A 58-year-old female had been treated with five courses of rituximab plus CHOP chemotherapy from May 2011 to September 2011 for a diffuse large B-cell lymphoma stage III B. Before the last treatment, the patient presented severe fatigue, abdominal pain, daily temperatures of up to 38.3°C and occasional night sweats. The hematocrit was 28 percent hemoglobin 9.5
g/dL with a white-cell count of 2.32 × 109
/L (59% neutrophils and 41% lymphocytes), and platelet counts 51 × 109
/L. The levels of bilirubine, alkaline phosphatase, prothrombin time, and creatinine were normal. Albumin was 3.1
g/dL (normal 3.5 to 5
g/dL). Tests for viral hepatitis A, B, and C were negative. The level of ALT was 100
U/L and that of AST was 70
U/L. The level of beta 2-microglobulin was normal, while alpha-fetoprotein was 440
ng/mL. A restaging PET/computed tomography (CT) scan () shows an almost complete resolution of that metabolic activity in lymphnodes involved at diagnosis (right neck, axillae, paratracheal, periaortic, and both inguinal regions) in addition FDG-PET shows several areas of hypermetabolism in the liver (SUV 10.7) indicating the presence of a high grade malignancy. CT scanning revealed multiple hepatic mass (<5
cm.) which shows heterogeneous arterial enhancement after the administration of contrast material. Percutaneous ultrasound guided core biopsies revealed on histologic specimens a poorly differentiated HCC with typical cytological features: giant cells with large nuclei and macronucleoli, multinucleated giant cells (Figures , , and ). A PCR detection of intrahepatic HBV-DNA was performed using described nested PCR methods with primers targeting the S, polymerase, precore-core, and X regions of the HBV genome; unexpectedly, all four HBV regions of HBV DNA were detectable in the liver of this apparent case of cryptogenic hepatocellular carcinoma. Given the size and spread of the tumor with its bilobar involvement, the tumor was deemed not susceptable to surgical resection or ablative therapy and sorafenib therapy was initiated with a dosage of 400
mg orally twice a day. Despite this treatment, however, the patient's condition rapidly worsened and she died after 30 days.
Restaging PET/computed tomography.
Giant cell with large nuclei and macronucleoli, multinucleated giant cells.