Hepatoid Carcinomatosis Without Primary Liver Lesion

Abstract

Purpose: Hepatoid carcinomas are a rare group of neoplasms with features resembling hepatocellular carcinoma. We are describing a case of hepatoid carcinomatosis with no evidence of a primary lesion by CAT scan or surgical exploration. Methods: The patient is a 63 year old female who presented with abdominal bloating, nausea and vomiting. She had negative workup for anemia with upper and lower scopes. She had also been having increased fatigue and early satiety. Cardiac workup was negative. PMHx: hyperlipidemia, hypertension, COPD, S/P Hysterectomy 20 years ago. Smoker of 32 years. Medication: pravastatin, estropipate, irbesartan, L-methylfolate, propranolol, Iron, sumatriptan. PE: (+) ascites and lower extremity edema without evidence of lymphadenopathy. Patient had CT abdomen and pelvis which showed dilated small bowel, mild ascites, and mesenteric stranding suspicious of infiltrative disease. An NG was placed and abdominal paracentesis was done, albumin gradient was less than 1.1 with high protein. Blood markers for Ca-125 1102, CEA 6.3, alpha feto protein 232161. Patient underwent exploration for possible small bowel obstruction and debulking of the tumor. During surgery patient was noted to have diffuse peritoneal implants that covered small bowel omentum, and liver capsule without invasion. Biopsy showed poorly differentiated carcinoma with hepatocellular differentiation, immuno stain was strongly positive AFP. There was no evidence of primary tumor in any location by CT and later on MRI. Patient was started on Nexavar® (Sorafenib) and has been doing fairly well after one year of follow up. Results: In 1982, Prat and colleagues described a series of 7 unusual ovarian tumors with features resembling hepatocellular carcinoma, with no evidence of primary hepatic malignancy. This phenomenon has been identified as a hepatoid variant form of yolk sac tumor, also known as H-YST. Since then, multiple case reports of similar malignancies arising from stomach, colon, renal pelvis, pancreas, gallbladder have been described. There is one feature in common, that being the production of Alpha Feto Protein. Conclusion: Our case is very unusual, our patient was diagnosed with primary hepatoid carcinomatosis. She is S/P Hysterectomy, negative CAT scan of a primary lesion, and her follow up CAT scan was also negative for any new lesions.Figure