Hepatocellular Carcinoma & hepatic Cystic echinococcosis presenting as Synchronous single lesion

Background and Aim: Hepatocellular carcinoma (HCC) constitutes more than 90% of the primary tumor of the liver; approximately 85% in Cirrhotic background. Significant risk factors for HCC include viral hepatitis, alcoholic liver disease, and NAFLD/NASH. Its very rare for liver cystic echinococcosis (CE) and HCC to co-exist. Studies have shown that E. granulosus infection promotes proliferation of HCC cells by immunomodulation. A preoperative diagnosis may be very challenging, when imaging features are atypical and if HCC and CE present as a single lesion. Case Report: A 35 yr old female, presented to us (at Department of Gastroenterology, BHU with complaints of gradual onset RUQ pain abdomen*2 months with abdominal distension and low-grade fever*2 weeks. Ascitic fluid analysis showed low SAAG, presence of free hooklet & protoscolex. TPCT abdomen s/o large heterogenous, hypoattenuating mass (12*8.5*13.5cm) in right lobe, on contrast adminstration, peripheral rim and multiple linear enhancements seen at multiple sites with nonenhancing large central necrotic area & tumor thrombus in Portal vein. Background liver was Non-cirrhotic. Positive biochemical results were low Hb (9gm/dl), increased ALP (800IU/ml), Low Albumin (2.8mg/dl). Tumour markers (AFP=2.8ng/ml, PIVKA II=21mAU/ml) were within normal limits. Viral hepatitis markers were negative. Antiechinococcal Ig-G was found to be positive. In view of diagnostic dillema, she underwent USG guided liver biopsy which revealed histology s/o well differentiated HCC & IHC showed HepPar-1, Arginase, Glypican-3, INSM-1 and TTF-1 positivity. She was finally diagnsed as HCC(BCLC-C) combined with hepatic hydatid disease with probable rupture into peritoneal cavity. She was adminstered long term oral Albendazole & TACE cycles. Conclusion: HCC and hepatic hydatid cyst synchronous prsence is very rare scenario in clinical practice, especially in a non-cirrhotic background both presented as a single lesion which poses great challange for preoperative diagnosis. Awareness of such associtaion will help clinicians in formulating proper managment.