St. Luke's University Health Network Bethlehem, PA
Farah Harmouch, MD1, Hammad Liaquat, MD1, Patrick Callaghan, DO2, Lisa Stoll, MD, MPH3, Kimberly J. Chaput, DO1; 1St. Luke's University Health Network, Bethlehem, PA; 2St. Luke's Hospital, Bethlehem, PA; 3Saint Luke's, Bethlehem, PA
Introduction: Hepatocellular carcinoma (HCC) typically presents as a solitary mass on imaging with abdominal pain, derangement of liver enzymes, hepatic dysfunction, and occurs most commonly on a background of cirrhosis from diverse etiologies. We present a case of HCC that presented as an abscess with an enterohepatic fistula.
Methods: A 68-year-old male with hypertension, type 2 diabetes mellitus, and Crohn’s disease (CD) in clinical remission for >1 year, presented with right lower quadrant (RLQ) pain for two days and 20lbs unintentional weight loss in one year. Initial vitals were T 98.8F, HR 109, BP 123/59. Physical exam revealed tenderness and a palpable mass in the right lower quadrant. Labs showed WBC 26.2x10^3/ul, AST 46 u/L, ALT 21 u/L, alk phos 76 u/L, T bili 0.9 mg/dl. Serum AFP level was 6681mg/ml while CEA and CA 19-9 were normal. HBsAg, total and IgM HBcAb, and HCV antibodies were non-reactive. He was started on IV antibiotics for sepsis. CT abdomen revealed a large right hepatic mass with foci of air, smaller hypoattenuating hepatic lesions suspicious for metastatic lesions, and carcinomatosis of the right mid-abdomen (Image 1). CT guided percutaneous drain was placed in the mass revealing feculent fluid with polymicrobial growth on culture. CT abdomen with oral contrast was done to assess status of the abscess post-drain placement and revealed oral contrast present within the center of a persistent abscess indicating an enterohepatic fistula (Image 2). Triple phase MRI suggested a primary hepatic lesion with central necrosis and fistulization with the adjacent colon and multiple hepatic lesions suggesting metastatic disease. Biopsy of the largest hepatic lesion revealed HCC with clear cell features (Image 3). Conservative management with drain placement and IV antibiotics had failed to resolve the abscess per imaging. Patient refused surgery and opted for hospice due to metastatic HCC diagnosis and died one month later. Discussion: To our knowledge, this is the fourth case of an enterohepatic fistula with CD and possibly the first in untreated HCC. About 20% HCC occurs in the absence of cirrhosis with the vast majority associated with HBV, HCV, alcohol use, or non-alcoholic fatty liver disease. While CD is well associated with intestinal and extra-intestinal malignancies, its association with HCC is unclear.
Image 1- CT scan without oral contrast revealed a large hypoattenuating, rim-enhancing collection with multiple foci of air within the right hepatic lobe, measuring approximately 10.5x22x11.7 cm (red arrows).
Figure 2– CT abdomen with oral contrast revealing an enterohepatic fistula (red arrows) in (A) and a large hepatic mass (green arrows) filled with oral contrast (yellow arrow) in (B).
Figure 3 - Triple phase MRI abdomen revealed multiple hepatic lesions (red arrows) in (A) suspicious for metastatic disease as well as a large mass with small area of central necrosis measuring 10.7 x 11.1 cm (green arrows) in (B).Liver biopsy H&E stain (20x) revealed clear cell HCC with sheets of tumor cells showing cytoplasmic clearing owing to the presence of abundant glycogen in (C). Arginase IHC stain (20x) revealed arginase expression confirming liver origin of tumor (D). Glypican-3 IHC stain (40X) showed diffuse glypican-3 expression within tumor cells confirming HCC (E). PAX8 IHC stain (20x) was absent for PAX8 expression excluding renal cell carcinoma (the main differential) (F).
Disclosures: Farah Harmouch indicated no relevant financial relationships. Hammad Liaquat indicated no relevant financial relationships. Patrick Callaghan indicated no relevant financial relationships. Lisa Stoll indicated no relevant financial relationships. Kimberly Chaput indicated no relevant financial relationships.