Non-secreting, Non-fibrotic Hepatocellular Carcinoma in an Average Risk Population

Abstract

Introduction: Hepatocellular carcinoma (HCC) is the fifth leading cancer worldwide. Non-fibrotic HCC (NFHCC) has been fairly reported especially in chronic hepatitis B infection. Nonetheless, recent epidemiological data indicates an overwhelming 12-42% of HCC arising from NAFLD (Non-Alcoholic Fatty Liver Disease) without cirrhosis or fibrosis revealing unexplored thoughts for carcinogenesis. Herein, we present a case of non-secreting NFHCC in an obese male with no apparent risk factors. Methods: We present a 63 year old Caucasian obese male (BMI 35.2 Kg/m2) with no significant past medical history who sustained injuries during a motor vehicle accident. Subsequently, trauma work up was significant for spinal fracture and an incidental right hepatic lesion. On further questioning, the patient denied alcohol abuse, exposure to toxins or family history for GI malignancy. The physical examination was unremarkable as well liver function test, coagulation profile, viral hepatitis serology, anti-nuclear antibody, anti-smooth muscle antibody, iron profile and alpha-fetoprotein(AFP) level. Results: To further investigate the hepatic lesion, a MRI of the abdomen with IV contrast revealed a 3.8 cm heterogenous lesion with ring enhancement suspicious for malignancy and diffuse steatosis otherwise normal biliary tree and pancreatic duct appearance. Malignancy was confirmed by liver biopsy. Subsequent colonoscopy result was benign.Figure 1Figure 2Figure 3After a discussion with the patient and surgery department, the plan was to proceed with surgical resection of the isolated hepatic tumor. The patient successfully underwent a laparoscopic hand-assisted resection of the segment 6 and 7 of the liver. The final surgical pathology confirmed a moderately differentiated HCC with hepatic steatosis. Conclusion: During the last decades, obesity and type 2 diabetes have strongly been associated to NAFLD related NFHCC driven by diverse intrahepatic cellular mechanisms. To the best of our knowledge, the behavior of non-secreting tumors, those lacking AFP, has not been entirely studied in association with NFHCC attributed to NAFLD. Partial resection of liver may be the appropriate option in a good surgical candidate like our patient or in Child-Pugh A cirrotics. If resected timely, a single HCC lesion in minimally to non-fibrotic liver has been reported to have better overall survival irrespective of tumor size. Finally, screening and management of HCC in apparent average risk populations will continue to be a matter of active debate.