title: Huge hepatocellular carcinoma with multiple intrahepatic metastases: An aggressive multimodal treatment.
abstract: BACKGROUND
  Huge hepatocellular carcinoma (HCC) possesses a potential risk for spontaneous rupture, which leads to a life-threatening complication with a high mortality rate. In addition, a large HCC is frequently accompanied by intrahepatic metastases.
  
  
  METHODS
  We describe, the case of a 74-year-old woman with a huge extrahepatically expanding HCC with multiple intrahepatic metastases who was treated by liver resection with repeated transcatheter arterial chemoembolization (TACE). To prevent tumor rupture or bleeding, we performed right hepatectomy. After the operation, TACE was applied for multiple intrahepatic metastases in the remnant liver. Furthermore, the elevated protein induced vitamin K absence (PIVKA II) level had decreased to limits within the normal range. Three months after the first TACE, computed tomography revealed several recurrences in the liver. TACE was applied for the second and third time and the tumors were well controlled.
  
  
  CONCLUSIONS
  Although, liver resection is occasionally performed for patients with huge HCC to avoid spontaneous tumor rupture, only surgical approach might not be sufficient for such advanced HCC. To achieve long-term survival, it is necessary to control the residual intrahepatic tumors. We could control multiple intrahepatic metastases with repeated TACEs after hepatectomy.
  
  
  CONCLUSIONS
  Multimodal treatment involving hepatectomy and TACE might be a good treatment strategy for patients with huge HCC with multiple intrahepatic metastases if the tumors are localized in the liver without distant or peritoneal metastasis.
authors.affiliation: Department of Surgery, Nara Medical University, 840 Shijo-cho Kashihara-shi, 634-8522 Nara, Japan.
authors.forename: Satoshi
authors.initials: S
authors.lastname: Yasuda
authors.affiliation: Department of Surgery, Nara Medical University, 840 Shijo-cho Kashihara-shi, 634-8522 Nara, Japan. Electronic address: t.nomi45@gmail.com.
authors.forename: Takeo
authors.initials: T
authors.lastname: Nomi
authors.affiliation: Department of Surgery, Nara Medical University, 840 Shijo-cho Kashihara-shi, 634-8522 Nara, Japan.
authors.forename: Daisuke
authors.initials: D
authors.lastname: Hokuto
authors.affiliation: Department of Surgery, Nara Medical University, 840 Shijo-cho Kashihara-shi, 634-8522 Nara, Japan.
authors.forename: Ichiro
authors.initials: I
authors.lastname: Yamato
authors.affiliation: Department of Surgery, Nara Medical University, 840 Shijo-cho Kashihara-shi, 634-8522 Nara, Japan.
authors.forename: Shinsaku
authors.initials: S
authors.lastname: Obara
authors.affiliation: Department of Surgery, Nara Medical University, 840 Shijo-cho Kashihara-shi, 634-8522 Nara, Japan.
authors.forename: Takatsugu
authors.initials: T
authors.lastname: Yamada
authors.affiliation: Department of Surgery, Nara Medical University, 840 Shijo-cho Kashihara-shi, 634-8522 Nara, Japan.
authors.forename: Hiromichi
authors.initials: H
authors.lastname: Kanehiro
authors.affiliation: Department of Surgery, Nara Medical University, 840 Shijo-cho Kashihara-shi, 634-8522 Nara, Japan.
authors.forename: Yoshiyuki
authors.initials: Y
authors.lastname: Nakajima
keywords: Hepatectomy; Hepatocellular carcinoma; Huge tumor; Intrahepatic; Multimodal treatment; Transcatheter arterial chemoembolization; metastases