peritoneal dissemination of hepatocellular carcinoma ( hcc ) occurs rarely and is usually considered a terminal stage .
dissemination of hcc was shown along the needle biopsy tract to the abdominal wall and by rupture of hcc and as the consequence of cancer peritonitis by tumor recurrence .
it should be considered that needle biopsy of the liver tumor can lead to dissemination to the abdominal wall .
rupture of hcc is fatal and needs emergent treatment , as tumor cells seed into the peritoneal cavity .
cancer peritonitis was shown in most cases with dissemination of hcc . however , dissemination of hcc without cancer peritonitis to the peritoneum apart from a primary tumor has not been reported . in our case
, the primary tumor was not ruptured and we had not performed needle biopsy of the liver tumor . under these circumstances , we diagnosed the liver tumor as hcc based on elevation of tumor markers such as alpha - fetoprotein ( afp ) and protein induced by vitamin k absence or antagonist - ii ( pivka - ii ) .
we report a case of peritoneal dissemination of hcc in which operation improved the patient 's quality of life .
peritoneal dissemination is a rare presentation of hcc , and we should thus examine the characteristics of further cases .
a 74-year - old man was admitted to our hospital because he had palpated a mass in the right lower quadrant region .
laboratory data were zinc sulfate turbidity test 19.2 ku , thymol turbidity test 10.8 ku , afp 86.6 ng / ml and pivka - ii 44.3 g / ml . hbs antigen and hcv antibody were negative .
ultrasonography showed a 3.5  2.6 cm high - echoic mass in the medial segment of the liver ( fig .
1 ) . enhanced computed tomography revealed a low - density area 3 cm in diameter in the same lesion and a giant well - defined mass , 5  10 cm in size , continuing from the diaphragm to left kidney between the stomach and spleen ( fig .
2 ) . angiography showed a hypervascular tumor in the medial segment of the liver .
fluoroscopy showed a tortuous lesion from the fundus to the superior of body of the stomach .
endoscopic retrograde cholangiopancreatography did not detect abnormal findings . laparotomy did not reveal ascites or blood in the peritoneal cavity . in the medial segment of the liver , there was a 3  3 cm tumor evaginated to the diaphragm .
there were another 5  5 cm tumor evaginated from left diaphragm and a 7  7 cm tumor at the hilum of the spleen . both tumors were not continuous and separated .
then we performed partial hepatectomy and resected the tumor of the diaphragm , the tumor of the hilum of the spleen with tail of the pancreas and spleen , and the tumor of the greater omentum .
, 2 years after the surgery , the patient remains alive without any evidence of recurrence .
peritoneal dissemination of hcc is rare and has been observed rarely in surgical patients . as a consequence of needle biopsy or rupture of the primary tumor , peritoneal dissemination
is essentially limited to the late stage of hcc [ 1 , 2 , 3 , 4 ] . in our case
, the primary liver tumor was not ruptured and we had not performed needle biopsy .
thus , our case is very rare . surgical treatment has been felt to be of little value in improving survival . despite recent advances in the
diagnosis and surgical management of hcc , no effective treatment for late - stage peritoneal metastases has been developed . occasionally , systemic chemotherapy was effective in cases of peritoneal dissemination of hcc .
miyake et al .   reported a case who developed peritoneal dissemination of hcc after hepatectomy , in whom marked tumor regression was found with a combination therapy of interferon - alpha-2b and oral tegafur / uracil .
there are some reports contributing to a patient 's life prognosis by surgical treatment [ 6 , 7 , 8 ] . in this case , we believe that resection of peritoneal dissemination prolonged survival with a good quality of life .
peritoneal dissemination is a rare presentation of hcc , with a reported incidence of 216% in autopsy or laparoscopy cases .
nakashima et al .   reported intraperitoneal dissemination such as diaphragm , douglas pouch , pancreas , spleen and gallbladder .
moreover , the rate of peritoneal dissemination of hcc was considered to be higher in cases with liver cirrhosis compared to no liver cirrhosis .
the mechanism of peritoneal dissemination from hcc was thought to be a rupture of exophytic hcc into the peritoneal cavity and subsequent seeding of metastatic deposits [ 10 , 11 ] .
however , yeh et al .   reported that only 4 ( 25% ) of 16 patients had peritoneal dissemination from preexisting ruptured hcc .
histopathologically , peritoneal dissemination of hcc is considered to be undifferentiated or poorly differentiated type . in our case ,
the primary lesion was a 3  3 cm tumor and an unruptured hcc , and all of the resected tumors were of well - differentiated type and steatosis .
yeh et al .   revealed that the afp values of patients developing peritoneal dissemination from hcc after hepatectomy were high ( mean 3,311.3 ng / ml ) .
tumor markers such as afp played an important role in indicating the presence of peritoneal dissemination from hcc .
furthermore , yeh and chen   reported that a high afp level and capsular invasion by the tumor cells may predispose posthepatectomy patients to peritoneal implantation from their hccs . in conclusion , even when disseminated hcc is found , surgical treatment should be considered for selected patients , provided that the lesions are discretely located .
 treatment for the peritoneal dissemination of hepatocellular carcinoma ( hcc ) has not yet been established . 
 we report a patient with hcc associated with disseminated intra - abdominal tumor . 
 a 74-year - old man was admitted to our hospital . 
 computed tomography showed a 3  3 cm mass in the left hepatic lobe and a giant mass between the stomach and spleen . at laparotomy 
 , the tumor was seen in the medial segment and evaginated to the diaphragm . 
 there was a tumor between the stomach and spleen , confirmed as a 5  5 cm tumor evaginated from the left diaphragm , and a 7  7 cm tumor adhesive to the spleen . 
 these two tumors were not continuous and were separated . 
 furthermore , we confirmed a 10  10 cm tumor in the pelvic cavity . 
 we performed partial hepatectomy , resection of the tumor evaginated from the diaphragm , resection of the tumor of the spleen and tail of pancreas , and resection of the tumor in the pelvic cavity . 
 histopathologically , all resected tumors were confirmed to be well - differentiated hcc . 
 hcc rarely disseminates intraperitoneally . 
 it is considered that the peritoneal dissemination of hcc occurred from poorly differentiated or undifferentiated type . 
 then this report is a rare case . 
 although surgical treatment of peritoneal dissemination of hcc is not curative , surgery may improve survival and provide good quality of life in selected cases . 
Introduction
Case Report
Discussion