The Case of the Disappearing Solitary Liver Lesion

Abstract

Purpose: Purpose: To report an interesting case where a lesion in liver seen on CT disappeared. Methods: 61yo male with past medical history of poorly controlled diabetes, hypertension, Hepatitis C genotype 1 never treated, and prior history of alcohol abuse is followed in GI clinic. During an annual screening in 2009 he had a CT scan which showed an ill-defined lesion in the right lobe of the liver described as an area of decreased attenuation. It was suspicious for heptocellular carcinoma (HCC). The remainder of the liver appeared cirrhotic on the CT scan. He was referred for liver biopsy. The biopsy was referred to the Armed Forces Institute of Pathology (AFIP). The biopsy was read as “large areas of scarring with ductular reaction and foci of atypical glandular proliferation raising the question of adenocarcinoma, however, a definite diagnosis cannot be established…” The patient was sent for EGD, Colonoscopy, PET scan, and consultation to oncology. The PET scan and endoscopies were unremarkable. The Alpha Fetal Protein (AFP) was 5.51 and raised to 7. Oncology was concerned, and referred the patient to general surgery. After a discussion between GI Hepatology and pathology, the patient was referred for repeat liver biopsy. The second biopsy showed “micronodular cirrhosis (stage IV fibrosis) associated with chronic hepatitis and grade 2 necroinflamatory changes and moderate steatosis.” Surgery was deferred, and the patient has followed over 2 years now with no evidence of hepatocellular carcinoma. He has had 2 repeat CT scans, and close clinical follow-up. Additionally an emphasis was made on weight loss and improved glycemic control. He remained asymptomatic. He had good weight loss, and better control of his blood sugar. His AFP remained in the 5-6 range. The 2 subsequent scans showed a decrease, and then complete a disappearance of his liver lesion. He continues to do well. Results: This case demonstrates the workup of an ill-defined liver lesion in the setting of a cirrhotic patient which in this patient was focal accumulation of fat mimicking neoplasm. Our patient had multiple factors contributing to his liver disease: a history of alcohol use, obesity, diabetes, and hepatitis C. While cancer is of concern, steatosis, nodular regeneration, and even focal nodular degeneration must be considered. With noninvasive treatment focusing on weight loss, glycemic control, and close follow-up our patient's liver lesion completely resolved and he continues to do well. Conclusion: Focal accumulation of fat can mimick HCC and with weight loss, better control of diabetes can disappear.