Primary Liver Tumor in a Young Man: A Brief Review of Diagnostic Strategies and Treatment Options

A 37-year-old man complained of diffuse abdominal pain, loose foamy stools, and weight loss of 11 kg over a 9-month period. A small-bowel biopsy was consistent with nontropical sprue; he was placed on a gluten-free diet and Flagyl but failed to respond. The poor response and continued weight loss prompted a radionuclide liver scan, which showed multiple filling defects. Sonography con- firmed multiple solid masses in the liver (fig. 1), and a directed needle biopsy (with sonography) revealed hepatocellular carcinoma. On subsequent admission, he appeared chronically ill and ca- chectic. On physical examination the vertical liver span was 16 cm. Urinary 5-hydroxyindoleacetic acid excretion and serum alpha-feto- protein were normal. Total parenteral nutrition was begun, and a transfemoral hepatic artery catheter was placed, through which he received infusions of Adnamycin and 5-fluorouracil (5-FU). Over the next month, he regained strength and appetite, and a hepatic artery catheter was implanted surgically. Instillation of fluorescein into the hepatic artery catheter at the time oflaparotomy showed predominant perfusion of the right lobe of the liver with some perfusion of the left lobe. Hyperalimentation was continued, and the patient was discharged. Adnamycin and 5-FU infusions were also continued. He began to experience intermittent episodes of diarrhea, nausea, and persistent hiccoughing. Mild ascites and encephalopathy were treated with Aldactone and Lactulose. Melanotic stools were attributed to gas- troesophageal varices, and a transfusion was required. By 3 months after surgical catheter implantation, he had received a total of 90 mg of Adnamycin and 11 g of 5-FU intraarterially. Chemotherapy was interrupted when abdominal pain, nausea, vomiting, and diarrhea increased, and he was readmitted. Upper gastrointestinal endoscopy showed postbulbar edema and swelling in the duodenum. He was again started on hyperalimentation and hepatic arterial Adnamycin infusion. He improved and was discharged to continue arterial infusion of 5-FU at home, but was readmitted about 3 months later with recurrence of upper gastrointestinal symp- toms. Repeated sonographic studies of the liver during treatment showed no objective evidence of tumor regression. The patient died 3 months later from progressive liver failure.