A 40-year-old male patient with a history of depression treated with psychotherapy.
His general condition was compromised for a month.
One week before consultation, the patient presented intermittent pain in the right hypochondrium that did not respond to analgesics.
Three days before the consultation, the patient had an unquantified fever.
The initial evaluation highlighted heart rate of 110 lx', respiratory rate of 29 breaths/minute, axillary temperature of 38.5°C, right lung base murmur and decreased right lung base hypochondrance pain.
Laboratory tests showed: leukocytes 12,000 cells/mm3, with neutrophils of 78% and bacilliforms of 1%; hemoglobin 12.6 g/dl; erythrocyte sedimentation rate 85 mm/h; alkaline phosphatase 116 mg/dl
Abdominal ultrasound showed a predominantly hypoechogenic irregular margin lesion, with hyperechoic areas inside, 14 cm x 7 cm, located in the right hepatic lobe (Sg6 and Sg7).
Abdominal computed tomography (CT) showed a predominantly hypodense image, with irregular edges in Sg7 and Sg8, with slight peripheral impregnation after the use of intravenous contrast medium.
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Other lab tests showed IgGhepa antigen, hepatitis B virus (ACE), 0.6 ng/ml; alpha fetoprotein (AFP), 0.87 ng/ml, CA-19.9, 0.15 U/ml; negative antibodies IgM for hepatitis A
Due to persistent signs of systemic inflammatory response and suspected liver abscess, she was taken 48 h after admission to drainage guided by CT scan of the abdomen, where 150 mi of hemorrhagic fluid was obtained, showing almost complete collapse CT image control.
The study of the material showed the cytochemical analysis: predominantly hemorrhagic fluid, Gram negative and culture negative and the sample was considered inadequate for cytology.
The patient persisted with signs of systemic inflammatory response. A control abdominal CT scan showed complete reproduction of the hepatic lesion.
It was decided to drain the patient through laparotomy, where a cavity was found in Sg6 and Sg7, with content inside it, adhered to the parietal peritoneum and diaphragm.
No other lesions or abdominal lymphadenopathies were found.
Contemporary biopsy of the lesion showed fibroconnective tissue in extensively necrotic parts, recognizing some cells with atypical cells.
Deferred biopsy showed a malignant undifferentiated sarcomatous tumor without presenting elements.
Immunohistochemical study with streptoavidin biotin (Zimed) technique concluded a poorly differentiated hepa-tocarcinoma, with positivity for high and low molecular weight cytokeratins CD30, alkaline phosphatase and AFPCE.
Gastroscopy, endoscopy, chest CT, CT of the abdomen and pelvis, and testicular ultrasound showed no new lesions.
A new surgical exploration was performed with the intention of performing a hepatic resection.
A lesion was found in Sg7 and Sg8, with intact diaphragm and parietal peritoneum, without other liver lesions or adenopathies.
Right hepatectomy was performed with partial resection of the diaphragm and primary repair.
Deferred biopsy included the right lobe of the liver with a large expansive tumor lesion of 11.5 x 7.5 cm, with subjacent disposition in extensively necrotic and cavitated parts, with no evidence of cirrhosis in the liver.
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Microscopically, the tumor was predominantly composed of an epithelial component with few sarcomatoid areas.
The epithelial component showed cells with moderate amounts of cytoplasm and increased nuclei of size with granular chromatin thick and frequent mitoses.
The sarcomatoid component was spindle-shaped in the pleptytic areas, with a nucleolus technique, alternating with areas of necrosis and formation of granulatory tissue.
Concluding the diagnosis of poorly differentiated hepatocellular carcinoma sarcomatoid variety.
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In the postoperative period there was transient liver dysfunction, which resolved on the seventh postoperative day and a vertigo syndrome on the fifth postoperative day, which was studied with CAT and magnetic resonance imaging (MRI) of brain origin tenth day after surgery.
She was discharged in good condition on the sixteenth postoperative day.
Twenty days after surgery the first control was performed, being asymptomatic, with control abdominal CT without evidence of recurrence.
