Wu WK, Patel K, Padmanabhan C, Idrees K. Hepatocellular carcinoma presenting as an extrahepatic mass: A case report and review of literature. World J Gastrointest Oncol 2024; 16(5): 2241-2252 [PMID: 38764834 DOI: 10.4251/wjgo.v16.i5.2241]
Corresponding Author of This Article
Kamran Idrees, MBBS, Chief, Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, 2220 Pierce Avenue 597 Preston Research Building, Nashville, TN 37232, United States. kamran.idrees@vumc.org
Research Domain of This Article
Surgery
Article-Type of This Article
Case Report
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Gastrointest Oncol. May 15, 2024; 16(5): 2241-2252 Published online May 15, 2024. doi: 10.4251/wjgo.v16.i5.2241
Hepatocellular carcinoma presenting as an extrahepatic mass: A case report and review of literature
Wei Kelly Wu, Krutika Patel, Chandrasekhar Padmanabhan, Kamran Idrees
Wei Kelly Wu, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, United States
Krutika Patel, Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN 37232, United States
Chandrasekhar Padmanabhan, Kamran Idrees, Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, United States
Author contributions: Wu WK, Padmanabhan C, and Idrees K analyzed and interpreted the patient’s data and directed clinical care; Patel K performed the histological examination of the surgical specimen; Wu WK wrote the initial manuscript draft. All authors contributed to manuscript revisions and approved the final manuscript.
Informed consent statement: The requirement of ethical approval was waived by the Institutional Review Board given that the description of a clinical case of a single patient does not meet the federal definition of human subjects research.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Kamran Idrees, MBBS, Chief, Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, 2220 Pierce Avenue 597 Preston Research Building, Nashville, TN 37232, United States. kamran.idrees@vumc.org
Received: January 2, 2024 Peer-review started: January 2, 2024 First decision: January 25, 2024 Revised: February 3, 2024 Accepted: March 20, 2024 Article in press: March 20, 2024 Published online: May 15, 2024 Processing time: 128 Days and 12.2 Hours
Abstract
BACKGROUND
Hepatocellular carcinoma (HCC) is a primary liver tumor generally diagnosed based on radiographic findings. Metastatic disease is typically associated with increased tumor diameter, multifocality, and vascular invasion. We report a case of a patient who presented with extrahepatic HCC metastasis to a portocaval lymph node with occult hepatic primary on computed tomography (CT). We review the literature for cases of extrahepatic HCC presentation without known hepatic lesions and discuss strategies to differentiate between metastatic and ectopic HCC.
CASE SUMMARY
A 67-year-old male with remotely treated hepatis C was referred for evaluation of an enlarging portocaval, mixed cystic-solid mass. Serial CT evaluations demonstrated steatosis, but no cirrhosis or liver lesions. Endoscopic ultrasound demonstrated a normal-appearing pancreas, biliary tree, and liver. Fine needle aspiration yielded atypical cells. The differential diagnosis included duodenal or pancreatic cyst, lymphoproliferative cyst, stromal or mesenchymal lesions, nodal involvement from gastrointestinal or hematologic malignancy, or duodenal gastro-intestinal stromal tumor. After review by a multidisciplinary tumor board, the patient underwent open surgical resection of a 5.2 cm × 5.5 cm retroperitoneal mass with pathology consistent with moderately-differentiated HCC. Magnetic resonance imaging (MRI) subsequently demonstrated a 1.2 cm segment VIII hepatic lesion with late arterial enhancement, fatty sparing, and intrinsic T1 hyperintensity. Alpha fetoprotein was 23.3 ng/mL. The patient was diagnosed with HCC with portocaval nodal involvement. Review: We surveyed the literature for HCC presenting as extrahepatic masses without history of concurrent or prior intrahepatic HCC. We identified 18 cases of extrahepatic HCC ultimately found to represent metastatic lesions, and 30 cases of extrahepatic HCC found to be primary, ectopic HCC.
CONCLUSION
Hepatocellular carcinoma can seldomly present with extrahepatic metastasis in the setting of occult primary. In patients with risk factors for HCC and lesions suspicious for metastatic disease, MRI may be integral to identifying small hepatic lesions and differentiating from ectopic HCC. Tumor markers may also have utility in establishing the diagnosis.
Core Tip: Hepatocellular carcinoma (HCC) metastases are typically associated with increased tumor diameter, multifocality, and vascular invasion. We report a rare case of HCC metastasis to a portocaval lymph node with initially occult hepatic primary. Our case illustrates that multimodal evaluation including alpha fetoprotein and contrast-enhanced magnetic resonance imaging may improve the sensitivity of identification of primary HCC lesions. We also reviewed the literature for HCC presenting as extrahepatic masses (18 cases: Metastatic lesions; 30 cases: Primary ectopic HCC), and discuss that, in patients with extrahepatic sites of HCC, thorough assessment for intrahepatic lesions is critical to classifying disease as metastatic HCC or ectopic HCC.
