Hepatocellular carcinoma in Riedel’s lobe
R. Zamfir, V. Brasoveanu, I. Popescu, M. Boros, V. HerleaImagini pentru chirurgi, no. 1, 2008
* Center of General Surgery and Liver Transplantation
* Department of Radiology and Medical Imagery
* Department of Pathology
In clinical practice congenital abnormalities of liver are very rare (1). Many kinds of congenital abnormalities of the liver are described: agenesis or absences of it’s lobes or segments, lobar atrophy or hypertrophy, transposition of the gallbladder and Riedel's lobe (2). According to Riedel’s description (the one who describe it first), it is " a downward tongue-like projection of the anterior edge of the right liver lobe to the right of the gallbladder"(3). We didn’t find in the literature primary tumors of Riedel’s lobe, so, we consider worth requesting the following case.
Case report
A 65-year-old woman was admitted in our Center for right abdominal mass. The ultrasonography revealed a 30/30 cm solid, heterogeneous mass, with Doppler signal inside. The CT-scan described an abdomino-pelvic mass with the upper border near the hepatic hilum and the lower border at the hip-joint level; posterior, the tumor compressed the hepatic hilum, the right liver lobe, the gallbladder, the inferior vena cava and the right kidney; the tumor was heterogeneous, with many cystic areas and micro nodular calcifications (Fig. 1 A, B). The laboratory results were normal (including the markers AFP, CEA and CA19-9).
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The intraoperative exploration showed a large liver mass, connected to segment VI and occupying the right side of the abdomen (Riedel’s lobe) (Fig. 2 A). A resection of the mass with "en-block" cholecistectomy was performed. The specimen weighed 2300 grams. When sectioned, the tumor presented cystic areas, necrosis, collagen lamellar fibrosis and tumoral areas with multinodular aspect (Fig. 2 B). The microscopic examination (Hematoxilin-Eosine stain x 40) of the tumoral areas revealed hepatocelular carcinoma (HCC) with moderate differentiation (Edmondson/Steiner II/III). (fig. 3).
The postoperative course was uneventful, the patient being discharged 9 days after surgery.
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Discussion
There are various indications for surgery in a patient with Riedel's lobe.
Chronic symptoms as pain and the presence of an abdominal mass have been reported (4).
Torsion of the lobe can present itself as an emergency requiring immediate surgery (5).
Additional pathology can be found at the level of the Riedel's lobe: hydatic cyst or metastases from a breast cancer (6, 7).
The above described case is the first primary malignant Riedel’s lobe tumor reported. The ischemic changes and pedicle fibrosis due to repeated torsion episodes could
possibly explain the genesis of the tumor.
HCC in Riedel’s lobe is a difficult diagnosis for imagery, and the tumor can be detected only after removal of the involved lobe. The possibility of an undetected malignancy represent an additional reason to resect a Riedel’s lobe when diagnosed.
References
1. Actan, Z.A., Savas, R., Pinar, Y., Arslan, O. - Lobe and segment anomalies of the liver. J. Anat. Soc. India, 2001, 50:15.
2. Coinaud, C. - Surgical Anatomy of the liver revisted. Paris 1989.
3. Riedel, BMKL - Ueber den zungenfrmigen Fortsatz des rechten Leberlappens und seine pathognostische Bedeutung für die Erkrankung der Gallenblase nebst Bemerkungen über Gallensteinoperationen. Berliner klinische Wochenschrift, 1888, 25:577.
4. Popescu, I., Zamfir, R., Brasoveanu, V., Boros, M., Herlea, V. - A rare indication for liver resection. Chirurgia (Bucur.), 2005, 100:75.
5. Lefaucher, C., Dupuis, E., Muller, J., Laham, A. - Torsion of Riedel's lobe. Two cases (author's transl). J. Chir., 1978, 115:25.
6. Kune, G.A., Schellenberger, R. - Current management of liver hydatid cysts: results of a 10-year study. Med. J. Aust., 1988, 149:26.
7. Soo, M.S., Adatepe, M.H. - Metastatic lesions arising in a Riedel's lobe. Findings from a sulfur colloid liver-spleen scan. Clin Nucl Med., 1990, 15:814.