Giant pedunculated hepatocellular carcinoma with hemangioma mimicking intestinal obstruction

Abstract

Background: Pedunculated hepatocellular carcinoma (P-HCC) has rarely been reported and is characteristically large and encapsulated. Only sporadic cases have been published, in which P-HCC was combined with other liver tumors (mostly benign), making the diagnosis difficult.

Case presentation: We report a patient who was admitted to our hospital with clinical features of intestinal obstruction and a palpable mass in the right iliac fossa. Ultrasound, computed tomography and magnetic resonance imaging demonstrated an encapsulated mass of unclear origin and characteristics of liver hemangioma. Laboratory tests revealed elevated α-fetoprotein (> 800 ng/ml) and cancer antigen 125 (> 51.2 U/ml). With a possible diagnosis of giant liver hemangioma, we proceeded to surgery. During surgery, a giant pedunculated tumor was discovered on the inferior surface of the right lobe of the liver, hanging free in the right abdominal cavity towards the right iliac fossa. The macroscopic appearance of the tumor was compatible with liver hemangioma. Tumor resection was performed at a safe distance, including the pedicle. The rest of the liver appeared normal. Histopathological examination revealed grade II and III HCC (according to Edmondson-Steiner's classification) with nodular configuration, central necrosis, and infiltration of the capsule. Underneath the tumor capsule, residual tissue of a cavernous hemangioma was recognized. The resection margins were free of neoplastic tissue.

Conclusion: This rare presentation of a giant P-HCC combined with a hemangioma with features of intestinal obstruction confirmed the diagnostic difficulties of similar cases, and required prompt surgical treatment. Therefore, patients benefit from surgical resection because both the capsule and the pedicle prevent vascular invasion, therefore improving prognosis.

Figure 1

MRI images of the pedunculated tumor. A: MR T2 coronal image showing a heterogeneous tumor mass underneath the right hepatic lobe. Arrow indicates tumor pedicle. B: MR T2 fat suppressed axial image depicting a heterogeneous signal intensity liver mass. C: MR T1 axial image showing a large right liver lobe mass displacing intestinal loops.

Figure 2

Intraoperative sequence of the pedunculated HCC resection (A, B, C).

Figure 3

Resected tumor mass.

Figure 4

Histological images. A. Histological section (H&E stain) of the described cavernous hemangioma (arrow) located underneath the hepatic capsule, adjacent to the HCC (arrowhead) (magnification × 100). B. Areas of hemangioma at higher magnification(× 200).