Review Question - QID 108436

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Hepatocellular Carcinoma (HCC) Introduction Overview QID: 108436 (M1.ON.17.4707)

QID 108436 (Type "108436" in App Search)

A 67-year-old male presents to his primary care physician for evaluation of fever and an unintended weight loss of 25 pounds over the last 4 months. He also has decreased appetite and complains of abdominal pain located in the right upper quadrant. The patient has not noticed any changes in stool or urine. He emigrated from Malaysia to the United States one year prior. Social history reveals that he smokes half a pack per day and has 5-7 drinks of alcohol per day. The patient is up to date on all of his vaccinations. Physical exam findings include mild jaundice as well as an enlarged liver edge that is tender to palpation. Based on clinical suspicion, biomarker labs are sent and show polycythemia and an elevated alpha fetoprotein level but a normal CA 19-9 level. Surface antigen for hepatitis B is negative. Ultrasound reveals a normal sized gallbladder. Given this presentation, which of the following organisms was most likely associated with the development of disease in this patient?

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Acute angle branching fungus

25%

34/137

Curved gram-negative bacteria

10/137

Enveloped DNA virus

28%

38/137

Naked DNA virus

12/137

Trematode from undercooked fish

27%

37/137

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This presentation is most consistent with a diagnosis of hepatocellular carcinoma (HCC). HCC is endemic in parts of Asia due to contamination of food by the carcinogen aflatoxin produced by aspergillus, a species of fungus that branches at acute angles (around 45 degrees) on pathological examination.

The two major cancers to consider in the right upper quadrant are hepatocellular carcinoma and cholangiocarcinoma. The presence of alpha-fetoprotein and polycythemia without an elevation of CA 19-9 are classic findings of HCC, which is supported by the normal appearing stool and urine. One important HCC association is that it is endemic to parts of Asia due to aflatoxin food contamination.

Incorrect Answers:
Answer 2: Helicobacter pylori is a curved gram-negative bacteria that primarily infects the stomach and early GI tract. It is associated with gastric adenocarcinoma and MALT lymphoma. Besides constitutional symptoms of malignancy, these would present with early satiety and epigastric pain without findings of jaundice or elevated alpha fetoprotein levels.

Answer 3: Ebstein-Barr virus is an enveloped DNA virus that is associated with nasopharyngeal carcinoma as well as several types of lymphoma. These would present with either facial symptoms or systemic symptoms (such as night sweats) respectively. EBV is unrelated to HCC. Hepatitis B is an enveloped DNA virus that could cause HCC; however, this is unlikely given this patient's negative hepatitis B surface antigen.

Answer 4: Papillomavirus is a naked DNA virus that produces the oncogenic factors E6 (inactivating p53) and E7 (inactivating retinoblastoma protein). Infection with oncogenic strains of HPV such as 16 and 18 is associated with cervical and genital cancer.

Answer 5: Clonorchis sinensis is a trematode that is acquired from eating undercooked fish. This fluke causes bile duct inflammation and obstruction eventually leading to cholangiocarcinoma if untreated. Cholangiocarcinoma would present with symptoms of bile duct obstruction such as pale stool, dark urine, jaundice, and pruritus.

Bullet Summary:
HCC is characterized by jaundice, RUQ pain, and elevations of alpha-fetoprotein in addition to general symptoms and has a strong association with aspergillus aflatoxin contamination in its endemic form.

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