肝細胞癌切除後腹膜転移巣に対し腹腔鏡下切除を施行した1例

Laparoscopic resection for peritoneal metastasis of hepatocellular carcinoma : report of a case

◆要旨：患者は58歳，女性．1年3か月前に，肝外側区域辺縁の肝外突出型肝細胞癌に対し開腹肝部分切除を行った．その際，近傍に4か所の腹膜転移を認め切除した．術前に高値であった血清AFP値はいったん正常化したが再上昇し，腹部CTで肝S5表面と左横隔膜下に腹膜転移を疑う腫瘤を指摘された．他に明らかな転移巣は認めず，診断と治療を兼ねて腹腔鏡下手術を施行した．両病変とも壁側腹膜に覆われた腹膜転移であり，腹腔鏡下に切除した．これまでに肝細胞癌腹膜転移に対して開腹で切除を行い良好な予後を得た報告例は散見される．腹膜転移は画像による正確な診断が困難であり，開腹所見で多くの播種が発見され切除を断念する場合も考えられる．今回施行した腹腔鏡下手術は低侵襲に診断と治療が可能であり，有効な手段と思われた．

A 58 year old woman underwent hepatectomy for hepatocellular carcinoma and resection of four nodules of peritoneal metastases around the main tumor. Fifteen months later, her serum AFP levels elevated markedly. Abdominal CT scan revealed a 3cm tumor on the surface of Couinaud's segment 5 of the liver and a 1cm tumor on the left diaphragm. Laparoscopic surgery was performed for the purpose of diagnosis and treatment. Because laparoscopic observation revealed no other lesions, these two peritoneal metastases were resected by using a LCS device under laparoscopy. Although surgical resection of peritoneal metastasis of HCC is unusual, a few cases of favorable outcomes have been reported. Extrahepatic metastasis of HCC should be resected, if the lesions are completely resectable and the intrahepatic recurrence is well controlled. There have been no previous reports of laparoscopic resection of peritoneal metastasis. This may be the first report, and the strategy seems to be useful for accurate diagnosis and simultaneous treatment with minimal surgical invasiveness.