MEDizzy - A 51-year-old male alcoholic with a history of chronic liver

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Gastrointestinal System

A 51-year-old male alcoholic with a history of chronic liver disease presents with increasing weight loss and ascites. Physical examination reveals a slightly enlarged, soft, nontender prostate. Examination of the scrotum is unremarkable, and fecal occult blood tests are negative. A chest x-ray is unremarkable, but a CT scan of the abdomen reveals a single mass in the left lobe of the liver. Workup reveals elevated levels of α-fetoprotein in this patient’s blood. Which of the following is the most likely diagnosis?

ExplanationThe most common primary malignancy of the liver is the hepatocellular carcinoma (hepatoma). These tumors are associated with certain viral infections (hepatitis B and hepatitis C viruses), aflatoxin (produced by Aspergillus flavus), and cirrhosis. Microscopic sections of these tumors reveal pleomorphic tumor cells that form trabecular patterns, which are similar to the normal architecture of the liver. Hepatomas may secrete α-fetoprotein (AFP), but this tumor marker may also be seen in yolk sac tumors or fetal neural tube defects. Clinically, hepatocellular carcinomas have a tendency to grow into the portal vein or the inferior vena cava and may be associated with several types of paraneoplastic syndromes, such as polycythemia, hypoglycemia, and hypercalcemia. There is a microscopic fibrolamellar variant of hepatocellular carcinoma that is seen more often in females, is not associated with AFP, is grossly encapsulated, and has a better prognosis. It is important to compare the characteristics of hepatocellular carcinomas with those of another type of primary tumor of the liver, namely cholangiocarcinoma, which is a malignancy of bile ducts. This tumor is associated with Thorotrast and infection with the liver fluke (C sinensis), but it is not associated with cirrhosis. Histologically, the tumor cells contain cytoplasmic mucin, which is not found in hepatomas. Instead, these malignant cells may contain cytoplasmic bile. Malignant metastatic tumors are the most common tumors found in the liver. Grossly there may be multiple or single nodules, which microscopically usually resemble the primary tumor. For example, metastatic colon cancer to the liver histologically reveals adenocarcinoma. Metastatic disease to the liver usually does not cause functional abnormalities of the liver itself, and the liver enzymes and bilirubin levels in the blood are usually normal. Angiosarcomas are highly aggressive malignant tumors that arise from the endothelial cells of the sinusoids of the liver. Their development is associated with certain chemicals, such as vinyl chloride, arsenic, and Thorotrast. A malignant tumor of the liver that is found in children is the hepatoblastoma. Microscopically, these tumors consist of ribbons and rosettes of fetal embryonal cells