Amir Sultan, MD
Division of Gastroenterology & Hepatology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
A 45-year-old farmer from rural Ethiopia presented with a 5-month history of progressive right upper quadrant pain accompanied by a dragging sensation and loss of appetite. He had no history of bleeding, change in mentation or other illness.
Physical exam
| Blood pressure | Pulse | Respiratory Rate | Pulse Oximetry | Temperature |
|---|---|---|---|---|
| 130/80 | 88 | 16 | 94 % | 36.5 0C |
General:
Thin and frail
HEENT:
Pink conjunctiva, muddy sclera
Neck:
No palpable lymph nodes
Respiratory:
Clear Chest
Abdomen:
Flat abdomen, Irregular edge of liver palpable 5 cm below the right costal margin. Total liver span 16 cm. No splenomegaly or shifting dullness.
Extremity:
No edema
Neurologic:
Conscious, no flapping tremor
Imaging and Laboratory Information
WBC – 4000
Hgb – 12.8 gm/dl
Platelet – 148,000
ALT – 44
AST – 99
ALP – 131
K – 4.6
Na – 137
HBsAg – Positive
Anti HCV Ab - Negative
Clinical Differential Diagnosis
Ultrasound Imaging Findings
Differential Diagnosis Based on Imaging
Clinical Course and/or Management
Ultrasound demonstrated a large, moderately echogenic mass with central hypodensity and a peripheral hypoechoic rim. The unaffected parenchyma appeared normal with no features of cirrhosis. Ultrasound guided liver biopsy was performed, allowing the definitive diagnosis of hepatocellular carcinoma. The patient was referred for surgical evaluation. However due to the large size of the mass and local invasion surgery was deferred. Palliative treatment was provided.
Diagnosis
Hepatocellular Carcinoma
Discussion
Hepatocellular carcinoma is the fourth leading cause of cancer death worldwide. Major risk factors include hepatitis B infection, alcohol, Hepatitis C infection, non-alcoholic fatty liver disease, and aflatoxin exposure. Sub-Saharan Africa and China are major endemic areas with very high incidence of the malignancy. Ultrasound plays an important role in detecting suspicious lesions, which can then be further evaluated with more definitive studies. Larger lesions more than 20 mm in diameter may demonstrate features such as a peripheral hypoechoic rim (halo sign) and mosaic pattern. In addition, measurement of serum alpha-fetoprotein (AFP) level may help strengthen the diagnosis even though up to a third of cases may be non-secretory.
Liver biopsy in cases of suspected HCC is generally avoided due to risks of bleeding and tumor seeding. The tumor may instead be diagnosed with contrast enhanced CT, MRI, or contrast-enhanced ultrasound. However, if there is diagnostic difficulty or if advanced imaging is unavailable, liver biopsy may be used, as in this case. Delayed diagnosis, especially in resource-limited settings, contributes to substantial variability in survival worldwide.
Management of HCC depends on the status of the unaffected liver parenchyma; size, number, and distribution of lesions; and whether there is evidence of local invasion or of distant metastases. Treatment options include liver transplantation, liver resection, local ablative procedures, and trans-arterial chemoembolization (TACE). In addition, targeted tyrosine kinase inhibitor therapy (such as Sorafenib and Lenvatinib) is available for patients who are not candidates for curative therapy1,2.
References