Hepatocellular carcinoma in pregnancy: a case report
Yang-Yuan Chen
1M.D.,
Yue Ren Chen
2M.D., Hwa-Koon Wu M.D.
3,
Division of Gastroenterology
China Medical University Hospital,
China Medical University, Taichung
1Division of Gastroenterology
2,Division of radiology
3Changhua Christian Hospital, Changhua, Taiwan
Correspondence and Reprints: Yang-Yuan Chen, M.D. China Medical University 3 Lane 138 Tai-An 2nd Street Changhua, 500 TAIWAN
Fax: +886-4-7359253 E-mail: [email protected]
Background:
masses are known to behave more aggressively during pregnancy. In particular, liver masses associated with pregnancy represent a significant diagnostic and therapeutic challenge. We reported the case of a 28-year-old female positive for HBsAg and incidental hepatic mass during prenatal examination. We suggest a rational approach to diagnosis and management.
Case report:
A 28-year-old female was referred for incidental hepatic mass. She had no history of alcohol consumption but had been known to be a hepatitis B carrier (HBsAg) since puberty without follow-up. On routine abdominal ultrasound at
the 33rd week of gestation, a hepatic mass 10.0 cm in size was located over the right hepatic lobe. Blood chemistry revealed impaired liver function (GPT 53U/L) and others revealed within normal limit. Serum virus hepatitis titer revealed the patient to be HBsAg positive, HBeAg negative, anti-HCV negative and HIV negative. Elevation of serum alpha-fetoprotein was found (241.41ng/mL). MRI without contrast revealed a hepatic tumor over S4 about 13.0 x 10.0 cm in size, hyperintense on T2W1 and hypointense on T1W image and central scar formation (Figure 1(b), arrow). The patient was admitted for cesarean section at 38th weeks of gestation after her baby more maturation. She underwent open liver biopsy at same time as the cesarean section which was delivery a healthy baby. Pathology study reported hepatocellular carcinoma. Abdominal CT with contrast study after delivery revealed a huge lobulated heterogenous mass lesion with central scar formation (Figure 1(b), arrow). Segmental hepatectomy of S4b and S5 was performed a month later. This patient was discharged with improved condition. Then she received regular follow-up at our out patient department in every 3 months.
Discussion:
The majority of neoplastic hepatic mass in non-pregnant patients are malignant. In contrast, masses identified during pregnancy are commonly
more benign. Previous reports of benign hepatic mass associated with pregnancy include liver hemangioma, liver cell adenoma and focal nodular hyperplasias (FNH) (Athanassiou AM et al. 1998). Hepatoma is extremely rare.
Several image investigations were used in the evaluation of hepatic masses in a non-pregnant patient. However, contrasted enhanced CT area is rarely used to avoid ionizing radiation during pregnancy, which may result in fetal malformation (Siegmann KC et al. 2009). Abdominal ultrasound is as first choice for evaluation. Ultrasound can distinguish between cystic or solid lesions but may not be used for the differential diagnosis of solid hepatic lesions.
Non-contrast MRI study is useful in the evaluation of hepatic mass in pregnancy. Vascular invasion is a typical image finding in patients with hepatoma. Central scar presentation is a specific finding of FNH and is not typically seen in hepatoma (Bahirwani R et al. 2008). Central scar formation was found in our patient during the initial image study.
HCC appears to have a more rapid course throughout pregnancy (Giannitrapani L et al. 2006). After diagnosis of HCC in pregnancy, a previous report also suggested early pregnancy termination followed by surgical
resection, if possible (Sherman M et al. 2011). While Fetal outcome was favorable in our case, intrauterine fetal death had been reported in other cases.
In conclusion: Hepatic masses in pregnancy represent a significant
diagnostic and therapeutic challenge. hepatoma is an extremely rare finding during pregnancy. Image evaluation combined with abdominal ultrasound and non-contrast MRI are recommended if a pregnant patient with hepatic mass is known as a hepatitis B carrier, and found to have abnormal elevation of alpha-fetoprotein. Hepatic mass with central scar formation, FNH and HCC shall be also survey.
References:
Athanassiou AM, Craigo SD. Liver masses in pregnancy. Semin Perinatol. Apr
Siegmann KC, Heuschmid M, Claussen CD. [Diagnostic imaging during pregnancy]. Dtsch Med Wochenschr. Apr 2009;134(14):686-689;
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Bahirwani R, Reddy KR. Review article: the evaluation of solitary liver masses.
Aliment Pharmacol Ther. Oct 15 2008;28(8):953-965.
Giannitrapani L, Soresi M, La Spada E, Cervello M, D'Alessandro N, Montalto G. Sex hormones and risk of liver tumor. Ann N Y Acad Sci. Nov
2006;1089:228-236.
Sherman M, Burak K, Maroun J. et al. Multidisciplinary Canadian consensus recommendations for the management and treatment of hepatocellular carcinoma. Curr Oncol. 2011; 18(5):228-40
Figure legends:
Figure 1(a): MRI without contrast revealed a hepatic tumor over S4 with
Figure 1(b): Abdominal CT with contrast study revealed a huge lobulated
