Discussion
Hepatocellular carcinomas (HCC) are aggressive tumors prone to metastasis and make up approximately 75% of primary hepatic malignancies [10], with exophytic tumors being one of the most rare presentations. Risk factors include Hepatitis B, Hepatitis C, alcohol use, and non-alcoholic fatty liver disease (NAFLD), which result in cirrhosis and ultimately develop into HCC [1-3]. It is the most common primary liver malignancy [2] and the fourth most common cause of cancer-related death worldwide and its incidence is rising [4]. Diagnosis requires histological evaluation and staging is primarily based on computed tomography (CT scan) and magnetic resonance imaging (MRI).
Hepatocellular carcinoma is histologically classified into four grades using the Edmonson-Steiner Classification. Grade I carcinoma includes a mostly-differentiated tumor which is arranged in a thin trabecular pattern. Grade II shows enlarged nuclei with abundant cytoplasm, with cells maintaining trabecular pattern. Grade III carcinoma demonstrates large, hyperchromatic nuclei with less bile and acinar formation. The hallmark of grade III disease is the abundance of tumor giant cells. Grade IV carcinoma is poorly differentiated, with tumor cells varying in cytoplasmic abundance and quality, along with near absence of bile. These cells are disorganized, and cohesion molecules are often absent [12].
Pedunculated HCC (P-HCC) presents as two subtypes either with or without a pedicle [13]. Moderate or poor differentiation demonstrates an unfavorable prognosis if not intervened upon early, primarily due to their rapidly progressive nature [9]. When compared to non-pedunculated neoplasms (NP-HCC), P-HCC tumors >5cm demonstrate poor outcomes. These masses protrude into the abdomen so there is limited growth into adjacent liver parenchyma. As a result, they are more often amenable to curative resection if resected in a timely manner. Presence of a tumor capsule suggests early staging, and tends to play a role in resisting tumor expansion. As the portal vasculature supplies blood to the liver, vascular invasion plays an important role in recurrence [11]. Patients who present with recurrent disease tend to have peritoneal carcinomatosis, as well as metastasis to the spleen [12] and adrenal glands [14].
HCC causes chronic inflammation and persistent cytokine release [5] along with angiogenesis [3]. The release of VEGF is responsible for the development of new blood vessels, which are both structurally and functionally abnormal. These vessels are highly permeable and provide poor oxygenation resulting in hypervascular regions with necrosis [6].
Surgical resection has been shown to be curative and is considered first-line therapy if R0 resection is possible to achieve. Such interventions depend on the size and location of the tumor, as well as the pre-operative liver function and these patients require evaluation for post-resection liver volume [7-8]. This large pedunculated neoplasm was separate from the left lobe of the liver, which is precisely why its resection was a feasible option. Fluids were provided at a low rate to keep central venous pressure low, to avoid post-operative bleeding at the liver. The intra-operative decision to perform a sleeve gastrectomy was because there was concern for the posterior stomach to have positive margins, as it was adhered densely to the neoplasm.