Hepatocellular carcinoma presenting as an extrahepatic mass: A case report and review of literature

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.

Keywords: Case report; Extrahepatic; Lymph node; Metastasis; Portocaval.

Figure 1

Lesion growth on computed tomography. Serial intravenous-contrasted Computed tomography scans of the abdomen and pelvis demonstrated increase in size of the patient’s portocaval mass (arrows). A: 3.6 cm × 2 cm, 8 months prior to presentation; B: 5.2 cm × 3.2 cm, time of presentation.

Figure 2

Histopathologic evaluation of the resected mass. A: Hematoxylin and eosin staining at low and high magnification reveals vague nodules of large polygonal cells with eosinophilic granular to clear vacuolated cytoplasm, steatotic and clear-cell changes, increased mitosis, necrosis and rare hyaline bodies; B: Immunohistochemistry demonstrates positive staining for HepPar1, arginase-1, and glypican-3.

Figure 3

Magnetic resonance imaging of the liver. Magnetic resonance imaging abdomen demonstrated a 1.2 cm lesion in segment VIII with late arterial enhancement, fatty sparing, and intrinsic T1 hyperintensity. A: T1-weighted, pre-contrast; B: T1-weighted immediate post-contrast; C: T1-weighted, 5 min post-contrast.