This collection highlights high quality case reports exploring tumors of the liver published in the visceral surgery section of our journal. Case reports aim to highlight unique cases of patients that present with an unexpected/unusual diagnosis, treatment outcome, or clinical course. Case reports provide insight into the differential diagnosis, decision making, and clinical management of unusual cases and are a valuable educational tool. This Research Topic will only accept Case Report submissions, reports must be original with the aim to significantly advance the field to be considered.

Karolinska Institutet (KI)

. This research topic covers a variety of medical procedures and treatments related to the liver: <ul> <li>Robotic surgery was used to remove a cystic lesion from a 55-year-old woman, with advantages such as easier repair and control of vascular injuries, and reduced intraoperative blood loss.</li> <li>ALPPS and HAIC were used to induce rapid hypertrophy of the liver remnant and increase the ratio of the FLR/SLV, respectively.</li> <li>Near-infrared fluorescence imaging using ICG was used to assist in achieving a negative margin and lymphatic clearance around the biliary tree.</li> <li>A mixed neuroendocrine-non-neuroendocrine neoplasm was successfully treated with etoposide and cisplatin-based chemotherapy.</li> <li>Primary hepatic leiomyoma was successfully diagnosed preoperatively using ultrasound-guided fine needle trucut biopsy and surgically resected.</li> </ul>

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Frontiers in Surgery

Visceral Surgery

Case Reports in Visceral Surgery: Tumors of the Liver

Surgical resection remains the mainstay of curative treatment for primary hepatic malignancies and colorectal metastases to the liver. Most experience regarding liver surgery has been gained from resection of colorectal metastases, cholangiocarcinoma, and hepatocellular cancer (HCC). Outcome after liver surgery has improved over recent decades. However, there are many clinical challenges in the preoperative assessment and management of liver tumors that entail novel solutions that have yet to be evaluated, especially rare tumor forms.The development of imaging techniques and extensive use of computer tomography has resulted in a growing number of small liver lesions being detected. Many of these are benign and do not require surgical treatment, but may sometimes be difficult to distinguish from hepatocellular carcinoma. HCC is the most common primary liver cancer. There are, however, rare cases where the tumor is a combination of HCC and neuroendocrine tumor (NET), possibly a result of poorly differentiated tumor cells developing into different lines such as NET and HCC (<a href="https://doi.org/10.3389/fsurg.2021.678853">Lan et al.</a>).Liver lesions may be resected to reduce local symptoms as long as they are carefully selected and a benign diagnosis has been confirmed preoperatively. The histopathologic complexity of the liver and its involvement in various functions of the digestive and immunological systems make it a hotbed for tumors of various origins. Gonadal hormone substitution may induce hepatic adenomas that vanish as soon as treatment is interrupted (<a href="https://doi.org/10.3389/fsurg.2021.665367">Liu et al.</a>). Leiomyomas are mesenchymal tumors that are sometimes seen in immunosuppressed patients (<a href="https://doi.org/10.3389/fsurg.2021.691674">Djokic et al.</a>). The choice between surgical treatment and conservative management thus requires careful consideration of the specific characteristics of each tumor, preferably in multidisciplinary collaboration.Surgical methods have developed rapidly over the last two decades, in particular robot-assisted laparoscopy. This has made it possible to carry out minimally invasive surgery that was considered impossible only a few years ago, including resections along major vessels and deeply located lesions (<a href="https://doi.org/10.3389/fsurg.2021.681012">Solomonov et al.</a>). Although there are few well-designed randomized controlled trials confirming the safety and cost-benefit of robot-assisted liver surgery, rapid development of the technique may render the latest presented report outdated as soon as it is published.The ability of the liver parenchyma to regenerate has been used as a method to reduce the risk for postoperative organ failure. The combination of liver partition and local portal vein ligation for staged hepatectomy (ALPPS) induces hypertrophy of the liver remnant, and has been shown to be a way of enabling more extensive liver resection. ALPPS is carried out as a two-stage procedure. In the first stage, transection along the part of the liver to be resected is made together with local portal ligation. The patient is then allowed to recover for approximately 2 weeks during which the liver remnant regenerates. In the second stage, the deportalized liver lobe is removed. In cases with cirrhosis, however, the liver remnant may fail to regenerate. A potential solution in such cases may be hepatic arterial infusion chemotherapy to the part of the liver to be resected (<a href="https://doi.org/10.3389/fsurg.2021.746618">Zhuo et al.</a>). The technique has been tested and results are promising. However, this technique should be evaluated further before being accepted in routine clinical practice.Visualization of bile ducts and tissue planes is a great challenge in liver surgery. Near-infrared fluorescence (NIRF) imaging after intravenous injection of indocyanine green (ICG) is a method that is gradually becoming routine in benign gallbladder surgery. A recent report showed that NIRF can also be used in surgery for gallbladder cancer, enabling wedge liver resection even when the gallbladder cancer invades the parenchyma along the bile ducts (<a href="https://doi.org/10.3389/fsurg.2021.655805">Yu et al.</a>). NIRF will probably become a routine technique in various situations, particularly when detecting ischaemia and visualizing the bile ducts intraoperatively.Some liver tumors are today considered inaccessible for surgery with radical intent, but with continuing development of techniques for managing various liver lesions, we anticipate new progress in the near future. New imaging techniques that incorporate artificial intelligence may help in preoperative planning and execution of surgery of these cancer forms, further extending the horizon of liver tumor management. This, together with the development of robot-assisted laparoscopy, will lead to minimally invasive surgery becoming the first-hand choice in liver surgery.The author confirms being the sole contributor of this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Editorial: Case Reports in Visceral Surgery: Tumors of the Liver

Introduction: Cystic liver lesions may be benign cysts, parasitic infestations, or malignant tumors requiring surgical resection. Hilar location and relation to major vasculature present challenges in conventional surgical access and resection.Materials and Methods: We describe totally robotic excision of a cystadenoma in a 55-year-old woman without complication. Time points in the accompanying video (<ext-link ext-link-type="uri" xlink:href="https://youtu.be/Tn_QPgpSHA4" xmlns:xlink="http://www.w3.org/1999/xlink">https://youtu.be/Tn_QPgpSHA4</ext-link>) are embedded within the text.Results: Advantages of the robotic technique lie in overcoming the natural restriction of conventional laparoscopic instruments, easier repair, and control of intraoperative vascular injuries using EndoWrist® instruments, ergonomic dissection close to major vasculature and reduced intraoperative blood loss as dissection is easier.Discussion: Indications for robotic surgery included the large size of the cystic lesion, its intrahepatic location, and compression of the inferior vena cava (IVC) and right and middle hepatic veins. Had robotic removal of the lesion not been feasible, the entire lobe of the liver would have required resection.

Introduction: Cystic liver lesions may be benign cysts, parasitic infestations, or malignant tumors requiring surgical resection. Hilar location and relation to major vasculature present challenges in conventional surgical access and resection.Materials and Methods: We describe totally robotic excision of a cystadenoma in a 55-year-old woman without complication. Time points in the accompanying video (<a href="https://youtu.be/Tn_QPgpSHA4">https://youtu.be/Tn_QPgpSHA4</a>) are embedded within the text.Results: Advantages of the robotic technique lie in overcoming the natural restriction of conventional laparoscopic instruments, easier repair, and control of intraoperative vascular injuries using EndoWrist® instruments, ergonomic dissection close to major vasculature and reduced intraoperative blood loss as dissection is easier.Discussion: Indications for robotic surgery included the large size of the cystic lesion, its intrahepatic location, and compression of the inferior vena cava (IVC) and right and middle hepatic veins. Had robotic removal of the lesion not been feasible, the entire lobe of the liver would have required resection.

Case Report: Robotically Assisted Excision of Cystic Tumor Located in a Difficult to Access Area in the Liver

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) can induce rapid hypertrophy of the liver remnant. However, with a background of liver cirrhosis or other chronic liver diseases, patients with a huge hepatocellular carcinoma (HCC) may sometimes face insufficiency of hepatocellular regeneration after associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). Herein, we report a 56-year-old male with a vast HCC (13.3 × 8.5 × 13 cm) whose ratio of the future liver remnant (FLR)/standard liver volume (SLV) was 28.7% when the disease was first diagnosed. Inadequate hypertrophy of FLR was shown in postoperative volumetric assessment a month after stage I ALPPS. After multidisciplinary team discussion (MDT), the patient was decided to follow three courses of hepatic arterial infusion chemotherapy (HAIC) with oxaliplatin, fluorouracil, and leucovorin (FOLFOX4). The last HAIC was performed together with transhepatic arterial embolization (TAE). Finally, ratio of the FLR/SLV increased from 28.7% to 40% during three-month intervals, meeting the requirements of the surgery. Stage II ALPPS, right trisectionectomy, was then successfully performed. There was no recurrence at half years of follow-up. In our case, HAIC seems to be more potent than transcatheter arterial chemoembolization (TACE) in maintaining the hyperplasia of the liver remnant, reducing tumor load, and preventing tumor progression in patients with a large HCC during ALPPS procedure. HAIC, following the first step of ALPPS, a pioneering treatment modality aiming for inadequate hypertrophy of FLR induced by ALPPS, could be an alternative procedure for patients with a vast HCC in clinical practice.

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) can induce rapid hypertrophy of the liver remnant. However, with a background of liver cirrhosis or other chronic liver diseases, patients with a huge hepatocellular carcinoma (HCC) may sometimes face insufficiency of hepatocellular regeneration after associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). Herein, we report a 56-year-old male with a vast HCC (13.3 &#xd7; 8.5 &#xd7; 13 cm) whose ratio of the future liver remnant (FLR)/standard liver volume (SLV) was 28.7% when the disease was first diagnosed. Inadequate hypertrophy of FLR was shown in postoperative volumetric assessment a month after stage I ALPPS. After multidisciplinary team discussion (MDT), the patient was decided to follow three courses of hepatic arterial infusion chemotherapy (HAIC) with oxaliplatin, fluorouracil, and leucovorin (FOLFOX4). The last HAIC was performed together with transhepatic arterial embolization (TAE). Finally, ratio of the FLR/SLV increased from 28.7% to 40% during three-month intervals, meeting the requirements of the surgery. Stage II ALPPS, right trisectionectomy, was then successfully performed. There was no recurrence at half years of follow-up. In our case, HAIC seems to be more potent than transcatheter arterial chemoembolization (TACE) in maintaining the hyperplasia of the liver remnant, reducing tumor load, and preventing tumor progression in patients with a large HCC during ALPPS procedure. HAIC, following the first step of ALPPS, a pioneering treatment modality aiming for inadequate hypertrophy of FLR induced by ALPPS, could be an alternative procedure for patients with a vast HCC in clinical practice.

Case Report: Hepatic Artery Infusion Chemotherapy After Stage I ALPPS in a Patient With Huge HCC

Surgery is the mainstay of treatment for resectable gallbladder cancer. Near-infrared fluorescence (NIRF) imaging using ICG is an innovation in laparoscopic surgery, which can provide real-time navigation during the whole operation. In this article, we present a 56-year older woman with gallbladder cancer, in which we evaluated the applicability of NIRF imaging using ICG for tumor and biliary tree visualization during the operative procedure of gallbladder cancer. The tumor and biliary tree were clearly visualized by utilizing a green fluorescence dye. The patient was successfully operated radical resection of gallbladder cancer under fluorescence laparoscope, without any complications. According to this case, the utilization of ICG based NIRF imaging is feasible and beneficial in identifying tumors and the biliary tree during radical resection. It can assist in the achievement of a negative margin and lymphatic clearance around the biliary tree. However, further studies are needed to corroborate the results of this case.

Surgery is the mainstay of treatment for resectable gallbladder cancer. Near-infrared fluorescence (NIRF) imaging using ICG is an innovation in laparoscopic surgery, which can provide real-time navigation during the whole operation. In this article, we present a 56-year older woman with gallbladder cancer, in which we evaluated the applicability of NIRF imaging using ICG for tumor and biliary tree visualization during the operative procedure of gallbladder cancer. The tumor and biliary tree were clearly visualized by utilizing a green fluorescence dye. The patient was successfully operated radical resection of gallbladder cancer under fluorescence laparoscope, without any complications. According to this case, the utilization of ICG based NIRF imaging is feasible and beneficial in identifying tumors and the biliary tree during radical resection. It can assist in the achievement of a negative margin and lymphatic clearance around the biliary tree. However, further studies are needed to corroborate the results of this case.

Attempt of Real-Time Near-Infrared Fluorescence Imaging Using Indocyanine Green (ICG) in Radical Resection of Gallbladder Cancer: A Case Report

In this work, we reported a young man complaining of asthenia and intermittent fever for 10 days, and an ultrasound showed an undefined lesion on his liver. Facing the patient's situation with severe agranulocytosis, anemia, and thrombocytopenia, we passed through a tough diagnostic process for choosing an appropriate treatment for him with an ambiguous result of pathological biopsy. The undefined liver lesion was successfully solved by withdrawing the androgen for observation, without lobectomy. The lesion gradually diminished over 2 years of follow-up.

In this work, we reported a young man complaining of asthenia and intermittent fever for 10 days, and an ultrasound showed an undefined lesion on his liver. Facing the patient&apos;s situation with severe agranulocytosis, anemia, and thrombocytopenia, we passed through a tough diagnostic process for choosing an appropriate treatment for him with an ambiguous result of pathological biopsy. The undefined liver lesion was successfully solved by withdrawing the androgen for observation, without lobectomy. The lesion gradually diminished over 2 years of follow-up.

Case Report: An Undefined Liver Lesion in a Young Man With Severe Aplastic Anemia: A Teachable Moment

Background: Neuroendocrine tumors are heterogeneous malignancies that originate from the neuroendocrine system. Previous studies show that this cancer type mainly localizes in the gastrointestinal tract and often metastasizes to the liver. Primary liver neuroendocrine tumors are very rare and primary hepatic neuroendocrine tumors (PHNET) with concurrent hepatocellular carcinoma (HCC) are extremely rare. To the best of our knowledge, only few PHNET cases have been identified, making their diagnosis difficult. Here, we report the biggest ever reported and “deceiving” lesion of a mixed neuroendocrine-non-neuroendocrine neoplasm in the liver, aiming to raise awareness and improve treatment of the disease.Case Presentation: Here, we report a preoperative misdiagnosed case that presented with hepatocellular carcinoma clinical features and no extrahepatic tumors. Postoperative pathology confirmed that it was a mixed neuroendocrine-non-neuroendocrine neoplasm. The patient was then referred for etoposide and cisplatin-based chemotherapy. No disease recurrence was observed at the 6-month follow-up.Conclusion: We report a very rare and easily misdiagnosed case and we speculate that there were “undifferentiated cells” undergoing neuroendocrine and hepatocellular carcinoma differentiation, during which some hepatocellular carcinoma cells express neuroendocrine features. We recommend proper surgery and postoperative platinum-based chemotherapy in the management of this disease.

Background: Neuroendocrine tumors are heterogeneous malignancies that originate from the neuroendocrine system. Previous studies show that this cancer type mainly localizes in the gastrointestinal tract and often metastasizes to the liver. Primary liver neuroendocrine tumors are very rare and primary hepatic neuroendocrine tumors (PHNET) with concurrent hepatocellular carcinoma (HCC) are extremely rare. To the best of our knowledge, only few PHNET cases have been identified, making their diagnosis difficult. Here, we report the biggest ever reported and “deceiving” lesion of a mixed neuroendocrine-non-neuroendocrine neoplasm in the liver, aiming to raise awareness and improve treatment of the disease.Case Presentation: Here, we report a preoperative misdiagnosed case that presented with hepatocellular carcinoma clinical features and no extrahepatic tumors. Postoperative pathology confirmed that it was a mixed neuroendocrine-non-neuroendocrine neoplasm. The patient was then referred for etoposide and cisplatin-based chemotherapy. No disease recurrence was observed at the 6-month follow-up.Conclusion: We report a very rare and easily misdiagnosed case and we speculate that there were “undifferentiated cells” undergoing neuroendocrine and hepatocellular carcinoma differentiation, during which some hepatocellular carcinoma cells express neuroendocrine features. We recommend proper surgery and postoperative platinum-based chemotherapy in the management of this disease.

Mixed Neuroendocrine Carcinoma and Hepatocellular Carcinoma: A Case Report and Literature Review

Introduction: Primary hepatic leiomyoma (PHL) is a rare benign hepatic tumor with unclear pathogenesis. It more commonly occurs in immunosuppressed patients, while only 24 cases have been described among immunocompetent individuals. To date, only one successful preoperative diagnosis of PHL has been achieved.Case Presentation: Here we report a case of PHL in a middle-aged woman with no history of immunosuppression. Preoperative diagnosis of PHL was established using ultrasound-guided fine needle trucut biopsy (FNTB). Nevertheless, due to the growing nature of tumor and patient's symptoms, we proceeded with surgical resection, which confirmed the diagnosis of PHL. At 6-month follow up, the patient is in good condition with no evidence of tumor recurrence.Conclusions: PHL is an uncommon tumor that should be considered in the differential diagnosis of rare liver tumors. Image guided FNTB appears to be effective in achieving preoperative diagnosis of PHL. Surgical resection, however, remains both diagnostic and curative in the management of PHL.

Introduction: Primary hepatic leiomyoma (PHL) is a rare benign hepatic tumor with unclear pathogenesis. It more commonly occurs in immunosuppressed patients, while only 24 cases have been described among immunocompetent individuals. To date, only one successful preoperative diagnosis of PHL has been achieved.Case Presentation: Here we report a case of PHL in a middle-aged woman with no history of immunosuppression. Preoperative diagnosis of PHL was established using ultrasound-guided fine needle trucut biopsy (FNTB). Nevertheless, due to the growing nature of tumor and patient's symptoms, we proceeded with surgical resection, which confirmed the diagnosis of PHL. At 6-month follow up, the patient is in good condition with no evidence of tumor recurrence.Conclusions: PHL is an uncommon tumor that should be considered in the differential diagnosis of rare liver tumors. Image guided FNTB appears to be effective in achieving preoperative diagnosis of PHL. Surgical resection, however, remains both diagnostic and curative in the management of PHL.