Right Hepatectomy for Non-Cirrhotic Hepatocellular Carcinoma
The first major liver resection (right hepatectomy) was performed by the ILC Team at Aster Hospital, Mankhool on a 28-year-old female who was incidentally detected to have an 11 cm hepatocellular carcinoma (HCC) in the right lobe of the liver. A solid lesion in a cirrhotic liver is generally an HCC. In non-cirrhotic livers, solid lesions may be due to hemangioma, hepatic adenomas, focal nodular hyperplasia, cholangiocarcinoma, HCC, metastases and rarely tuberculoma or lymphoma. The diagnosis is essentially based on cross-sectional imaging with CT and MRI. The index patient had a contrast enhancement pattern characteristic of HCC on a dynamic triple phase CT scan. While HCC usually develops in a background of liver cirrhosis, about one-third cases occur in a non-cirrhotic liver. The patient’s alpha-fetoprotein (AFP) levels were normal. AFP levels are elevated in only two-thirds of HCC and AFP is not mandatory for a diagnosis of HCC. Biopsy is usually not required for diagnosis if the radiological findings are characteristic.
Management of patients with cirrhosis and HCC depends on the size and number of tumors and the condition of the liver. Patients with single small lesions can either undergo liver resection or radiological ablation. Patients with large tumors and numerous lesions can be offered only palliative treatment. Patients in the intermediate category (satisfying specified size and number criteria) are usually offered liver transplantation. On the other hand, liver resection is the treatment of choice for HCC that develops in a non-cirrhotic liver irrespective of the size of the lesion, if the resection is technically feasible. Such patients tolerate resection of up to 70% of the liver parenchyma.
A 28-year-old female presented with non-specific upper abdominal pain and was detected to have a large heterogeneous lesion on ultrasound scan. Contrast-enhanced triple phase CT scan showed an 11 cm lesion in the right lobe of the liver. There was intense enhancement seen on the arterial phase (first image) and rapid washout in the portal venous (second image) and delayed phase. A capsule could be appreciated around the lesion. These findings were highly suggestive of HCC. There was no evidence of cirrhosis on imaging. LFT and AFP were normal. Markers for hepatitis B and C were negative. The patient did not have any history of OCP use.
Major Liver resection is a complex surgery that should be undertaken by experienced surgeons in established HPB units. When more than 3 liver segments are resected, it qualifies as major liver resection. Good critical care is extremely important after liver resection since there is a potential risk of liver failure, infections, bleeding and bile leaks. The morbidity after a major liver resection is about 20% while the mortality is about 1-2%. The index patient underwent the procedure without any blood transfusion, had an uneventful postoperative recovery and was discharged on the 6th post-op day.
Dr. Mathew Jacob MRCS, FRCS, CCT (UK)
Dr. Kaiser Raja MD, DM
Aster Hospital, Mankhool