title: Surgical resection of recurrent extrahepatic hepatocellular carcinoma with tumor thrombus extending into the right atrium under cardiopulmonary bypass: a case report and review of the literature.
abstract: BACKGROUND
  Recurrent hepatocellular carcinoma accompanied by a right atrial tumor thrombus is rare. No standard treatment modality has been established. Surgical treatment may be the only curative treatment; however, surgery has been considered high risk. We herein describe a patient who underwent resection of a recurrent right atrial tumor thrombus under normothermic cardiopulmonary bypass on a beating heart.
  
  
  METHODS
  A 60-year-old man underwent a right hepatectomy for hepatocellular carcinoma with diaphragm invasion. During the preoperative cardiac screening, he was diagnosed with an old myocardial infarction with triple-vessel coronary disease. Percutaneous coronary intervention was performed for the left anterior descending artery and left circumflex coronary artery. High-grade stenosis remained in his right coronary artery. Nine months later, computed tomography showed recurrent hepatocellular carcinoma in the diaphragm and a tumor thrombus extending from the suprahepatic inferior vena cava into the right atrium. Surgical resection of the recurrent tumor was performed through a right subcostal incision with xiphoid extension and median sternotomy. The recurrent tumor was incised with the diaphragm and pericardium. Intraoperative ultrasonography revealed that the tumor thrombus was free from right atrium wall invasion and that the right atrium could be clamped just proximal to the tumor thrombus. The right atrium, infrahepatic vena cava, left and middle hepatic veins, and hepatoduodenal ligament were encircled. Cardiopulmonary bypass was performed to prevent ischemic heart disease caused by intraoperative hypotension. Total hepatic vascular exclusion was then performed under normothermic cardiopulmonary bypass on heart beating. The inferior vena cava wall was incised. The tumor thrombus with the diaphragmatic recurrent tumor was resected en bloc. The patient had a favorable clinical course without any complications.
  
  
  CONCLUSIONS
  The recurrent hepatocellular carcinoma in the diaphragm and the right atrial tumor thrombus were safely resected using normothermic cardiopulmonary bypass on heart beating.
authors.affiliation: Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, 1-1 Seiryou, Aoba, Sendai, 980-8574, Japan. mineto@med.tohoku.ac.jp.
authors.forename: Mineto
authors.initials: M
authors.lastname: Ohta
authors.affiliation: Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, 1-1 Seiryou, Aoba, Sendai, 980-8574, Japan.
authors.forename: Chikashi
authors.initials: C
authors.lastname: Nakanishi
authors.affiliation: Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, 1-1 Seiryou, Aoba, Sendai, 980-8574, Japan.
authors.forename: Naoki
authors.initials: N
authors.lastname: Kawagishi
authors.affiliation: Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, 1-1 Seiryou, Aoba, Sendai, 980-8574, Japan.
authors.forename: Yasuyuki
authors.initials: Y
authors.lastname: Hara
authors.affiliation: Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, 1-1 Seiryou, Aoba, Sendai, 980-8574, Japan.
authors.forename: Kai
authors.initials: K
authors.lastname: Maida
authors.affiliation: Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, 1-1 Seiryou, Aoba, Sendai, 980-8574, Japan.
authors.forename: Toshiaki
authors.initials: T
authors.lastname: Kashiwadate
authors.affiliation: Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, 1-1 Seiryou, Aoba, Sendai, 980-8574, Japan.
authors.forename: Koji
authors.initials: K
authors.lastname: Miyazawa
authors.affiliation: Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, 1-1 Seiryou, Aoba, Sendai, 980-8574, Japan.
authors.forename: Satoru
authors.initials: S
authors.lastname: Yoshida
authors.affiliation: Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, 1-1 Seiryou, Aoba, Sendai, 980-8574, Japan.
authors.forename: Shigehito
authors.initials: S
authors.lastname: Miyagi
authors.affiliation: Division of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryou, Aoba, Sendai, 980-8574, Japan.
authors.forename: Yukihiro
authors.initials: Y
authors.lastname: Hayatsu
authors.affiliation: Division of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryou, Aoba, Sendai, 980-8574, Japan.
authors.forename: Shunsuke
authors.initials: S
authors.lastname: Kawamoto
authors.affiliation: Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Graduate School of Medicine, Tohoku University, 1-1 Seiryou, Aoba, Sendai, 980-8574, Japan.
authors.forename: Yasushi
authors.initials: Y
authors.lastname: Matsuda
authors.affiliation: Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Graduate School of Medicine, Tohoku University, 1-1 Seiryou, Aoba, Sendai, 980-8574, Japan.
authors.forename: Yoshinori
authors.initials: Y
authors.lastname: Okada
authors.affiliation: Division of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryou, Aoba, Sendai, 980-8574, Japan.
authors.forename: Yoshikatsu
authors.initials: Y
authors.lastname: Saiki
authors.affiliation: Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, 1-1 Seiryou, Aoba, Sendai, 980-8574, Japan.
authors.forename: Noriaki
authors.initials: N
authors.lastname: Ohuchi
keywords: Cardiopulmonary bypass; Hepatocellular carcinoma; Recurrence; Right atrial tumor thrombus