General Surgery · Year 3 · from General Surgery

Case 3: Hepatocellular Carcinoma

Patient Demographics

  • Age: 62 years
  • Sex: Male
  • Occupation: Retired factory worker

Chief Complaint

"I had a scan for something else and they found a spot on my liver."

History of Present Illness

The patient was undergoing workup for vague abdominal discomfort when an abdominal ultrasound revealed a liver mass. He denies weight loss, jaundice, or abdominal swelling. He has a history of chronic hepatitis C infection that was treated and cured 3 years ago with direct-acting antivirals. He has been told he has "some liver scarring" but has not had regular surveillance.

Past Medical History

  • Chronic hepatitis C (SVR achieved 3 years ago with sofosbuvir/ledipasvir)
  • Cirrhosis (diagnosed on prior biopsy, compensated)
  • History of IV drug use (remote, now clean 20 years)
  • No prior liver decompensation (no ascites, variceal bleeding, or encephalopathy)

Medications

  • None currently

Physical Examination

  • Vitals: Normal
  • General: Appears well, no cachexia
  • Abdomen:
  • Soft, non-tender
  • No palpable hepatomegaly or splenomegaly
  • No ascites
  • Skin: No spider angiomata, palmar erythema, or jaundice
  • Extremities: No edema

Laboratory Results

  • Platelets: 112,000/μL (low - consistent with cirrhosis)
  • Albumin: 3.8 g/dL
  • Total bilirubin: 1.1 mg/dL
  • INR: 1.1
  • Creatinine: 0.9 mg/dL
  • AFP: 86 ng/mL (elevated, normal <10)
  • Hepatitis C: SVR confirmed (undetectable viral load)

Liver Function Assessment

  • Child-Pugh Score: A5 (well-compensated cirrhosis)
  • MELD score: 8

Imaging

Multiphasic CT Liver:

  • 3.5 cm mass in segment VI of liver
  • Arterial phase hyperenhancement
  • Washout on portal venous and delayed phases
  • Diagnostic for HCC (LI-RADS 5)
  • No portal vein invasion
  • No satellite lesions
  • No extrahepatic disease

MRI Liver with Primovist:

  • Confirms 3.5 cm HCC in segment VI
  • No additional lesions
  • Hepatobiliary phase hypointensity (characteristic of HCC)

Diagnosis

Hepatocellular carcinoma (HCC), single lesion, 3.5 cm, in compensated cirrhosis

Staging

  • BCLC Stage A (early stage - single tumor <5 cm, preserved liver function)
  • Milan criteria: Within (single tumor ≤5 cm)

Treatment Options Discussed

  1. Surgical resection: Good option for single lesion with preserved liver function
  2. Liver transplantation: Treats both HCC and underlying cirrhosis
  3. Ablation: Alternative for tumors <3 cm or if not surgical candidate

Transplant Evaluation

  • Within Milan criteria
  • Listed for liver transplant with MELD exception points
  • Expected wait time: 6-12 months in this region

Bridge Therapy (While Awaiting Transplant)

  • Transarterial chemoembolization (TACE) performed
  • Good response with tumor necrosis on follow-up imaging

Liver Transplant (10 months after listing)

  • Deceased donor liver transplant performed
  • Explant pathology:
  • 2.8 cm HCC with extensive necrosis (TACE effect)
  • Well-differentiated
  • No vascular invasion
  • No satellite lesions
  • Background cirrhosis with no dysplastic nodules

Post-Transplant Course

  • Immunosuppression: Tacrolimus-based regimen
  • Discharged POD 8
  • Close surveillance for HCC recurrence and rejection

Follow-up

  • AFP normalized
  • CT surveillance: No recurrence at 1 year
  • Excellent graft function

Teaching Points

  1. HCC surveillance essential in cirrhotics (US + AFP every 6 months)
  2. SVR from HCV does not eliminate HCC risk in cirrhotics
  3. Diagnosis often by imaging criteria (LI-RADS 5) without biopsy
  4. BCLC staging guides treatment selection
  5. Milan criteria determine transplant eligibility
  6. Bridge therapy (TACE, ablation) while awaiting transplant
  7. Transplant treats both cancer and underlying liver disease

Clinical Image

Image Description: Multiphasic CT scan demonstrating a hepatocellular carcinoma with characteristic arterial phase hyperenhancement. The tumor shows avid contrast uptake during the arterial phase with subsequent washout, diagnostic of HCC in the setting of cirrhosis.

Attribution: Image from Wikimedia Commons, Category:CT images of liver cancer. Source: https://commons.wikimedia.org/wiki/Category:CT_images_of_liver_cancer

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