Case Presentation

March 2003

Hongling Wang, M.D. and John H. Sun, M.D.

Departments of Pathology and Gastroenterology, UMDNJ

 

 

Patient:  The patient is a 78 year-old male who was referred to GI clinic for evaluation of elevated alpha-fetal protein.

Allergy:  NKDA

Medications:

–                     Flomax 0.4mg qd

–                     Prevacid 30mg qd

–                     Asacol 400mg 2 tbs tid

–                     No OTC medication or herbal supplement

Past Medical History:

–                     Hepatitis C

–                     Ulcerative colitis since 1999

–                     BPH

–                     CAD/Angina

–                     TIA

Past Surgical History:

–                     Back surgery

–                     Eye surgery

–                     Inguinal hernia repair

Family History:

–                     Two brothers died with a history of hypernephroma.

–                     Mother had cirrhosis, etiology unknown.

Social History:

–                     Quit smoking 40 years ago, No EtOH, No recreational drug use

 

Physical Exam:

–                     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 thyromegaly

–                     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

–                     Extremities: No clubbing, cyanosis, or edema.  No palmer erythema

  

 

Clinical course:

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.

 

l    Other risk factors of HCV:

–            One exposure to a prostitute in 1981

? Contaminated yellow fever vaccine during World War II (Stationed in India)

l    8/1996

–            HAV positive, HBsAg negative, HBsAb negative, HBcAb negative, HCV Ab positive
–            AFP 2.58, 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

l    3/1999

–            AST 155, ALT 125, BILI 1.2, TSH 3.17,

AFP 3.5, PSA 2.12

–            Normal echo texture of liver, GB showed no calculi, the CBD was not dilated, the pancreas appeared normal, the spleen was not enlarged

l   4/1999: Had an episode of acute bloody diarrhea

–            Colonoscopy with biopsy: Diffuse chronic active inflammation with acute cryptitis and extensive epithelia regenerative changes.

–            EGD: At GE junction, focal intestinal metaplasia with chronic inflammation.  A focus of pancreatic metaplasia is present

l   6/2000: Repeat colonoscopy

–            No evidence of any active colitis

l   7/2000

–            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

l   11/2001

–            Abdominal U/S: The liver is diffusely increased in echogenicity and heterogeneous.  No definite focal mass lesions.  Splenomegaly.  Left kidney cyst.

l    2/2002: Second episode of esophageal variceal bleed

–            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.

l   4/2002

–            AFP 16.9 (<6.1)

–            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.

l   6/2002: Repeat EGD with esophageal variceal banding ligation

–            Congestive gastropathy

–            Normal duodenum

l   9/2002: AFP 88.1

 

MRI Abdomen

 

l    The liver appears shrunken and distorted with a lobular external contour, consistent with cirrhosis.

l    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.

l   No additional focal hepatic lesions are identified. 

l   Splenic enlargement suggests portal hypertension. 

l   There 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).

 

 

 

CT Scan Guided Liver Fine Needle Aspiration

 

 

Cellular specimen with numerous groups of cells in papillary configuration

 

 

 

Central fibrovascular core can be seen clearly at this magnification

 

 

 

 

Malignant cells with high N/C ratio, pleiomorphism, hyperchromasia and mitosis (arrow)

 

 

 

 

Multinucleated giant cells are present

 

 

Comparison of normal hepatocytes (green arrow) and the malignant cells (black arrow)

 

 

 

The diagnosis (based on the morphology of the FNA specimen): Poorly Differentiated Papillary Adenocarcinoma.

 

Discussion

 

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.

 

The Relative Frequency of Various Tumors of the Liver