1. Case 24

2. Clinical Presentation
74 year old male
RUQ discomfort
Weight loss ~ 16 lbs
Decreased appetite
4 months

3. Medications
Diovan
Aciphex
Social History
Occasional alcohol (~15g/week)
Practicing attorney
Travel  worldwide (i.e. Asia, Africa)
Eating mixed nuts daily for 40 years
Family History
Non-contributory

4. Physical Exam BMI 30 Abdominal fullness, mild RUQ tenderness
Hepatomegaly  6 cm below costal margin
No spider angiomata, palmar erythema, ascites, asterixis

5. Laboratory AST: 111, ALT: 64, AlkP 145 Alb 2.9
Platelets: 293,000 Tbil: 1.0, INR1.1
Hepatitis B & C serology  negative
Fe sat%  WNL
AFP  8.0

6. 16.8 x 15.2 cm

7. Laparotomy Plan  right lobectomy Findings
No Cirrhosis
17 cm tumor
Diffuse microsatellite lesions
Frozen section  HCC, mild steatosis
No liver resected

8. Chemotherapy Intra-arterial carboplatin IV doxorubicin Bevacizumab
Minimal improvement
Chemoembolization cisplatin

9. After
Before
8 X 9.5 cm
15.8 X 16.2 cm

10. Follow up (cont’) ↑↑↑ AFP 157.1 Yttrium-90 microspheres (Therasphere®)
↓ AFP 15.5/ Tumor 8 X 9 cm
Cholestatic hepatitis
(AST 189, ALT 171, ALKP 894, Tbil 2.4)
Death