Direct biliopancreatoduodenal invasion by hepatocellular carcinoma: Report of the first resected case and review of the literature

A rare resected case of hepatocellular carcinoma (HCC) invading the duodenum, the common bile duct (CBD), the gallbladder, and the pancreas is described. A 63-year-old man presented with a painful upper abdominal mass. Radiologic findings showed a 25-cm liver tumor arising from segment IV with an invasive extension to the hepatoduodenal ligament and pancreatoduodenal region, with a single intrahepatic metastasis. The patient successfully underwent a left hepatectomy in conjunction with a pylorus-preserving pancreatoduodenectomy (PD). As an unusual procedure, liver parenchymal transection was followed by PD to explore tumor resectability, because the overhanging liver mass precluded full hepatoduodenal ligament dissection. He was discharged without surgical complications, being free from antianalgesics, which had been used preoperatively. The main tumor was histologically diagnosed to be a poorly differentiated HCC with sarcomatous change invading the duodenum, the CBD, the gallbladder, and the pancreas. Unfortunately, aggressive hepatic and nodal recurrence, which was resistant to salvage chemotherapy, caused the patient's death at 8 months postoperatively. This is the first documented case of HCC with biliopancreatoduodenal invasion resected by hepatopancreatoduodenectomy. Literature review suggests a significant role of resection in selected patients with HCC with contiguous gastrointestinal tract invasion, particularly when the HCCs are naive without any forms of previous treatment. However, further surgical and nonsurgical experience is necessary to determine the oncological validity of aggressive surgery for HCC invading the biliopancreatoduodenal region.