A 43 years male presented

with Hepatic SOL

Presented by Dr.Jabin Sultana Tonni
FCPS part-2,Trainee (General Surgery)
SU- 5, SSMCMH
Particulars of the patient
Name : Mr. Liton Sarker
Age: 43 years
Sex : Male
Occupation : Mason
Marital status : Married
Address : Sonakandi, Munsiganj
Date of admission: 09-09-2023
Date of examination: 10-09-2023
Chief Complaints
• Diagnosed case of chronic hepatitis B carrier for 2.5 years.

• Incidental finding of liver mass by ultrasonogram on follow-up visit 2

months back.
History of present illness
According to the statement of the patient, he was living apparently a
healthy life. Soon after his mother and brother’s death due to cirrhosis
of liver due to chronic hepatitis B infection, he felt concerned & got
himself tested & was found to be a Hepatitis B carrier. He was on
medication for Hepatitis B & was visiting hepatologist for
follow-up every 6 monthly.
Continued ..
Two months back,while follow-up visit,a liver mass was detected by
Ultrasonogram. Then his hepatologist referred him to
our unit for further assessment & management. He didn’t complain of
any kind of pain or abdominal discomfort.There is no history of
fever,vomiting,hematemesis, melena or altered bowel habit.He has no
history of weight loss or loss of appetite.
Continued..

His bowel & bladder habit were normal.He

is normotensive and nondiabetic.
History of past illness
He has no significant history of any past illness.There’s no history of
jaundice.

Personal History
He is non-smoker, no history of IV drug abuse, no history of exposure.
Family History
He is married and has a son.
He has family history of hepatitis B infection.His mother & two brother
were suffering from liver cirrohosis due to chronic hepatitis B infection
& had died most likely of liver cirrhosis.
Drug history
He was on Tab.Entecavir (0.5mg) since 2021.

Allergic history
He had no history of allergic reaction to any foods or known drugs.
Immunization History
He is immunized according to current EPI schedule and also vaccinated
for COVID-19.

Socio economic History

He belongs to a lower middle class family.
General examination
Appearance: Anxious
Body built: Average
Cooperation: Cooperative
Nutritional status: Average ,BMI -18.9 kg/m2
Anemia: Mildly anemic
Jaundice: Absent
Cyanosis: Absent
Oedema: Absent
Dehydration: Absent
General Examination (continued)
Clubbing: Absent
Koilonychia: Absent
Leukonychia: Absent
Pulse: 82 bpm
Blood pressure: 110/80 mmHg
Temperature: Normal
Respiratory rate: 16 bpm
General Examination (continued)

Lymph node: All accessible LN are not palpable.

Neck vein: Not engorged
Thyroid gland: Not enlarged
Skin condition: Normal,no scar,no scratch mark
Systemic examination
Examination of the Abdomen:
Inspections:
Shape of abdomen: Normal
Flanks: Not full
Umbilicus: centrally placed,Inverted
slightly transversely slit.
Skin condition: Normal
Examination of the Abdomen [continued]
Visible peristalsis: absent
Visible pulsation: absent
Engorged vein: absent
Hernial orifices: are intact
Examination of the Abdomen [continued]
Palpation:
Superficial palpation-
Temperature-Normal
Tenderness- absent
Muscle guarding and rigidity- absent
Examination of the Abdomen [continued]
Deep palpation
Liver is not palpable.
Spleen is not palpable
Kidneys are not ballotable
Examination of the Abdomen [continued]
Percussion:
Tympanic over all the regions.

Auscultation:
Normal, bowel sound is present.

Digital rectal examination: reveals no abnormality.

Others systemic examinations
Respiratory , Cardiovascular, Neurological and others systemic
examinations reveals no abnormality.
Salient features
Mr.Liton Sarkar,43 years old, male,muslim,a hepatitis B Carrier hailing
from Sonakandi,Munshiganj was referred to Surgery unit-5, mitford
hospital by his hepatologist with the complaints of incidental findings
of Hepatic SOL in Ultrasonogram in his routine follow-up 2 months
back.He has no complaints of any abdominal pain or discomfort.
There’s no history of fever,vomiting, hematemesis,melena or altered
bowel habit,weight loss or loss of appetite.
Continued
His bowel & bladder habit were normal.He‘s normotensive and non
diabetic.
He has no history of past illness or history of jaundice.But he has strong
family history of hepatitis B infection. His mother & two brothers had
died most likely of liver cirrhosis.
He was on Antiviral therapy (Tab.Entecavir) for 2.5 years.
On general examination, the patient was looking anxious,mildly
anemic,no jaundice,no sign of dehydration
cyanosis,kolionychia,leukonychia,no engorged neck vein.
Continued...
All accessible lymph nodes are not palpable & Other vitals were within
normal limit.
On abdominal examination, abdomen was normal in shape,flanks were
not full,Umbilicus was centrally placed, inverted & transversely
slited.Abdomen was non tender & there was no organomegaly and
no ascites.
DRE and other systemic examination found no abnormality.
Provisional Diagnosis
Differential Diagnosis
• Hepatocellular Carcinoma
• Hemangioma
• Hepatic Adenoma
Investigation
• Liver Function Tests-
• Serum Bilirubin-0.6
• SGPT-47 U/L
• S.ALP-67 U/L
• Serum albumin : 3.7g/dl
• Prothrombin time-13 sec. INR-1.2
Investigations
• Tumor Markers-
• Alpha-Feto protein-84 U/ml
• CEA- 3.76 ng/ml
• CA 19.9- 2.06 U/ml
Investigations [continued]
Viral markers:
HBsAg: Positive
HBeAg: Negative
Viral DNA :HBV DNA- 1.38×10^4 IU/ml
Anti HCV- Negative
Investigations
USG of whole abdomen:
Liver is normal in size & shape. Echotexture of liver parenchyma is
coarse. There is well-defined echogenic area of mass lesion (28×28
mm) is seen in right lobe.

Impression: Coarse hepatic parenchyma with

echogenic mass in right lobe
Investigation (continued)
• Fibroscan of Liver- 1.Median stiffness -4.9 kPa
2.IQR/med- 8%

• Upper GI endoscopy : Normal findings

Investigation (continued)
CT scan of whole abdomen:
Liver is normal in size. One small solid hypodense SOL (about
25×24 mm) is seen in anterior part of right lobe. Shows
enhancement in arterial phase, portal phases with gradual
washout, venous & delayed phases. Rest of liver parenchyma
is normal
Investigation (continued)

Impression: Small solid SOL in

anterior part of right lobe
of junction
of segment V & VIII– HCC (?)
Clinical diagnosis

Hepatocellular carcinoma due to Chronic hepatitis B

Pre –operative assessment
Investigations for assessing the general condition :
CBC : Hb -14.5 g/dl
TC – 5120/cmm
PC –2,50000/cmm
Serum creatinine: 0.72 mg/dl
Serum electrolyte : Na- 140 K-3.8 Cl-103
RBS-8.1 mmol/L
Pre –operative assessment
Blood grouping : B (+ve)
Chest X ray : normal
ECG : normal
Echocardiogram : normal
Pre-Operative Child-Pugh Scoring-

• S.Bilirubin- 0.6 mg/dl +1

• S.Albumin- 3.7 g/dl +1
• INR- 1.2 +1
• Ascites- Absent +1
• Encephalopathy- Absent +1

• total score =5
• Child Class: A
Surgical plan
• Right Lobectomy
Pre operative Management
• Patient was counseled about his disease, treatment protocol &
prognosis.
• Improvement of nutritional status with maximum protein
supplementation tolerable by the patient.
• To ensure hepatic glycogen is maximal, patient received an
intravenous glucose load (1L of 10% dextrose) prior to surgery.
• Informed written consent was taken from the legal guardian.
Operation Note
• Date: 30/09/23
• Time: 11:30AM-03:30PM
• Venue: GOT, SSMCMH
• Name of indication: Hepatocellular Carcinoma due to
Chronic Hepatitis B
• Name of operation: Non anatomical resection of Hepatic
segment V, VI & partially VII
Contd...
• Surgical approach : Open
• Incision: Modified Makuuchi

Laparatomy Findings:
• Hard irregular 3×3 cm intraparenchymal
mass was found involving hepatic
segment V,VI and partially VII.
• Rest of liver parenchyma was cirrhotic.
Surgical Procedure
• Assesment of locoregional & distant metastasis & operability.
• Caudally dissection of right triangular ligament & then coronary
ligament.
• Mobilisation of Right Lobe was done
• Inflow was controlled by Pringle’s manoeuvre.
• Cholecystectomy was done.
• Wide local free margin of tumor selected & resected by crush and
clump technique.
[continued]
• Haemostasis & control of
bleeding was done with
Prolene 3-0 RB.
• Resected bed was embedded
with spongstat.
• After keeping 20Fr Drain tube
at Hepatorenal pouch,wound
was closed by No.1 PDS loop.
• Skin was closed by Stapler.
Histopathology of the specimen
Gross description:
Slicing of liver specimen reveals a 3.0x2.7x2.5 cm well circumscribe
tumour. It is 0.3 cm away from the capsule and 1.5 cm away from the
nearest resection margins. It also reveal multinodularity in its outer
surface.Sections of liver tumor reveal-
An well differentiated hepatocellular carcinoma.
• Capsular invasion is present.
• Lymphovascular invasion is present.
• Perineural invasion is not seen.
• The surgical resection margin is free.
Histopathology of the specimen
Sections of gallbladder wall reveal moderate infiltration of
inflammatory cells and mild fibrosis.

Diagnosis-
1. Liver SOL: Hepatocellular carcinoma,well differentiated in the
background of cirrhosis.
2. Gallbladder: Free of tumor.
Post operative period
• His post operative period was uneventful.
• He was allowed sips of water on 4 th POD & liquid diet on 5th POD.
• Drain Collection was approx. 400-500ml /24hour upto 5th POD, then
gradually deceased to nil.
• On 22th POD drain tube was off & all stitches were off.
• After consulting with Oncology department, he was advised to take
Tab. Sorafenib as adjuvant chemotherapy & got discharged on
27/10/23 with advice to follow up after 4 weeks .
Follow-Up:
• Patient was followed up after 1 month post operatively on 20/11/23
when liver function test, AFP which was within normal limit.
• Next follow up was planned after 1 month
Any Questions
Hepatocellular Carcinoma
• HCC is the fifth most common malignancy worldwide, with an
estimated 750,000 new cases diagnosed annually.
• Because of its high fatality, it is the third most common cause of
cancer death worldwide.
• Major risk factors are-
• Viral hepatitis (B or C),
• Alcoholic cirrhosis
• Hemochromatosis
• NASH
Continued..
• Although cirrhosis is not present in all cases, it has been estimated to
be present 70% to 90% of the time.
• In a person with cirrhosis, the annual conversion rate to HCC is 2% to
6%.
• In patients with chronic HCV infection, cirrhosis is usually present
before the HCC develops.
• However, in cases of hepatitis B virus infection, HCC tumors can occur
before the onset of cirrhosis.
Clinical features of HCC
• HCC exhibits a male dominance with an average sex ratio of 3:1
• In early stage, HCC in asymptomatic and is only discovered by
screening (ultrasound, AFP) in individuals at risk of the disease
In symptomatic disease,
Predominant symptoms:
• Abdominal mass
• Anorexia
• Weight loss
• Abdominal or chest pain
• Sometimes jaundice and
peripheral stigmata of CLD
Physical findings:
• Abdominal distention or,
• Presence of hepatic mass
• Bruit (in 10%)
• Ascites
Laboratory studies
• Abnormalities of LFT
• Anemia
• Serum AFP levels elevated
Imaging
• Ultrasonogram – demonstrate size and position of the lesion
• Multiphase CT scan – HCCs are typically hypervascular with blood
supplied predominantly from the hepatic artery. Thus, the lesion
often appears hypervascular during the arterial phase of CT studies,
and relatively hypodense during the delayed phases due to early
washout of the contrast medium by the arterial blood.
• MRI – HCC is variable in T1-weighted images and usually hyperintense
on T2-weighted images. It follows enhancement as contrast CT.
Role of Biopsy in HCC
• Different types of liver masses have distinct appearances and patterns
of contrast enhancement on CT and MRI, facilitating the clinician in
the diagnosis and formulation of treatment plan.
• A potentially resectable lesion which is likely to be HCC should not be
biopsied prior to attempting surgical resection.
Treatment plan
Surgical resection Hepatic transplantation
• 5 year survival rate 35-38% • 5 year survival rate 45%
• Recurrence rate 55% at 5 years • Recurrence rate 20% at 5 years