCT) 4.77 ng/ml, and interleukin-6 (IL-6) 201.5 pg/ml. Hepatitis B surface antigen and hepatitis C virus antibody were negative. An abdominal computed tomography (CT) scan showed that the lesion filled the gallbladder cavity. The wall of the lower segment of the common bile duct was thickened. Liver cirrhosis was also revealed. This gallbladder tumor showed punctate enhancement in the hepatic arterial phase and then became less dense than the liver parenchyma in the portal phase (Figure 2). No regional lymph nodes were enlarged.
The preoperative diagnosis was considered gallbladder tumor with acute cholangitis, which was potentially malignant. Therefore, hepatectomy of segment IVb, cholecystectomy and common bile duct exploration were planned in this case. Intraoperative exploration revealed extensive intraperitoneal adhesions and gallbladder enlargement with dimensions of 12 cm x 4 cm x 3 cm. The gallbladder was solid and tough, while the liver was soft. Because there was no metastasis to the lymph nodes or peritoneum, we performed a monobloc resection of the gallbladder and hepatic segment IVb, and common biliary duct exploration was also performed. The frozen section of the intraoperative specimen indicated a malignant tumor (gallbladder lumen occupying) and probable metastasis of HCC. Subsequent biliary exploration found several stones in the lower part of the common bile duct. After the stones were removed, the lower part of the common bile duct was observed with a choledochoscope, and no tumor invasion or neoplasm was found. Macroscopically the diseased gallbladder appeared to be filled with white soft tumor tissue, and some tissue had extended along the cystic duct to the common bile duct (Figure 3A). The operative time was 360 min, and blood loss was 200 ml. The postoperative paraffin histopathology and immunohistochemistry showed a moderately differentiated HCC with necrosis (Figure 3B). The final diagnosis was amended to HCC recurrence in gallbladder, choledocholithiasis and acute cholangitis. Antibiotics and hepatoprotective drugs were used in postoperative management, and the patient recovered uneventfully within 10 days.
The follow-up showed that the patient was in good condition and survived more than 40 months with no signs of tumor recurrence. To date, the patient has not taken any targeted drugs and immunotherapy drugs we recommended for treatment after surgery. The patient refused the medication because of the significant side effects of sorafenib at the time of the first relapse.
HBV, hepatitis B virus; HCV, hepatitis C virus; Alc, alcoholic hepatitis; Mt, multiple tumors; St, single tumor; NA, not available; S, synchronous; M, metachronous; GBTT, gallbladder vein tumor thrombus; MIG, massive intragallbladder growth; mp, muscularis propria; m-mp, mucosal layer-muscle layer; sm, submucosal layer; Mod, moderate; mo, month.