CARTAS AL DIRECTOR

 

Ruptured caudate lobe hepatocellular carcinoma presents with lesser sac tumor

Carcinoma hepatocelular del lóbulo cuadrado roto que se presenta como tumor

 

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Palabras clave: Carcinoma hepatocelular. Lóbulo caudado. Resección. Saco menor.

Key words: Hepatocellular carcinoma (HCC). Caudate lobe. Rupture. Lesser sac.

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Sr. Director:

The lesser sac is located anterior to the pancreas and immediately posterior to the body of the stomach (1-3). Caudate lobe liver and splenic artery are also the parts of the lesser sac (4). A fluid collection in the lesser sac in not a typical manifestation of benign ascites, and its presence should direct a search for a pathologic condition in neighboring organs (5). We present a 38-year-old male complained of abdominal pain for one week. Contrast enhanced CT of abdomen demonstrated one heterogeneous enhancement 7.5 cm mass with central necrosis in the caudate lobe liver, and hematoma over lesser sac were found.

 

Case report

A 38-year-old male, hepatitis-B carrier for ten years, complained of abdominal pain for one week. After admission, physical examination revealed tenderness pain over periumbilical region. General laboratory examinations revealed hemoglobin 10.1 mg/dL, platelet count 59,000/uL, aspartate aminotransferase 54 IU/L, alanine aminotransferase 37 IU/L and alpha-fetoprotein 54 ng/mL. Contrast enhanced CT of abdomen showed one heterogeneous enhancement mass about 7.5 x 7.0 x 7.2 cm with central necrosis in the segment 1 of liver (Fig. 1, black arrow). Another cystic lesion about 8.2 x 7.9 x 11 cm over the retrogastric region (Fig. 1, white arrow). A laparotomy with left lobectomy and removal of caudate lobe tumor was carried out (Figs. 2 A & B), caudate lobe hepatocellular carcinoma (HCC) with rupture and hematoma formation in the pancreatogastric portion of the lesser sac were found intraoperatively. The histology of caudate lobe tumor showed HCC.

 

Discussion

The lesser sac is the abdominal cavity formed by the lesser and greater omentum. It is connected with the greater sac via the epiploic foramen. Acute pancreatitis and its complications are the most common underlying causes of lesser sac lesions (6,7).

CT of abdomen is useful to confirm the differential diagnosis.

Our case was a hepatitis-B carrier, presented with abdominal pain for one week. Contrast enhanced CT of abdomen showed one heterogeneous enhancement mass with central necrosis in the caudate lobe liver and the differential diagnosis may include primary hepatoma, retroperitoneum or diaphragmatic crural origin tumor, such as: leiomyosarcoma, or malignant fibrous histiocytoma. The differential diagnosis of another cystic lesion over the retrogastric region may include pancreatic pseudocyst or duplication cyst of stomach. In viewing of the history, clinical symptoms and the hematoma lesion in the lesser sac could be traced from the caudate lobe HCC, rupture of caudate lobe liver was the first impression.

This case draws our attention to a condition that rupture of caudate lobe HCC could present with hematoma of lesser sac

 

C. H. Lin, H. F. Hsieh¹, S. J. Chou², J. C. Yu, T. W. Chen and C. B. Hsieh

Division of General Surgery. Department of Surgery, Tri-Service General Hospital.
National Defense Medical Center. Taipei, Taiwan. ¹Department of Surgery. Yee-Zen General Hospital.
Taoyuan. Taiwan, Republic of China. ²Department of Surgery. Cardinal Tien Hospital. Taipei, Taiwan

 

References

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6. Jeffrey RB, Federle MP, Goodman PC. Computed tomography of the lesser peritoneal sac. Radiology 1981; 141: 117-22.

7. Siegelman SS, Copeland BE, Saba GP, Carmeron JL, Sanders RC, Zerhouni EA. CT of fluid collections associated with pancreatitis. AJR Am J Roentgenol 1980; 134: 1121-32.