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.