title: Giant pedunculated hepatocellular carcinoma with hemangioma mimicking intestinal obstruction.
abstract: BACKGROUND
  Pedunculated hepatocellular carcinoma (P-HCC) has rarely been reported and is characteristically large and encapsulated. Only sporadic cases have been published, in which P-HCC was combined with other liver tumors (mostly benign), making the diagnosis difficult.
  
  
  METHODS
  We report a patient who was admitted to our hospital with clinical features of intestinal obstruction and a palpable mass in the right iliac fossa. Ultrasound, computed tomography and magnetic resonance imaging demonstrated an encapsulated mass of unclear origin and characteristics of liver hemangioma. Laboratory tests revealed elevated α-fetoprotein (> 800 ng/ml) and cancer antigen 125 (> 51.2 U/ml). With a possible diagnosis of giant liver hemangioma, we proceeded to surgery. During surgery, a giant pedunculated tumor was discovered on the inferior surface of the right lobe of the liver, hanging free in the right abdominal cavity towards the right iliac fossa. The macroscopic appearance of the tumor was compatible with liver hemangioma. Tumor resection was performed at a safe distance, including the pedicle. The rest of the liver appeared normal. Histopathological examination revealed grade II and III HCC (according to Edmondson-Steiner's classification) with nodular configuration, central necrosis, and infiltration of the capsule. Underneath the tumor capsule, residual tissue of a cavernous hemangioma was recognized. The resection margins were free of neoplastic tissue.
  
  
  CONCLUSIONS
  This rare presentation of a giant P-HCC combined with a hemangioma with features of intestinal obstruction confirmed the diagnostic difficulties of similar cases, and required prompt surgical treatment. Therefore, patients benefit from surgical resection because both the capsule and the pedicle prevent vascular invasion, therefore improving prognosis.
authors.affiliation: 2nd Propedeutic Department of Surgery, Laiko General Hospital, University of Athens, Medical School, Athens, Greece. tkaratz@med.uoa.gr
authors.forename: Theodore
authors.initials: T
authors.lastname: Karatzas
authors.forename: Anastasios
authors.initials: A
authors.lastname: Smirnis
authors.forename: Dimitrios
authors.initials: D
authors.lastname: Dimitroulis
authors.forename: Dimitrios
authors.initials: D
authors.lastname: Patsouras
authors.forename: Kostantinos
authors.initials: K
authors.lastname: Evaggelou
authors.forename: Stylianos
authors.initials: S
authors.lastname: Kykalos
authors.forename: Gregory
authors.initials: G
authors.lastname: Kouraklis
mesh_terms: D018394:CA-125 Antigen / Q000097:blood; D006528:Carcinoma, Hepatocellular / Q000473:pathology* / Q000601:surgery; D003937:Diagnosis, Differential; D005260:Female; D006392:Hemangioma, Cavernous / Q000473:pathology* / Q000601:surgery; D006801:Humans; D007415:Intestinal Obstruction / Q000175:diagnosis*; D008113:Liver Neoplasms / Q000473:pathology* / Q000601:surgery; D008875:Middle Aged; D000509:alpha-Fetoproteins / Q000032:analysis
chemical_list: D018394:CA-125 Antigen; D000509:alpha-Fetoproteins