Hepatocellular Cancer in a Non-cirrhotic Hepatitis C Patient

Abstract

Introduction: Cirrhosis is the number one predisposing factor for development of hepatocellular cancer (HCC), but rarely, it has also been observed in hepatitis C patients with no underlying cirrhosis. Surveillance of HCC has been postulated for hepatitis B, hepatitis C, cirrhosis, alcoholic cirrhosis, genetic hemochromatosis, and primary biliary cirrhosis, but there are no guidelines developed for screening of non-cirrhotic hepatitis C patients. A 60-year-old man with past medical history significant for chronic hepatitis C presented to his primary care office with a vague abdominal pain present for the past few months, with early satiety and poor appetite. The patient reported social drinking and denied any past smoking or illicit drug usage. His physical examination was unremarkable except for hepatomegaly, with a liver span of 3-4 cm. Hepatitis C antibody was positive with hepatitis RNA quantitative of 7000,000 IU/mL. Hepatitis B surface antigen, hepatitis B core IgM, and hepatitis A IgM were negative. Alpha-fetoprotein, Ca-99, CEA, and chromogranin were unremarkable. Laboratory work was unremarkable except elevated alkaline phosphatase (ALP) 154 U/L (34-104 U/L), AST 157 U/L (13-39 U/L), and ALT 95 U/L (7-52 U/L). Ultrasound of the abdomen revealed a large left-sided malignant-appearing liver mass. A follow-up triple phase CT (Figures A and B) of the abdomen demonstrated a liver mass 9.3 x 9 x 9 cm in size directly compressing the stomach, with no evidence of peritoneal metastasis and absence of cirrhosis. The patient underwent partial left hepatic lobectomy, segment 2 and 3 lateral segmentectomy with 7-mm tumor free margin, with no evidence of peritoneal metastasis. Intraoperative ultrasound of the liver revealed normal anatomy with the absence of hepatic metastasis. Pathologic analysis of the hepatic mass illustrated moderately differentiated hepatocellular carcinoma consistent with a trabecular pattern without significant fibrosis, absence of fibrous lamellae, and abundant necrosis (Figure C). The patient was thus diagnosed with stage II (T2NxMx) with 9 cm of moderately differentiated hepatocellular cancer. On follow-up, there was a remarkable improvement in his functional status. ALP, AST, and ALT were followed sequentially and the levels normalized to 80 U/L, 40 U/L, and 53 U/L within 4 months. The patient opted for conservative management with 6 monthly follow-ups with CT Abdomen scan for the next 2 years.Figure 1