Hepatic abscess mimicking hepatocellular carcinoma in a patient with alcoholic liver disease
A 70-year-old man was admitted to our hospital due to general weakness for 2 days. He did not have any specific medical history. However, he had a history of heavy alcohol drinking for more than 30 years. The laboratory tests at the time of admission revealed that elevated serum levels of total bilirubin (6.3 mg/dL), direct bilirubin (5.1 mg/dL), aspartate aminotransferase (450 IU/L), alanine aminotransferase (254 IU/L), gamma-glutamyl transpeptidase (399 IU/L), alkaline phosphatase (180 IU/L), and lactate dehydrogenase (890 IU/L). Serologic tests for hepatitis A, B and C were negative. The complete blood count showed decreased level of white blood cell count (3,200 mm-3) and platelet count (61,000 mm-3). However, the level of hemoglobin was within normal limits. Coagulation profiles and C-reactive protein were also within normal limits. The test for serum tumor markers revealed marked elevated level of CA19-9 (462.2 U/mL) and normal levels of alpha-fetoprotein (5.15 IU/mL) and CEA (3.45 ng/mL).\nThe dynamic contrast-enhanced CT images showed a 6 cm well-encapsulated mass in the right hepatic lobe, with the enhancement pattern of early arterial enhancement and delayed washout. And also, CT images showed enlargement of right and caudate lobe of the liver, and wall thickening and enhancement of both intrahepatic bile ducts (). However, the biliary duct was not dilated. Based on these CT findings in addition to the increased level of CA19-9, the initial tentative diagnosis was a hepatic malignant tumor such as HCC or mass-forming cholangiocarcinoma with underlying alcoholic liver disease and intrahepatic cholangitis. Dynamic gadolinium-enhanced MR imaging was subsequently performed. On fat-suppressed T1-weighted image (), the mass consisted of large area of hypointensity and small area of hyperintensity, which looked reversed with respect to signal intensity on fat-suppressed T2-weighted image (). Small portion of T1 hyperintensity within the mass was interpreted to represent the presence of hemorrhage. The hypointense area of the mass on pre-contrast fat-suppressed T1-weighted image was hyperintense, slightly hypointense and hypointense, respectively, on gadolinium-enhanced T1-weighted arterial, portal, and delayed-phase MR images that were obtained at 30 seconds, 75 seconds and 180 seconds, respectively, after the injection of gadolinium (). According to various imaging findings, such as early arterial enhancement and delayed washout, mosaic pattern of enhancement, internal hemorrhagic component, well defined tumoral capsule, and findings indicative of underlying alcoholic liver disease, the tumor was radiologically diagnosed as a HCC.\nSubsequently, right hepatectomy was decided to perform as a curative treatment. In addition, conservative treatment such as administration of hepatotonic agents and antibiotics to treat underlying alcoholic liver disease and cholangitis had been done for 1 month before operation. The laboratory test performed just before the operation revealed that serum levels of total bilirubin (0.8 mg/dL), direct bilirubin (0.4 mg/dL), aspartate aminotransferase (51 IU/L), alanine aminotransferase (40 IU/L), gamma-glutamyl transpeptidase (101 IU/L), alkaline phosphatase (60 IU/L), and lactate dehydrogenase (441 IU/L) and CA19-9 (14.7 U/mL) were markedly improved. Right hepatectomy was performed at 6 weeks after admission, according to the initial treatment plan.\nThe gross surgical specimen showed that a 6 cm brown to reddish lobulated mass with both solid and cystic portions was surrounded by whitish fibrous capsule, and included hemorrhagic necrosis, necrotic debris and internal whitish septa (). And also, multifocal irregular surface of the liver was demonstrated which was suggestive of chronic alcoholic liver disease. Microscopic examination revealed extensive areas of coagulative necrosis, infiltrations of chronic inflammatory cells including lymphoplasma cells and some eosinophils, fibrosis and focal areas of hemorrhage and hemosiderin pigments (). These histologic features resulted in the diagnosis of hepatic abscess and chronic alcoholic liver disease. He had an uneventful postoperative course, and has been alive for 59 months after surgery.