A 66-year-old male patient received systemic chemotherapy for metastatic colon cancer. During the introduction of the 38th dose of the 5-FU based regimen (5FU+folinic acid+irinotecan), he exhibited general fatigue followed by acute steatosis with liver dysfunction, accompanied by a steep decline of serum albumin and ascites formation. After cessation of the chemotherapeutic drug and receiving supportive care for hepatic dysfunction, the hepatic dysfunction rapidly improved. Following this episode, the effective chemotherapy continued for 32 months, until the patient's death due to interstitial pneumonia (The entire survival time was 68 months.). The regeneration of the hepatic volume was normal following three hepatectomies for his liver metastases. The histological findings harvested 12 months prior to the hepatic failure presented almost normal parenchyma of the background liver. Although irinotecan was the most suspicious cause for the steatosis, an acute form of the hepatic failure has hardly been reported before this case.

Clear cell hepatocellular carcinoma (CC-HCC) is a rare type of hepatocellular carcinoma (HCC), characterized by seat-like proliferation of large carcinoma cells with clear cytoplasm. Scirrhous hepatocellular carcinoma (SC-HCC) is also reported as a histologic variant of HCC, characterized by extensive fibrosis of the tumor.

A 56-year old man was found to have a heterogeneously enhanced round mass in the right lobe of the liver on dynamic enhanced computed tomography (CT). Gd-EOB-DTPA-enhanced magnetic resonance imaging (MRI) revealed a total of three tumors. Two tumors were located in segment 8 and the third in segment 6. Serum tumor markers revealed elevated alpha-fetoprotein 14.7 ng/mL and Protein Induced by Vitamin K Absence/antagonist II 1020 mAU/mL. These findings suggested triple HCCs in total, in segment 6 and 8 of the liver, and the patient underwent partial resection of segments 6 and 8. The microscopic findings of the resected specimens in segment 8 demonstrated that one was compatible with CC-HCC, and the other with SC-HCC. The tumor in segment 6 was diagnosed as a well-differentiated HCC. To our knowledge, this is the first report of hepatocellular carcinoma with co-existence CC-HCC and SC-HCC in the same liver segment.

An 80-year-old woman with previous history of hepatic segmentectomy for HCC, had a recurrence in the right lung over five years after her follow up. She received radiation therapy, followed by lenvatinib administration (8 mg/day). 54 days after the initiation of lenvatinib, she complained of dyspnea. The laboratory examination showed elevated inflammatory parameters, and her chest X-ray revealed right pleural effusion. Gram-positive cocci were detected by fluid culture, and the diagnosis of empyema was confirmed. Although the administration of antibiotics and continuous chest fluid drainage had been started, she developed ARDS and finally died from respiratory failure. The autopsy revealed disruption of the pleura connected to the necrotic metastatic lesion in the right lung, indicating that empyema occurred subsequent to tumor necrosis induced by lenvatinib. We report this rare case with a pleural complication after the treatment with lenvatinib to HCC.

An 87-year-old man was referred to our hospital with hepatocellular carcinoma (HCC) of 20 mm in diameter in segment 5 of the liver. Subsequently, radical treatment by radiofrequency ablation (RFA) was successfully conducted. Six months after RFA, he received direct acting antiviral treatment and achieved eradication of the hepatitis C virus (HCV). Two years following HCV eradication, a solitary abnormal nodule in his right lung was detected, accompanied by an increase in his serum des-gamma-carboxy prothrombin level. Subsequent partial lung resection was successfully performed, and the resected specimen revealed a metastasis of the HCC. Three years after lung metastasectomy, a metastatic focus at the T6 vertebra was detected. Radiation therapy, followed by systemic chemotherapy of lenvatinib, an oral multi-kinase inhibitor, was conducted. Recently, we encountered this HCC case exhibiting distant metastasis and lacking intrahepatic recurrent lesions. In such a case, treatment selection based on the treatment progress and condition is essential for the prognosis extension.