Hepatic “pregnancy”: hepatocellular carcinoma with extensive extrahepatic growth
A female in her 50s, no previous personal history, presented to the Emergency Department with a 7 months history of progressively worsening abdominal diffuse pain associated with increasing abdominal volume. On physical examination, huge ill-defined abdominal masses were identified (Figure 1).
Admitted for further investigation, and on computed tomography (CT) scan demonstrated multiple hepatic and peritoneal tumors: liver reveals enlarged dimensions, particularly at the left lobe, recording a diffusely heterogeneous parenchyma, with numerous nodular lesions, characterized by hyperenhancement in arterial phase and washout on the portal venous/delayed-phases; the largest one, exophytic, measuring 15.5 cm × 25 cm × 22 cm and extending from the left liver until the pelvic excavation; in the right liver, the larger tumor was about 9.6 cm in larger diameter. Overall, the masses occupied roughly two-thirds of intra-abdominal volume. There were minimal ascites and the intrahepatic and extrahepatic bile ducts diameters were normal (Figure 2).
Biochemical analyses show alanine amino-transferase value and aspartate aminotransferase value were normal. Hepatitis virus infection (including hepatitis B virus, hepatitis C virus and hepatitis D virus) was tested negative.
Symptomatic control was very difficult, namely severe pain and food intolerance. So, the clinical case was discussed in hepato-biliary multidisciplinary team. Although without any typical nosological behavior, there were clinical and imaging criteria to conclude for the malignant nature of the lesions. Accordingly, palliative surgery was proposed and carried out.
A hepatic left medial sectionectomy on bloc with peritoneal and segment IV tumorectomies was performed (Figure 3). The pathologic report concluded for: hepatocellular carcinoma pT4 G2 R2. The post-operative recovery was uneventful and with immediate symptoms relief. The patient was discharged on the 4th post-operative day.
The patient started on sorafenib and, about 3 months after the palliative operation, maintains a good general condition [Eastern Cooperative Oncology Group (ECOG)-1] and is almost asymptomatic.
In follow-up period, the alpha-fetoprotein value ranged between 30 and 65 U/mL (normal values: <5.8 U/mL).
Therefore, this case report intends to emphasize that malignancy should always be considered in the differential diagnosis of large abdominal masses.
A giant intra-abdominal mass that filled most of the abdomen as presentation of hepatocellular carcinoma is a rare case, not often reported in the literature.
Despite continuous advancements in the management of this disease, prognosis remains dismal. The best option for potential cure and long-term survival is surgical resection but, in some selected cases, this intervention may be indicated as a palliative procedure.
Surgery, even though aggressive and invasive, in selected advanced oncologic cases can be an effective approach to symptomatic control and improvement of the quality of life, as demonstrated in our patient.
Acknowledgments
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