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Background Patients with cirrhosis due to hepatitis B and C are at risk of developing hepatocellular carcinoma (HCC). These patients are periodically screened by imaging studies and alpha-fetoprotein (AFP) levels. Case report We present a case of a 58-year-old male with established, biopsy proven cirrhosis due to hepatitis C. He remained clinically stable for 11 years. One year prior to death, his AFP levels started to rise, reaching 300 000 IU/mL before death. Ultrasound, triple phase CT and MRI of the liver confirmed cirrhosis but failed to find any definite tumour. No tumour was seen elsewhere. He died of liver failure and the question asked by clinicians at autopsy was ‘Where is the tumour?’. At autopsy, the liver was enlarged and cirrhotic, weighing 3985 g. No obvious discrete mass lesion, suggestive of HCC, was seen on gross examination. No other mass lesions were identified elsewhere. Microscopic examination revealed extensive infiltration of liver by nodules of moderately differentiated HCC interspersed amongst cirrhotic nodules. Conclusion This case is a very rare variant of HCC which diffusely involves the liver without forming a discrete dominant mass and macroscopically mimics cirrhosis. Diagnosing this variant of HCC on a background of cirrhosis is therefore a clinical and radiological challenge. This pattern of HCC has been described in some case series, predominantly as an incidental finding in cirrhotic explanted livers with mild or no rise in AFP levels. Our case is unique as there was a high clinical suspicion of HCC, given the alarming rise in AFP levels, but radiologically no such lesion was detected. |
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