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Polypoid Metastatic Hepatocellular Carcinoma of the Esophagus
Occurring After Endoscopic Variceal Band Ligation
K. Kume, I. Murata, I. Yoshikawa, K. Kanagawa, M. Otsuki
Third Department of Internal Medicine, University of Occupational and Environmental Health,
School of Medicine, Kitakyusyu, Japan
This report describes a rare case of metastatic hepato- An endoscopic examination revealed a semipedunculat-
cellular carcinoma (HCC) presenting as a polypoid ed polypoid mass at the lower part of the esophagus,
mass in the lower esophagus after endoscopic variceal where EVL had been performed 3 months previously.
band ligation (EVL). A 56-year-old man underwent The histologic examination at autopsy revealed that the
EVL for variceal bleeding in September 1993. He pre- polypoid mass consisted of metastatic HCC that had
sented with dysphagia and tarry stool in December 1993. spread via the retrograde portal flow.
Introductions A physical examination on admission revealed anemia and
purpura at the anterior chest, and his abdomen was tender.
Hepatocellular carcinoma (HCC) frequently invades the Laboratory studies revealed anemia (Hb 7.3 g/dl), thrombo-
vascular spaces of the liver. Hematogenic metastasis of cytopenia (4000/mm3), hypoalbuminemia (3.2 g/dl), hyper-
HCC may subsequently occur through the systemic vessels bilirubinemia (total bilirubin 1.5 mg/dl) and a high level of
or the portal system. Portal blood flow can be reversed by a-fetoprotein (12 200 ng/ml). A coagulation work-up
increased intrahepatic resistance and arteriovenous commu- showed a prothrombin rate of 71.9 % and partial thrombo-
nications in patients with liver cirrhosis associated with plastin of 33.2 seconds (control, 30.7 seconds).
HCC, which may cause retrograde metastasis of HCC via
the portal system [1 ± 4]. We present here a rare case of Esophagoscopy showed an oozing semipedunculated poly-
esophageal metastasis from HCC through the portal sys- poid mass covered with thick white exudate in the lower
tem, at a site where endoscopic variceal band ligation part of the esophagus, where EVL had been done in Sep-
(EVL) had been performed. tember 1993. The base and margin of the polypoid mass
were slightly elevated, and the surrounding area was cov-
Case Report ered with normal mucosa, suggesting submucosal tumor
growth (Figure 1). Endoscopic biopsy was not performed,
A 56-year-old man was admitted to our hospital with dys- because of the risk of bleeding. At this time, the endo-
phagia and tarry stools on December 27, 1993. He had first scopic findings suggesting the presence of the tumor be-
presented with liver dysfunction and was diagnosed as hav- neath the submucosal layer indicated the possibilities of
ing chronic hepatitis due to prior infection in April 1987 unusual overgrowth of granulation tissue following EVL,
by hepatitis B virus. Subsequently, esophageal varices with or metastatic tumor from HCC. Esophageal varices disap-
risk signs had developed in December 1988, and multiple peared completely in the proximal esophagus.
HCCs occupying the right lobe of the liver were noticed
in April 1992. He had undergone endoscopic injection A computed tomography (CT) scan of the chest showed
sclerotherapy in December 1988, and EVL in September thickening of the lower part of the esophageal wall, and
1993, for variceal bleeding. In addition, transcatheter multiple nodules in both lungs, suggesting esophageal and
arterial embolization was performed for HCC in April pulmonary metastases of HCC. Abdominal ultrasonogra-
1992 and March and October 1993. phy and CT demonstrated multiple nodules occupying the
entire liver with portal vein tumor thrombi. Bone scintigra-
phy revealed a metastatic lesion in the 9th vertebra.
At 2 months after admission, the patient died of hepatic
Endoscopy 2000; 32 (5): 419 ± 421
Georg Thieme Verlag Stuttgart New York
· failure with progression of HCC. At autopsy, widespread
ISSN 0013-726X invasions and metastases of HCC were found in the esoph-
420 Endoscopy 2000; 32 Kume K et al
agus, the portal vein, the spleen, the gallbladder, the com- Discussion
mon bile duct, the diaphragm, the bilateral adrenal glands,
and both lungs. In the portal system, tumor emboli were Autopsy and surgical series have suggested the presence of
found in the portal, left gastric, and splenic veins, as well metastases of HCC in the lung (18.1 ± 49.2 %), the lymph
as esophageal varices. A yellowish friable polypoid mass nodes (26.5 ± 41.7 %), bone (4.2 ± 16.3 %), and the adrenal
was found in the lower esophagus (Figure 2). Histologic glands (8.4 ± 15.4 %) [5 ± 8]. Metastasis to the esophagus is
examination showed the mass in the esophagus to be com- extremely rare, being present in less than 0.4 % of patients
posed of a moderate differentiated HCC with the same his- with HCC [5 ± 8]. HCC may spread by metastasis via the
tologic appearance as the primary liver tumors, and multi- blood or lymph stream, peritoneal dissemination, or direct
ple tumor emboli occupied the variceal lumina beneath the invasion. The bloodborne metastasis of HCC may occur
mass in the esophageal wall (Figure 3 a ± c). through the systemic vessels [9] or the portal vein [4].
HCC frequently invades the blood vessels, because the tu-
Figure 1 An esophagoscopic image Figure 2 The gross appearance of the tumor with the esophagus
showing a partially bled semipedunculated at autopsy. A yellowish friable polypoid mass was seen in the low-
polypoid mass in the lower part of the er esophagus
esophagus
Figure 3 Histologic findings showing the tumor in the esophagus and the primary tumor in the liver. a The mass in the esophagus was
composed of hepatocellular carcinoma (HCC) and multiple tumor emboli occupying the variceal lumina beneath the mass in the esoph-
ageal wall (arrows). HE stain, original magnification 20. b The tumor in the esophagus was moderate-differentiated HCC showing the
same histologic appearance as the primary tumors (c). Original magnification 200. c The primary tumor in the liver was moderate-dif-
ferentiated HCC. Original magnification 200
Polypoid Metastatic Hepatocellular Carcinoma of the Esophagus Endoscopy 2000; 32 421
mor cells abut on vascular spaces. The reported incidence References
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1
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5
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10
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14
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cognize metastasis of HCC in the esophagus while the pa-
tient is alive. In our case, autopsy examination revealed a
firm adhesion of the emboli onto the vascular wall with Corresponding Author
possible mural infiltration, but no extravascular metastases
were noted in the esophagus. M. Otsuki, M.D., Ph.D.
Third Dept. of Internal Medicine
These findings suggest that metastatic HCC is seldom ex- University of Occupational and Environmental Health
posed to the lumen of the esophagus, which may be one School of Medicine
reason why metastasis to the esophagus is seldom found 1-1, Iseigaoka
during the patient s lifetime. In the present case, we were Yahatanishi-ku
able to observe the metastatic tumor endoscopically. Such Kitakyusyu 807-8555
a situation appears extremely rare, and we could not find Japan
another example in a review of the literature. It is suggest-
ed that tumor emboli in the portal system were trapped at Fax: + 81-93-6920107
the site where the variceal bloodstream had been interrupt- E-mail: mac-otsk@med.uoeh.u.ac.jp
ed by EVL, and the metastatic tumor had then grown and
Submitted: 12 August 1998
broken through the ulcer base due to EVL, producing a
Accepted after Revision: 17 August 1999
polypoid mass.