Introduction

HCC is well known complication of liver cirrhosis. The current standard of care for patients with cirrhosis involves systematic 6 monthly screening with ultrasound and serum alpha-fetoprotein testing. (1) The Aberdeen Hepatoma surveillance clinic has been instituted since 2005 and currently 707 patients under screening program. It is a one-stop nurse led clinic wherein the ultrasound scan, blood testing and clinical review is done in a single visit, with sequential visits planned every 6 months. ​

Aims & Methods

In this study we aimed to identify outcome of HCC detected in hepatoma clinic compared to those identified symptomatically. Data collected retrospectively of patients referred to HCC MDT at Aberdeen Royal infirmary over period of 5 years. Diagnosis of HCC was made based on liver ultrasound and serum AFP as per guidelines

Results

130 patients were identified with HCC through both pathways. 17 patients were detected as part of the surveillance programme and the rest were directly referred to the HPB MDT through the symptomatic pathway. The predominant subjects were males 102 (78.4%) and the cause of liver cirrhosis was as follows: MASLD 39%, ARLD 29%, Chronic HCV 11%, HBV 4%, Haemochromatosis 3%, PBC 2%, autoimmune hepatitis and PSC 1%. The mean age of patients detected in the surveillance group was 65 years ± 6.14 SD as opposed to those in the symptomatic group 71 years ± 9.99 SD. AFP was normal in 50% of surveillance group. The BCLC staging in the surveillance group was stage 0-A (20%), stage B 45%, In the symptomatic group patients were in stage 0-A 7%, Stage B 22%, and stage C, D 55% respectively.
Curative options including liver transplant and resection was possible in 20 % of surveillance patients as opposed to 7% in symptomatic patients. Palliative options like RFA, TACE and Sorafenib was offered in 60% of surveillance patients and 42% of symptomatic patients. In 20 % of surveillance patients no treatment could be offered as opposed to 55% symptomatic patients.

Conclusion

The mean age of the patients detected in the surveillance clinic was 5 years less than the symptomatic group suggesting that the programme was picking patients early. More curative and palliative procedures could be offered to this subgroup for this reason. The BCLC staging confirmed that most patients in the surveillance programme were in the early stages as opposed to the symptomatic group. Despite having an entrenched surveillance programme most patients were presenting symptomatically, suggesting that more efforts are needed to identify patients with cirrhosis who are at an added risk for developing HCC.

References

1. European Association for the Study of the Liver. EASL Policy Statement on liver cancer screening. Accessed 31 May 2022. Available from: https://easl.eu/publication/easl-policy-statement-on-liver-cancerscreening/.

Clinical Case Summary

A 72-year-old patient with a history of atrial fibrillation on treatment and cirrhosis, presented with subjective fevers and abdominal distention for 2 months. An initial laboratory work-up showed an inflammatory syndrome and a prothrombin level of 40 %. The rest of the work-up was unremarkable. A computed tomography (CT) scan of the abdomen showed dysmorphic liver with signs of portal hypertension and abundant ascites with micronodular infiltration of the greater omentum.
Paracentesis showed ascitic fluid (AF) with total nucleated cells 2400 with 5% neutrophils and 87% lymphocytes and protein levels at 40. Cytology was negative for malignancy.
Initially, the patient was considered for diagnostic laparoscopy to investigate the persistent abdominal symptoms. However, in light of the current epidemiological context, marked by a heightened incidence of tuberculosis in the region, a systematic workup for tuberculosis was prioritized. Direct examination and culture for acid-fast bacilli (AFB) were negative, however Xpert Mtb/Rif was positive. standard chest X-ray showed a normal parenchyma with a small right pleural effusions. Thoracentesis was done and pleural fluid AFB culture was negative.
He was started on isoniazid, rifampin, pyrazinamide and ethambutol and was discharged with a close follow up.

Clinical Case Summary

A 12-year-old girl, previously healthy, was admitted to pediatric ward with jaundice, itchy skin, and
general weakness for about 10 days. Physical examination revealed jaundice, discrete exophthalmos,
and tachycardia. Laboratory tests showed significantly elevated transaminases, total and conjugated
bilirubin and bile acids, with a mild increase in GTP. INR, ammonia and albumin levels remained within the range. In the first stage of diagnosis, infectious factors (primary and secondary hepatotropic viruses), Wilson's disease and alpha-1-antitrypsin deficiency were ruledout. Elevated ANA antibody levels and increased serum IgG titers have been found, but a liver panel was negative. Imaging studies (MRI) showed no changes in the liver and bile ducts. After consultation with the pediatric gastroenterologist thyroid function tests were performed which revealed: undetectable TSH, high fT4 and fT3. In the course of further diagnostics, positive titers of anti-Tg, anti-TSHr, and anti-TPO antibodies and enlarged thyroid in USG were obtained, which led to a diagnosis of Graves' disease. The treatment included methimazole and propranolol, which stabilized the patient's general condition and improved laboratory parameters within a few days. Currently, the patient is continuing methimazole therapy and remains euthyroid, with liver function tests completely normalized.
The clinical case illustrates the coexistence and mutual influence of liver and thyroid diseases. The patient was initially suspected of having AIH induced by autoimmune thyroid disease. The negative liver panel results could indicate a seronegative variant of AIH. The patient was scheduled for a liver biopsy to establish a definitive diagnosis, but the test was postponed due to a marked improvement in liver parameters as a result of the control of thyrotoxicosis. Complete clinical and laboratory improvement after treatment with thionamides, without the use of typical AIH therapy, argues against this diagnosis.

Disclosure

No conflict of Interest

Clinical Case Summary

A 77-year-old patient with diabetes insipidus underwent an abdominal computed tomography scan due to upper quadrant abdominal pain. The exam showed concentric thickening of the main and intrahepatic bile ducts. A subsequent magnetic resonance cholangiopancreatography, with diffuse thickening of the main and intrahepatic bile ducts, with diffusion restriction and reduced biliary duct caliber, without lithiasis. Due to the suspiecion of a malignant biliary stricture, the patient was proposed for endoscopic retrograde cholangiopancreatography (ERCP) with cholangioscopy. The cholangiogram showed diffuse rarefaction of the intra and extrahepatic bile ducts, with focal dilatation of the intrahepatic bile ducts. After biliary sphincterotomy, cholangioscopy revealed a narrowed main bile duct extending to the hepatic hilum, with neovascularization, and papillary projections. Multiple biopsies were taken and a plastic stent was placed. Cholangioscopy-guided biopsy revealed granulation tissue and stroma with numerous histiocytes and eosinophils. Immunohistochemistry identified histocytes expressing CD68, S100, and CD1a, consistent with biliary involvement by Langerhans Cell Histiocytosis. The procedure was complicated by acute pancreatitis, requiring Intensive Care Unit admission. The patient’s hydroelectrolytic disorders were caused by pituitary involvement (lymphocytic hypophysitis associated with granulomatous disease). The patient started corticosteroid therapy with clinical and analytical improvement.
Langerhans Cell Histiocytosis is characterized by histiocytes proliferation, with progressive fibrosis due to tissue infiltration. In this case, diabetes insipidus was the first disease manifestation, due to lymphocytic hypophysitis. LCH is a rare cause of secondary sclerosing cholangitis, and early diagnosis through cholangioscopy was essential to initiate appropriate systemic therapy, preventing disease progression with multiorgan involvement.