Deveopment of hepatocellular carcinoma in a non-cirrhotic, long-term responder to antiviral therapy, chronic hepatitis C patient: what kind of surveillance?
A Caucasian 61-year-old man was referred to our Hospital in 1993 due to elevated aspartate aminotransferase (AST) (eight times the upper limit of normal) with a slight increase in the gamma-glutamyl transferase (GGT) and was diagnosed as having CHC. He had no history of alcohol abuse, intravenous drug use, blood transfusions and drug intake. The patient’s medical history was notable for lung silicosis and hypertension without any secondary complication. His body mass index (BMI) was 25.51 kg/m2. He tested positive for HCV antibodies and negative for other causes of liver disease (other viral infections, hepatic autoimmunity, medications, hyperferritinemia, metabolic diseases). In 1993 the assessment of HCV-RNA and genotype by serum polymerase chain reaction (PCR) were not available, so no relative data at the time of the diagnosis exist. Other laboratory findings included a preserved liver function and a normal platelet count (). Abdominal examination and ultrasonography excluded hepatosplenomegaly and hepatic nodules. The liver biopsy, performed in 1994, showed stage 2 fibrosis with a moderate necro-inflammatory activity (A2 grade) according to the Desmet’s classification [], and a mild microvescicolar hepatic steatosis.\nOne year later, in January 1994, he was treated with 3MU of interferon-alpha 2a (Roferon) three times a week for 48 weeks, achieving a biochemical and SVR.\nFrom 1996 to 2009 HCV-RNA was undetectable with normal AST/ALT.\nIn August 2009 the patient was referred to our emergency room for the onset of severe abdominal pain. On abdominal examination, there was distention, rebound and guarding with moderate ascites. The remaining physical examination and vital signs were normal. Laboratory findings showed mild anemia with normal platelet count and a preserved liver function. HCV RNA was undetectable and alpha-fetoprotein was elevated ().\nContrast-enhanced computed tomography (CT) found a large (8.6 cm) hepatic mass in segment IV, with a vascular pattern typical of HCC, ascites and no evidence of portal vein thrombosis. The subsequent diagnostic paracentesis confirmed the presence of hemoperitoneum.\nDuring his hospital stay, there was a spontaneous stabilization of hemoglobin levels and a progressive pain relief. The gastroscopy was negative for esophageal and gastric varices. Therefore, on 4th November 2009 he underwent a left hepatectomy extending to the fifth hepatic segment. Intraoperatively a plurinodular mass of 7 cm in diameter was found, well demarcated from the remaining liver parenchyma. Histological evaluation revealed a moderately-differentiated HCC (grade G2 according to Edmondson and Steiner) [], in the absence of vascular invasion; the number of mitosis was less than 1 per 10 high power fields. His liver fibrosis on the resected specimen remained at stage 2.\nHe was discharged at home on hospital day 24 and has returned to full activity. Three months after surgery the level of alpha-fetoprotein decreased from 49.6 ng/mL pre-resection to 2.4 ng/mL. At the last visit in June 2011 he was well and CT-scan showed no evidence of recurrent tumor.