Extrahepatic blood supply is seen in around 17-27% of hepatocellular carcinoma lesions. Evidence suggests that this extrahepatic supply most commonly originates from a right intercostal artery (70-83%) followed by left intercostal, omental and right renal arteries. Thus a comprehensive knowledge of variations in standard vascular anatomy and cognisance of factors influencing or predicting extrahepatic blood supply in HCC is instrumental in ensuring the success of surgical and interventional procedures. We present the unusual case of a 66-year-old male with HCC in Segment I of the liver with aberrant blood supply from the right renal artery in the absence of any risk factors for extrahepatic circulation. He successfully underwent transarterial chemoembolization. There was no evidence of residual disease on repeat imaging

Brathwaite, Collin E M

Hashmi, Hassan Raza

Khan, Muhammad Salman

Musa, Ahmad

Salam, Basit

Sohail, Amir Humza

English

eCommons@AKU

eCommons@AKU Department of Radiology Medical College, Pakistan 10-11-2021 Hepatocellular carcinoma with extrahepatic blood supply from right renal artery Amir Humza Sohail NYU Langone Hospital - Long Island, Mineola, USA. Ahmad Musa NYU Langone Hospital - Long Island, Mineola, USA. Muhammad Salman Khan University of Tennessee Health Science Center Bookstore, Radiology, Memphis, USA. Hassan Raza Hashmi NYU Langone Hospital - Long Island, Mineola, USA. Basit Salam Aga Khan University, basit.salam@aku.edu See next page for additional authors Follow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_radiol  Part of the Cardiovascular Diseases Commons, Gastroenterology Commons, Radiology Commons, and the Surgery Commons Recommended Citation Sohail, A. H., Musa, A., Khan, M. S., Hashmi, H. R., Salam, B., Brathwaite, C. M. (2021). Hepatocellular carcinoma with extrahepatic blood supply from right renal artery. Journal of Surgical Case Reports, 2021(10), rjab391. Available at: https://ecommons.aku.edu/pakistan_fhs_mc_radiol/485 Authors Amir Humza Sohail, Ahmad Musa, Muhammad Salman Khan, Hassan Raza Hashmi, Basit Salam, and Collin E M. Brathwaite This case report is available at eCommons@AKU: https://ecommons.aku.edu/pakistan_fhs_mc_radiol/485 1Journal of Surgical Case Reports, 2021;10, 1–3https://doi.org/10.1093/jscr/rjab391Case ReportC A S E R E P O R THepatocellular carcinoma with extrahepatic bloodsupply from right renal arteryAmir Humza Sohail1, Ahmad Musa1,*, Muhammad Salman Khan2,Hassan Raza Hashmi1, Basit Salam3 and Collin E.M. Brathwaite11NYU Langone Hospital – Long Island, Mineola, NY, USA , 2University of Tennessee Health Science CenterBookstore, Radiology, Memphis, TN, USA and 3The Aga Khan University, Radiology, Karachi, Sindh, Pakistan*Correspondence address. NYU Langone Hospital – Long Island, 222 Station Plaza North, Suite 300, Mineola, NY 11501, USA.Tel: +1-(516)-663-1625; E-mail: ahmad.musa@nyulangone.orgAbstractExtrahepatic blood supply is seen in around 17–27% of hepatocellular carcinoma lesions. Evidence suggests that thisextrahepatic supply most commonly originates from a right intercostal artery (70–83%) followed by left intercostal, omentaland right renal arteries. Thus a comprehensive knowledge of variations in standard vascular anatomy and cognisance offactors influencing or predicting extrahepatic blood supply in HCC is instrumental in ensuring the success of surgical andinterventional procedures. We present the unusual case of a 66-year-old male with HCC in Segment I of the liver withaberrant blood supply from the right renal artery in the absence of any risk factors for extrahepatic circulation. He successfullyunderwent transarterial chemoembolization. There was no evidence of residual disease on repeat imaging.INTRODUCTIONExtrahepatic blood supply is seen in around 17–27% of hepato-cellular carcinoma lesions. Evidence suggests that this extrahep-atic supply most commonly originates from a right intercostalartery (70–83%) followed by left intercostal, omental and rightrenal arteries. Thus a comprehensive knowledge of variationsin standard vascular anatomy and cognisance of factors influ-encing or predicting extrahepatic blood supply in hepatocellularcarcinoma (HCC) is instrumental in ensuring the success ofsurgical and interventional procedures. Transcatheter arterialchemoembolization is an endovascular procedure that attemptsto restrict blood supply to the tumor and is the standard locore-gional treatment for HCC in patients that fail to qualify for abla-tion or surgical resection. The success of trans-arterial chemo-embolization (TACE) hinges upon the ability to chemoembolizeall feeding vessels including extrahepatic feeders. Herein, weReceived: August 2, 2021. Accepted: August 11, 2021Published by Oxford University Press and JSCR Publishing Ltd. © The Author(s) 2021.This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/),which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.present the unusual case of a 66-year-old male with HCC withaberrant blood supply from the right renal artery in the absenceof any risk factors for extrahepatic circulation and successfullyunderwent TACE.CASE DESCRIPTIONA 66-year-old male was referred to our institution for manage-ment of a liver lesion found incidentally on abdominal imaging.There was no significant past medical or surgical history, andhe was asymptomatic. On physical examination, the patient wasvitally stable and all systemic examinations were unremarkable.Contrast-enhanced triple phase abdominal computed tomog-raphy (CT) scan showed an arterial enhancing lesion in Seg-ment I of liver with early washout, consistent with HCC (Fig. 1).This lesion received blood supply from the right renal artery(Fig. 2). Ultrasound-guided biopsy was performed to confirm the2 S. Amir et al.Figure 1: CT scan axial section delayed phase showing a 3.2 × 3.0-cm lesion(arrow) with early washout in Segment I of liver, consistent with hepatocellularcarcinoma.Figure 2: CT scan sagittal section arterial phase showing a branch (blue arrow)originating from the right renal artery (white arrow) supplying the lesion inSegment I of the liver.diagnosis of HCC, and subsequently the patient successfullyunderwent TACE. Figures 3 and 4 show the angiographic findingsof the right renal artery branch supplying the lesion. RepeatCT scan at 6-week follow-up showed no evidence of residualdisease.DISCUSSIONThe prevalence of extrahepatic circulation in HCC is well-documented [1]. Initial studies on extrahepatic circulation inpatients with HCC pointed towards the possibility of ligationof hepatic artery, a now obsolete treatment for HCC, as thecausative factor [2]. Recent evidence suggests that a previoushistory of TACE procedures is an important predisposing factorfor extrahepatic circulation in HCC [1]. However, in patientswithout a previous history of intervention, several factors canpredict the development extrahepatic circulation. Tumor size>5 cm, peripheral location of HCC—especially tumors in closeproximity of the diaphragm, hepatic ligaments or the barearea of liver i.e. Segments VII and VIII—owing to their oftendirect contact with extrahepatic structures, exophytic tumorswith omental or peritoneal adhesions and extrahepatic tumorinfiltration often major predictors of extrahepatic circulationFigure 3: Selective catheter angiogram of right renal artery (white arrow) showinga branch near its origin (blue arrow) supplying the hepatic lesion.Figure 4: Superselective delayed phase angiogram of right renal artery usingmicrocatheter showing well-defined tumor blush.[3, 4]. Further, prior abdominal surgery or a history of rupturedHCC are other important risk factors for development of extra-hepatic circulation [5–7]. It is noteworthy that our patient didnot have any of the above-mentioned risk factors. Importantly,the HCC lesion in our patient, located in Segment I, was only3.0 cm × 3.2 cm in size.In HCC, extrahepatic blood supply from right renal arteryoccurs in 3.5–12.0% of cases [3, 8]. Most commonly lesions in Seg-ment VI, followed by Segment VIII tumors, develop extrahepaticsupply from the superior capsular branch of right renal artery[9]. Origin of feeding vessel(s) directly from right renal artery,especially near its origin, as seen in our case, is extremely rare.Notably, preprocedure CT imaging generally has poor sensitivityfor detection of extrahepatic circulation from the right renalartery. Evidence on the success rate for TACE via right renalartery feeders is variable, with the success rate ranging from 41to 100%, and no major complications reported in literature [3].LEARNING POINTS• Hepatocellular carcinoma lesions may rarely have blood sup-ply directly from the right renal artery.• Angiography can help to confirm diagnosis of such lesionswith isolated blood supply from the right renal artery.Hepatocellular carcinoma with extrahepatic blood supply 3• In such lesions, transarterial chemoembolization shouldbe considered and can result in complete resolution of thelesion.REFERENCES1. Chen M, Cao J, Hu J, Topatana W, Li S, Juengpanich S,et al. Clinical-radiomic analysis for pretreatment predictionof objective response to first transarterial chemoemboliza-tion in hepatocellular carcinoma. Liver Cancer 2021;10:38–51.2. Michels NA. Collateral arterial pathways to the liver afterligation of the hepatic artery and removal of the celiac axis.Cancer 1953;6:708–24.3. Miyayama S, Matsui O, Taki K, Minami T, Ryu Y, Ito C,et al. Extrahepatic blood supply to hepatocellular carci-noma: angiographic demonstration and transcatheter arte-rial chemoembolization. Cardiovasc Intervent Radiol 2006;29:39–48.4. Charnsangavej C, Chuang VP, Wallace S, Soo CS, BowersT. Angiographic classification of hepatic arterial collaterals.Radiology 1982;144:485–94.5. Li Q, Ao G-K, Duan F, Wang Z-J, Yan J-Y, Wang M-Q. Incidenceand therapeutic frequency of extrahepatic collateral arteriesin transcatheter arterial chemoembolization of hepatocellu-lar carcinoma: experience from 182 patients with survivaltime more than 3 years. Eur J Radiol 2015;84:2555–63.6. Wang Y-L, Li MH, Cheng YS, Shi HB, Fan HL. Influentialfactors and formation of extrahepatic collateral artery inunresectable hepatocellular carcinoma. World J Gastroenterol2005;11:2637–42.7. Chung JW, Kim H-C, Yoon J-H, Lee H-S, Jae HJ, Lee W, et al.Transcatheter arterial chemoembolization of hepatocellu-lar carcinoma: prevalence and causative factors of extra-hepatic collateral arteries in 479 patients. Korean J Radiol2006;7:257–66.8. Kim H-C, Chung JW, Lee W, Jae HJ, Park JH. Recognizingextrahepatic collateral vessels that supply hepatocellularcarcinoma to avoid complications of transcatheter arterialchemoembolization. Radiographics 2005;25:S25–39.9. Ishikawa M, Yamagami T, Kakizawa H, Hieda M, Toyota N,Fukumoto W, et al. Transarterial therapy of hepatocellularcarcinoma fed by the right renal capsular artery. J Vasc IntervRadiol 2014;25:389–95.

Hepatocellular carcinoma with extrahepatic blood supply from right renal artery

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Hepatocellular carcinoma with extrahepatic blood supply from right renal artery

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