Prasad A. Bhate, Jatin A Patel, Pathik Parikh, Meghrai A. Ingle, Anniruddha Phadke, Prabha Sawant
Department of Gastroenterology First floor ,College building
Lokmanya Tilak municipal medical college and hospital,Sion, Mumbai, Maharashtra, India
Dr.Prasad Ashok Bhate
Hepatocellular carcinoma (HCC) is the commonest primary malignant tumor of the liver.HCC presenting as a pyogenic liver abscess is reported but is uncommon and rarely addressed in literature. It is challenging to diagnose HCC presenting as a pyogenic abscess.
A 38 year old male patient presented with the complaint of continuous, dull aching pain in the right hypochondrium for 2 months. The pain was of moderate intensity,non radiating and associated with high grade fever with chills. There was history of loss of appetite and weight loss of approximately 3 kilograms over two months.On examination he was febrile and hemodynamically stable. He had tender hepatomegaly 6 cm below the costal margin in the mid-clavicular line. The liver was firm in consistency, had rounded margins and a smooth surface.He had pallor and the rest of the general and systemic examinations were normal. Lab investigations revealed a TLC of 24,600 /cu.mm with 83 percent polymorphs,hemoglobin was 9.7 g/dl and platelets were 3.99lacs/cu.mm.His liver function tests were normal except for a raised alkaline phosphatase (ALP), with total bilirubin of 1.2 mg/dl, Direct:0.8 mg/ dl,Indirect:0.4 mg/dl,aspartate aminotransferase:35 IU/L,alanine aminostransferase:12 IU/L, ALP:260 IU/L (Normal upper limit:110), total protein:7.6 g/ dl,albumin: 4.6 g/dl,globulin:3.0 g/dl, INR: 1.06.Malaria antigen, Widal test,urine R/M,blood culture and urine cultures were all negative.He was positive for HBsAg and negative for HBeAg with HBV DNA titer of 1180 IU/mL.HIV and antiHCV antibodies were negative. Ultrasound abdomen revealed hepatomegaly (18.1 cm),spleen 10.1 cm.The gallbladder,portal vein and common bile duct were normal while minimal free fluid was found in the abdomen.A 9.9 x 6.8 x 9.4 cm sized mixed echogenic, predominantly hypoechoic collection was noted in seg V and VI of the liver, abutting the right kidney.Impression of a liver abscess was given. Intravenous antibiotics were started and ultrasound guided aspiration of the lesion was done. The cellular smears revealed innumerable neutrophils admixed with several foamy macrophages,bare nuclei and degenerated cells over a necrotic background. No amoebea, scolices or hooklets, epitheloid cell clusters or multinucleated giant cells were seen.No atypical or malignant cells were detected. Diagnosis of pyogenic liver abscess was suggested.Aspirate culture showed no growth,Indirect hemagglitination test for anti amoebaantibodies was negative and serum alfa fetoprotein was within normal limits (4.11 IU/ml).
An ultrasound guided liver biopsy findings showed fibrin plugs enmeshing few cords and ribbons of partly degenerated cuboidal cells. The cells possess granular acidophilic cytoplasm and rather monotonous round nuclei with minimal anisonucleosis. At places, “ghost outlines “of similar cells were seen. The polyhedral cells could represent a necrotic neoplasm however,the accompanying smears were entirely inflammatory. To further characterize the lesion dynamic C.T. abdomen (Figure 1) was done. It showed 12 x 7 x 7.5 cm heterogeneously enhancing soft tissue mass noted in segment VII of the liver and in the sub hepatic region. It showed multiple non-enhancing areas within. Rest of the liver was normal and no typical pattern of enhancement was noted. Thepatient’s fever responded and the TLC normalized after a course of antibiotics but his right hypochondrium pain persisted. In view of HBsAg positive status and persistent symptoms, MRI abdomen and repeat biopsy of the lesion were done.
MRI findings (Figure 2) showed a large,well defined 13 x 9 x 10 cm heterogeneous exophytic,bilobed, irregular mass lesion involving segments VI and VII of the liver. It showed hemorrhagic changes within, especially in the inferomedialexophytic component. On T2,hyperintense edema in the adjoining liver parenchyma was found. There wasno significant arterial phase enhancement,no evidence of contrast washout and the rest of the liver parenchyma appeared normal with no other focal lesions.The second imaging also did not show a typical pattern of enhancement.
The microscopy sections from the liver SOL showed tumor cells which were uniform and round,with moderate cytoplasm.Tumor cells were arranged in cords and sheets and few abnormal mitotic figures were present.Diagnosis ofa malignant epithelial tumor was made.The possibility of a neuro-endocrine tumor or a well differentiated HCC was suggested.A few sections showed features of chronic hepatitis with fibrosis.On Immunohistochemistry, the tumor cells expressed cytokeratin,hepatocyte specific antigen (OCYH1E5) and Glypican3 While they wereimmunonegative for synaptophysin,chromogranin A,CK-7 and CK-20.The Mib-1 index was approximately 60 -70 %.Impression ofa well differentiated hepatocellular carcinoma was provided based on the IHC.
So we had a patient who was positive for the HBsAg, presenting to us with what seemed to be only a pyogenic liver abscess, finally diagnosed with a well differentiated HCC following biopsy and IHC. He had atypical findings on imaging, normal serum AFP levels and showed no evidence of liver cirrhosis.The patient underwent hepatic resectionof the tumor.He tolerated the procedure well and is now under surveillance for recurrence.
HCC may present as liver abscess because of spontaneous tumor necrosis and/or biliary obstruction caused by tumor thrombi, superimposed with bacterial infection. Elevated serum alfa feto protein levels may help in diagnosing HCC but they may not always be raised, as in our case.A high index of suspicion is required to diagnose HCC as imaging and biomarkers may not always help.
- Lin YT, Liu CJ, Chen TJ, Chen TL, Yeh YC, Wu HS, et al. Pyogenic liver abscess as the initial manifestation of underlying hepatocellular carcinoma. Am J Med. 2011;124:1158–64.