Abstract:
Introduction: Hepatocellular carcinoma (HCC) is a primary malignancy of the liver that typically arises in the context of chronic liver disease and cirrhosis. Biochemical markers such as alpha-fetoprotein (AFP) and liver function tests (LFTs) are often used to aid diagnosis. However, up to 30-40% of patients with HCC may present with normal AFP levels, making early diagnosis challenging. Here, we report an unusual case of HCC in a middle-aged patient presenting with non-specific symptoms, normal biochemical markers, including AFP and LFTs, and a non-cirrhotic liver. This case highlights the need for a broader diagnostic approach beyond conventional laboratory tests to avoid missing atypical presentations of HCC.
Case Report: A 58-year-old male with no significant past medical history presented with vague abdominal discomfort and fatigue. Initial laboratory workup, including liver function tests (LFTs), AFP, and hepatitis serologies, was unremarkable. Abdominal ultrasound showed a mildly heterogeneous liver without distinct masses, prompting further evaluation with contrast-enhanced magnetic resonance imaging (MRI), which revealed a 3.5 cm lesion in the right hepatic lobe with arterial phase hyperenhancement and washout in the venous phase—findings highly suggestive of HCC. Serum levels of des-gamma-carboxy prothrombin (DCP) were elevated at 148 mAU/mL (normal < 40 mAU/mL), while AFP remained within normal limits. A percutaneous liver biopsy confirmed a well-differentiated HCC in a non-cirrhotic liver. The patient underwent a successful partial hepatectomy with clear margins.
Results: Histopathological analysis confirmed a moderately differentiated HCC with negative margins. The patient's postoperative course was uneventful, and follow-up imaging six months later showed no evidence of recurrence. This case illustrates the critical role of imaging and alternative biochemical markers, such as DCP, in diagnosing HCC, particularly in AFP-negative patients.
Conclusion: This case underscores the importance of maintaining a high index of suspicion for HCC in patients presenting with non-specific symptoms and normal laboratory values, particularly in non-cirrhotic livers. The use of alternative markers such as DCP, combined with advanced imaging modalities, can facilitate early diagnosis and improve outcomes. Clinicians should be vigilant and adopt a comprehensive diagnostic approach to avoid missing atypical presentations of HCC.
Audience Take Away Notes:
- Understanding the variability in the presentation of HCC and recognizing that normal lab values do not rule out malignancy.
- Familiarity with alternative biochemical markers such as DCP, GPC3, and miRNA in diagnosing AFP-negative HCC.
- Importance of comprehensive assessment, including imaging and histopathology, when biochemical markers are inconclusive.
- Broader perspective on differential diagnoses and avoiding tunnel vision, thereby improving diagnostic accuracy.
