34-year-old gentleman visited LPC, Mumbai with vague abdominal complaints and an USG & CT scan showing a large liver mass of unknown nature. He only had complaints of dyspeptic nature for few months. He did not have abdominal pain, vomiting, anorexia, jaundice, and fever, weight loss or GI bleed. There was no history of blood transfusion, previous liver disease or surgery. He did not have any co morbid factors like diabetes, hypertension, thyroid disorder, IHD, BA, TB, cirrhosis, kidney disease. He had never had alcohol and never smoked. General examination did not show any significant finding (pallor, cyanosis, jaundice, lymph nodes). Abdominal examination revealed a large palpable lump in the right hypochondrium, probably a mass arising from liver.
Since the imaging studies (USG & CT scan) he was carrying with him, were suboptimal i.e. not performed as per recommended international protocol for a liver tumor (triple phase liver protocol) and were also inconclusive it was decided to repeat them. Work up was started with blood investigation, which included CBC, LFT with PT/INR, tumor markers (AFP, CA19.9, CEA, Chromogranin A), HBsAg & anti HCV. All blood investigations including tumor markers were normal.
A triple phase IV contrast CT scan of abdomen& pelvis was performed. It showed a >10cm size liver tumor involving right lobe of liver. The tumor showed vascular enhancement in the arterial phase (hyperdense with surrounding liver parenchyma) with central necrosis. (PIC 1) In later / portal & delayed phase it became further hyperdense compared to surrounding liver parenchyma i.e. enhanced more. (PIC 2) These features were atypical for one particular tumor pathology and the differential diagnosis was a giant hemangioma (benign) vs Hepatocellular carcinoma (HCC—cancer) vs hepatic adenoma (potentially malignant) vs Focal nodular hyperplasia (benign). Since diagnosis could not be established a triple phase MRI was performed, which again gave similar possibilities.
PIC 1 - Arterial phase showing large tumor with vascular enhancement
PIC 2 - Portal phase showing further enhancement
PIC 3 - Angiography showing a highly vascularised tumor
Since a differentiation between benign and malignant was not possible a USG guided biopsy was done. Howeverbiopsy too was inconclusive. It showed mainly necrotic tissue. At places it showed atypical calls.As it was not possible to rule out a malignancy, a decision was taken to perform a hepatectomy. CT volumetry of liver showed that remnant liver volume after resection would be adequate (>35%). The lesion was very vascular. Hence a conventional angiography and tumor embolization was done one day prior to surgery with an aim to reduce intraoperative blood loss. (PIC 3).
Next day patient was taken up for a modified extended right hepatectomy. Exploratory laparotomy through a Mercedes Benz (modified bilateral sub costal) incision revealed a large vascular liver tumor (PIC 4). A modified extended right hepatectomy (right hepatectomy with a small area of left lobe i.e. liver segments 5,6,7,8 & 4b) was done with the tumor (PIC 5, 6, 7). Patient recovered uneventfully and was discharged after 8 days. Final histopathology & immunohistochemistry confirmed a well-differentiated hepatocellular carcinoma justifying our decision to go ahead with the surgery.
PIC 4 - Intraoperative picture showing a large tumor in right lobe of liver
PIC 5 - Intraoperative picture showing remnant liver after modified extended right hepatectomy
PIC 6 - Uncut specimen with the tumor
PIC 7 - Cut specimen with the tumor showing areas of necrosis and hemorhhage
Large liver tumors are a special problem in liver surgery and need special surgical skills for treatment. All efforts should be done to establish the nature of tumor. A biopsy should be done only if absolutely necessary. Whenever in doubt it is better to resect the tumor. Surgery can be safely performed in most situations with a mortality risk of <5%. However morbidity is still high in liver surgery especially in patients with such giant tumors.
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