Wang, M.D. and John H. Sun, M.D.
of Pathology and Gastroenterology, UMDNJ
patient is a 78 year-old male who was referred to GI clinic for evaluation of
elevated alpha-fetal protein.
Flomax 0.4mg qd
Prevacid 30mg qd
Asacol 400mg 2 tbs tid
No OTC medication or herbal supplement
Ulcerative colitis since 1999
Inguinal hernia repair
Two brothers died with a history of
Mother had cirrhosis, etiology unknown.
Quit smoking 40 years ago, No EtOH, No
recreational drug use
Vital Signs: Wt 171 lbs, BP 124/68, P 64
General: Appears well, NAD
Skin: A few scattered spider nevi on chest
HEENT: Anicteric sclera, clear conjunctiva,
no oral or pharyngeal lesions
Neck: Supple, no JVD, no adenopathy, no
Chest: Clear with good air entry, no
wheezes or rales. No gynecomastia
Abdomen: Soft, no dilated superficial
abdominal veins, normal bowel sounds, no distention, no ascites, no
hepatomegaly, no palpable spleen tip
clubbing, cyanosis, or edema. No palmer
The patient visited Turkey in
April 1996 and became ill there after 5 days with fever and malaise. He was treated with some intramuscular antibiotics. Thereafter, he was found to be hepatitis C antibody
positive. Since 1996, patient was found
to have persistent mildly elevated aminotransferase levels.
Other risk factors of HCV:
One exposure to a prostitute in 1981
? Contaminated yellow fever vaccine during World War II (Stationed in India)
HAV positive, HBsAg negative, HBsAb
negative, HBcAb negative, HCV Ab positive
Fe 119/ TIBC 324/ %Sat 37
Ferritin 272, Alk
Phos 73, GGTP 64, AST 159, ALT 116, BILI 0.7, Alb 4.1, Protein 8.0,
Ceruloplasmin normal level, ANA negative, PSA 1.4
AST 155, ALT 125, BILI 1.2, TSH 3.17,
Normal echo texture of liver, GB showed no
calculi, the CBD was not dilated, the pancreas appeared normal, the spleen was
4/1999: Had an episode of acute bloody
Colonoscopy with biopsy: Diffuse chronic
active inflammation with acute cryptitis and extensive epithelia regenerative
EGD: At GE junction, focal intestinal
metaplasia with chronic inflammation. A
focus of pancreatic metaplasia is present
6/2000: Repeat colonoscopy
No evidence of any active colitis
First episode of esophageal variceal bleed
and sclerotherapy was performed
Abdominal U/S: Liver appeared to be of
normal size, contour and echogenicity.
No ductal dilatation. Mild
splenomegaly. Enlargement of portal
vein raised the question of early cirrhosis
Abdominal U/S: The liver is diffusely
increased in echogenicity and heterogeneous.
No definite focal mass lesions.
Splenomegaly. Left kidney cyst.
2/2002: Second episode of esophageal
EGD: grade II-III varices, gastric varices with a bright red
cherry spot and active bleeding.
Sclerotherapy was performed on esophageal and gastric varices. Normal duodenum.
Flexible sigmoidoscopy: normal rectum, sigmoid, and normal
colon up to 50 cm insertion. 5.5, H 9.8, PLT 77, PT13.5/ INR1.2, P38
CXR: Heart is normal in size, the lungs
were clear without lesions.
AST 164, ALT 162, Alk Phos 158, BILI 0.6,
PLT 108, PT 14.0/ INR 1.25
Fe 96/ TIBC 339/ %Sat 28.3/ Ferritin 247
HCV type 2b with viral load 786,133
Abdominal U/S: The echo pattern of the
liver was slightly coarsened in a diffuse fashion without focal lesions. Prominence of main portal vein was again
noted. Left renal cyst was without
change from prior study.
6/2002: Repeat EGD with esophageal variceal
The liver appears shrunken and distorted
with a lobular external contour, consistent with cirrhosis.
There is a roughly 2 cm mass at the lateral
aspect of the right hepatic lobe, at the anterior aspect of the posterior
segment. This lesion is relatively T2
bright and blushes on the early arterial phase of the gadolinium administration
with prompt wash-out on subsequent phases.
No additional focal hepatic lesions are
Splenic enlargement suggests portal
is no suspicious pancreatic, adrenal or renal mass. There is no ascites.
Ultrasound examination of
the liver showing a 5x3x10 cm hypoechoic mass (between markers).
Guided Liver Fine Needle Aspiration
specimen with numerous groups of cells in papillary configuration
Central fibrovascular core can be seen clearly at this
cells with high N/C ratio, pleiomorphism, hyperchromasia and mitosis (arrow)
Multinucleated giant cells are present
of normal hepatocytes (green arrow) and the malignant cells (black arrow)
diagnosis (based on the morphology of the FNA specimen): Poorly Differentiated
Hepatic cell carcinoma
In order to make a diagnosis
of HCC, in FNA material, the most useful diagnostic criteria are similarity of
the tumor cells to liver cells, the prominence of nucleoli, a trabecular growth
pattern, and the presence of a sinusoidal stroma. The cytological features presented in this case include a
papillary growth pattern with a central fibrovascular core, lacking of
prominent nucleoli, bizarre-shaped malignant cells with high N/C ratio. A diagnosis of hepatic cell carcinoma can
not be made based on morphology.
Relative Frequency of Various Tumors of the Liver