An Unusual Case of Hepatocellular Carcinoma Without Pre-existing Liver Cirrhosis or Fibrosis in a Patient With Metabolic Syndrome

Abstract

Introduction: Hepatocellular carcinoma (HCC) is a rare, but well-recognized outcome among patients with advanced fibrosis. Metabolic syndrome is a risk factor for nonalcoholic fatty liver disease, as well as cirrhosis. We present a case report of isolated hepatocellular carcinoma without pre-existing liver fibrosis or cirrhosis occurring in a patient with metabolic syndrome. Case Report: A 63-year-old male with metabolic syndrome, defined by hypertension, type 2 diabetes mellitus, dyslipidemia with elevated triglyceride levels, and BMI of 32.5 had mild elevation in liver enzymes (AST, ALT, ALP, total bilirubin were 57, 82, 87IU/L, and 0.3mg/dl, respectively), which was attributed to nonalcoholic fatty liver disease. He had a symptomatic umbilical hernia and underwent further evaluation. The clinical work-up included an abdominal CT scan with IV contrast that revealed an incidental hepatic mass. A follow-up MRI of the abdomen revealed a mass in the dome of the liver. A PET scan, ordered to look for any metastatic disease and possible primary sources of tumor, revealed a 3.4 x 2.9-cm hypervascular hepatic mass in the right hepatic lobe with hypermetabolic activity compared to the normal liver parenchyma. Two small (0.7 cm in size), stable subpleural nodules in the right lower lobe of the lung were also detected, which were suspected to be due to granulomatous changes and not metastatic disease. Work-up for common causes of chronic liver disease, including viral serologies, was negative. Prothrombin time, INR, albumin, tumor markers including alpha-fetoprotein, CA-19, and carcinoembryonic antigen were within normal limits. The patient was referred to surgery for resection of the mass and underwent right hepatectomy. The surgical pathology revealed well-differentiated hepatocellular carcinoma. Interestingly, no cirrhosis or even fibrosis was seen in the surrounding hepatic parenchyma. The patient had an uncomplicated postoperative course. He remains asymptomatic and continues to have mild elevation in serum transaminases 1 year after his surgery. (AST, ALT, ALP, and total bilirubin were 102, 133, 136 IU/L, and 0.5 mg/dL, respectively). Conclusion: Our patient with metabolic syndrome developed hepatocellular carcinoma without pre-existing cirrhosis or advanced fibrosis. Metabolic syndrome may be a risk factor not only for chronic non-alcoholic liver disease, but also HCC, even in the absence of nonalcoholic steatohepatitis or advanced fibrosis. Further studies are required to identify a subset of metabolic syndrome patients at a higher risk for development of HCC, who may benefit from HCC screening.