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INTRODUCTION: Besides more common sites such as lung or peritoneum, hepatocellular carcinoma (HCC) can metastatize to rare sites. We report herein a new metastatic site of HCC: the nail-bed. We also review other recently reported rare site HCC metastases (RSHM). CASE REPORT: A 66-year-old woman with a 12-year history of resected-stage IA HCC who later presented lung, spleen and brain metastases treated with surgery, systemic therapies (sorafenib, sunitinib, capecitabine) and radiotherapy. The patient was referred to us because of a painful and rapidly evolving mass in the nail-bed of the left thumb. Biopsy confirmed nail-bed HCC metastasis, and the finger was amputated. The patient died few weeks later. CONCLUSION: This case was an opportunity for us to review RSHM. This type of metastasis seems to be an early event, in the context of advanced stage HCC with elevated protein induced by vitamin K absence-II (PIVKA II). The Lee nomogram is useful in detecting patients at high risk of developing RSHM. We would suggest insisting on systemic treatment in these metastatic patients although overall survival after RSHM diagnosis is poor.
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BACKGROUND: The use of fibrin for mesh fixation in laparascopic hernioplasty has theoretical advantages in that it could result in reducing postoperative pain. The objective of this study is to demonstrate this improvement in postoperative pain with the highest level of evidence possible. METHODS: Unicenter single surgeon prospective randomized double-blind study of transabdominal preperitoneal (TAPP) bilateral hernioplasties comparing autologous fibrin sealant (FG) used for mesh fixation on one side and staples (SG) on the other. Data were collected regarding anthropometric measures, costs, complications and pain evaluation at postoperative days 7, 30 and 180 using a visual analogue scale. The patients were also asked to answer the following simple question: "On which side do you have more pain?" RESULTS: Twenty-two eligible patients were included in the study. Both groups were comparable. The operating time was significantly longer (30 min more) in the FG. The incidence of seroma was similar in both groups, and that of hematoma was higher in the SG (0 vs. 9.1%). At 1 week, the visual analogue scale scores were significantly lower in the FG (median: 1.7 vs. 4.5; MWU:103.5, p < 0.05). At 1 month, this difference became clinical and statistically insignificant. 72.7% of the patients referred more pain on the side with staples at 1 week, 38% at 1 month, and 0% at 6 months (after patients with hernia recurrence were excluded). The recurrence rate was higher in the FG (9.9 vs. 13.6%). A hernia in the FG cost 200 Euros more than that in the SG, or even more if a complete economic study is considered. CONCLUSIONS: The use of fibrin produces less postoperative pain in the first week, but prolongs operating time and increases costs. Moreover, there appears to be a higher recurrence rate and a lower incidence of hematoma, while the incidence of seroma remains unchanged.
