A 61-Year-Old Woman With Abdominal Pain and Syncope

James J. McCombie, MB ChB; Erik D. Schraga, MD


June 01, 2016


CT of the abdomen and pelvis revealed a heterogeneous 4-cm mass within the dome of the right lobe of the liver, with a small high-attenuation area believed to represent an actively bleeding site (Figure 1). High-density material around the liver and under the right hemidiaphragm (Figure 2), which extended down along the right pericolic gutter into the pelvis and was consistent with blood, was also noted. The liver had a heterogeneous appearance suggestive of cirrhosis.

Figure 1.

Figure 2.

Hepatoma, or hepatocellular carcinoma (HCC), is a primary cancer of the liver and has an incidence of 5.2 per 100,000 population in the United States. In 80% of patients, some degree of underlying cirrhosis is present, with alcoholic cirrhosis being the major cause in the developed world. Other causes of hepatoma include chronic hepatitis B or hepatitis C infection, as well as alpha-1 antitrypsin deficiency, hemochromatosis, and primary biliary cirrhosis.

Drugs, such as anabolic steroids, and toxins, such as aflatoxin (which are produced by a species of Aspergillus that grows on stored grains and peanuts), have also been implicated in HCC. Finally, parasitic infestations, such as schistosomiasis, have been known to be responsible.

HCC is three to four times more common in males. The clinical manifestations are seldom distinctive and are often masked by those related to the background of cirrhosis or chronic hepatitis. HCC should be suspected if a patient with cirrhosis deteriorates without an alternative explanation.[1]

Surveillance should be considered for certain high-risk groups, including persons with chronic viral hepatitis, because this has been shown to improve survival. In a series of patients with chronic hepatitis B infection,[2] HCC tumor size was smaller (4.2 cm vs 7.7 cm) and less frequently present (2.6 vs 3.8) in the surveillance group than in the nonsurveillance group. Definitive treatment with surgery (20% vs 10%) and local ablative therapy (46% vs 19%) was more likely to be able to be performed in the surveillance group than in the nonsurveillance group.

Median survival was significantly longer in the surveillance group than the nonsurveillance group (88 weeks vs 26 weeks). The adjusted cumulative survival at 2 years was significantly longer in the surveillance group if the tumor volume doubling time was < 90 days.[2]

The presence of a mass > 2 cm on ultrasonography in a patient with underlying cirrhosis is 95% predictive of hepatoma. In addition, an increased alpha-fetoprotein (AFP) level virtually confirms the diagnosis, and the patient should be evaluated for surgery when appropriate.[2] If the AFP level is normal, further imaging with CT, MRI, or angiography should be used to help clarify the diagnosis. Biopsy is indicated only in cases of major diagnostic doubt.[3]


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