A 33-year-old female, at the third trimester of pregnancy, was diagnosed to have chronic hepatitis B at a premarital checkup 1 year ago. Regular prenatal examination at 28 weeks pregnancy showed abnormal liver function with a bilirubin level 2.9 μmol/L, alanine amino transaminase (ALT) 71 IU/L and aspartate aminotransferase (AST) 88 IU/L. A subsequent alpha-feto protein (AFP) was 973 μg/L, and ultrasound showed of a huge mass (155 mm × 134 mm) in the right liver. Her hepatitis B status showed HBsAg (+), Anti-HBe (+), Anti-HBc (+), HBV-DNA: 6.29 × 10e4 copies/mL. Magnetic resonance imaging (MRI) scan confirmed a huge lesion in the right liver, 15 cm × 15 cm × 14 cm, showing typical features of HCC and there was another nodule in segment 4 (size, 2.0 cm) showing features of a metastatic lesion from the HCC ().
MRI showed a 15 cm × 15 cm × 14 cm HCC at the right liver with contrast enhancement in the arterial phase (a) and portal venous wash out in the venous phase (b).
Ultrasound also showed intrauterine pregnancy with a 30 weeks normal fetus. The estimated weight of the fetus was 1478 ± 216 g. The plan was to carry out a synchronous right hepatectomy and cesarean section when the fetus had reached to an acceptable weight. After two weeks of wait, ultrasound estimated the fetal size to be equivalent to a 31 weeks normal fetus, with an estimated weight of 1713 ± 250 g.
On the date of the operation, the liver function was: total bilirubin, 3.5 μmol/L; albumin, 33.7 g/L; ALT, 58 IU/L; AST, 102 IU/L; alkaline phosphatase(ALP) 97 IU/L and indocyanine green retention rate at 15 min (ICG-R15) 3.4%. Cesarean section was performed at 32 gestational week. A normal male infant with a body weight of 1.8 kg was delivered. This was followed immediately by right hepatectomy using the anterior approach and wedge resection of the segment 4 nodule. No vascular inflow occlusion during liver transection was used. The liver was not cirrhotic. The intraoperative blood loss was 1000 mL. The operation took 260 min. The resected specimens showed a 15 cm tumor in the right liver and a 2.0 cm tumor in segment 4 (). The baby weighted 1.8 kg and he stayed in the neonatal units for 7 days. The post-operative course was uneventful. The patient was discharged home on operative day 10.
Intraoperative photograph of the liver tumor.
Liver remnant after right hepatectomy and wedge resection of a segment 4 nodule.
Histolopathology showed a moderately differentiated HCC. The segment 4 nodule was a focal nodular hyperplasia (FNH). The surgical margins were clear. Additionally, there was no malignant cell in the placenta or the umbilical cord. Pathological TNM grading of the tumor was T1N0M0. 3 months after surgery, she remained disease free. Both mother and infant were well.