A 79-year-old Caucasian man presented with profuse asthenia, unintentional weight loss (around 20 kg) over the last 3 months, and abdominal chronic pain in the right hypochondrium. He denied alcohol abuse and smoking. The past medical history reported essential hypertension under pharmacological treatment, sigmoid diverticulosis, and cholelithiasis. Physical examination revealed a treatable abdomen, aching on the deep palpation in the right hypochondrium, where the inferior margin of the liver was appreciated 5 cm below the costal arch and a hard irregular mass was recognized. No cervical, axillary, or inguinal lymphadenopathy were appreciated. A dermatological counselling excluded skin lesions. Digital rectal examination was negative. Breathing sound was clear without wheezing or crackle. The remaining physical examination was normal.
Blood tests showed ALT 91 U/l, GGT 308 U/l, total bilirubin level 1.7 mg/dl, Ca 19-9 1956 U/ml, AFP 1.6 ng/ml, CEA 12 U/ml.
Upper endoscopy and colonoscopy excluded esophago-gastric and colorectal lesions, respectively. Abdominal computed tomographic scan (CT-scan) showed a large hypodense liver mass in the right lobe (15 cm × 12 cm in size) on both arterial and portal phases involving the IV-V-VI-VII-VIII segments (Fig. 1a,b) which presented colliquative areas of necrosis within the lesion. Mild dilatation of intrahepatic biliary ducts was observed. Multiple isolated liver cysts were described in both lobes. Moreover, the lesion was very close to the gallbladder, which showed wall thickening and enhanced endoluminal tissue of uncertain origin. The cystic duct was enlarged, and focal endoluminal tissue was detected. Some enlarged lymph nodes in the right sub-diaphragmatic space were reported.
The radiologist, based on these findings, hypothesized the suspicion of gallbladder cancer or intrahepatic cholangiocarcinoma mass forming. A liver biopsy was performed under local anesthesia via combined US/CT guidance. The interventional radiologist used core needle biopsy device (Monopty 18G × 16 cm, BARD, Arizona, USA). Two specimens were collected. No complication occurred.
Histopathological analysis of the liver mass showed a well-differentiated squamous cell carcinoma with diffuse necrosis. Immunohistochemical staining was positive for cytokeratins (CK) 7, 19, and p63; anti-hepatocyte, MUC-5, TTF-1 were negative, suggesting the tumor as primary or metastatic squamous cell carcinoma of the liver (Figs. 2a–d and 3).
After the surprising and unexpected pathological report, a PET/CT scan was performed in order to rule out the presence of another primitive unknown tumor. The examination showed a single area of increased uptake in the right lobe of the liver, corresponding to the tumor mass. The uptake was inhomogeneous with the central part of the mass showing weak or no uptake and the peripheral regions showing an intense uptake. This finding could confirm the presence of areas of colliquative necrosis and areas of active neoplasm, as shown in Fig. 4. No other anatomic regions of altered metabolic captation were discovered. Therefore, the diagnosis of primary squamous cell carcinoma of the liver was confirmed.
After a multidisciplinary meeting involving surgeons, radiologists, oncologists, and hepatologists, the case was accurately discussed and the different treatment options were evaluated. The patient was initially scheduled for major liver resection (extended right hepatectomy after portal venous embolization), but he refused it. In consideration of the size of the mass and the paucity of scientific recommendations, a mini-invasive radiological approach was considered appropriate. A combined approach was proposed: percutaneous transhepatic microwave ablation and transarterial chemoembolization (TACE).
On the same day, the interventional radiology team performed microwave ablation via US guidance, with two different probes at 100 W of energy for 9 min (Evident™ MW Ablation System, Medtronic, Minneapolis, MN, USA) and transarterial chemoembolization (TACE). TACE was performed via left radial artery access, using Simmons 1 catheter and hydrophilic guidewire to negotiate the celiac axis and the proper hepatic artery. Unfortunately, celiac axis dissection was observed during angiographic study and the procedure was completed negotiating the hepatic artery via collateral hypertrophic vessels arising from the superior mesenteric artery. Arteriography of the right hepatic artery showed no relevant hypervascular mass as expected. Some anarchic and tortuous arteries were confirmed as tributaries of the mass (Fig. 5) and then embolized with microparticles (150–300 μm). The immediate post-procedural course was uneventful. The patient presented a global improvement of his quality of life in terms of abdominal pain relief. He was discharged with a poor prognosis.
At 1-month follow-up, an abdominal CT scan did not show significant differences, After the sixth month, the patient developed obstructive jaundice with significant dilatation of intrahepatic biliary system; the liver mass had grown and a percutaneous transhepatic biliary drainage was put in.
He died 9 months later.
