Hepatocellular carcinoma with duodenal invasion: a rare cause of duodenal bleeding

A 69-year-old man with alcohol use disorder presented with tarry stools for 1 week. Upon presenting at the hospital, his hemoglobin level was 4.3 g/dL (normal range: 13–18 g/dL). Esophagogastroduodenoscopy revealed a firm, dark-brown, irregularly island-like mass (around 3 cm) on a clean-based ulcer, with no active bleeding, on the anterior wall of the duodenal bulb (Figure 1A). Abdominal computed tomography of the duodenal lesion showed a 6.5 cm mass in the hepatic hilum with a satellite mass infiltrating the proximal duodenum (Figure 2). Histopathology of the lesion showed tumor elements that were weakly positive on α-fetoprotein immunostaining; thus, indicating a moderate differentiation of hepatocellular carcinoma (HCC). A few days later, the patient presented with recurrent gastrointestinal bleeding and underwent endoscopic argon plasma coagulation (ERBE Elektromedizin GmbH, Germany, VIO 200D; forced mode, gas flow 1.8 L/min, power setting 30 W) with an axial probe (2.3 mm in diameter, 220 cm in length) (Figure 1B), with a subsequent transcatheter arterial embolization. Temporary hemostasis was achieved; unfortunately, he died of tumor progression and persistent duodenal bleeding 2 months later. Extrahepatic metastases of HCC have been reported mainly in the lung and in regional lymph nodes, while direct invasion into the gastrointestinal tract is rare (0.5%–2% of the cases)1 and is generally associated with advanced disease (with a large tumor >5 cm).2 In these cases, the stomach and duodenum are the most frequent sites of direct invasion and commonly present with bleeding and gastric outlet obstruction. The first line of treatment for such cases would be a surgical resection with a pancreas-sparing duodenectomy.3 Other treatment approaches include external beam radiation therapy, transcatheter arterial embolization, and a local injection with an ethanol injection. However, attempts to control tumor bleeding often fail, and the prognosis of HCC with duodenal invasion is poor. Liang et al. reported that 50% of patients with duodenal invasion died within 3 months.4 If endoscopic findings reveal an infiltrating mass into the duodenal bulb, it should raise suspicions of direct invasion by a liver tumor (Table S1). All authors declare no conflict of interest. Informed consent was obtained from all participating adult subjects, together with the manner in which informed consent was obtained (ie, oral or written). Appendix S1 Supporting Information Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.