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A 24-year-old man was evaluated for 3 months of abdominal pain and new onset of shortness of breath, increased abdominal girth, and leg swelling. On physical examination, he was tachypneic, had dullness in flanks, and bilateral lower extremity edema. Liver biochemical tests were notable for marginal derangement and a normal alpha-fetoprotein. An abdominal computed tomography (CT) scan showed an 11.5-cm hepatic mass with satellite lesions, ascites, tumor extension into the inferior vena cava (IVC) causing obstruction, and bland thrombus extending from the lower IVC to the femoral veins bilaterally (Fig. 1A). A chest CT showed bilateral pulmonary emboli and bilateral pleural effusions. A 2D echocardiogram showed a presumed right atrial tumor thrombus (Fig. 1B). A liver biopsy showed large polygonal tumor cells with eosinophilic granular cytoplasm (positive stain for Heppar-1) surrounded by abundant fibrous stroma in parallel lamellae, consistent with a well-differentiated fibrolamellar variant of hepatocellular carcinoma (Fig. 1C,D). Given his advanced disease, he was not a candidate for hepatectomy, systemic chemotherapy, vascular intervention, or liver transplantation and was discharged to hospice care with symptomatic palliation.

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Figure 1. (A) Abdominal CT shows the presence of a large hepatic mass invading the inferior vena cava with ascites and bland thrombus in the lower inferior vena cava extending to the iliac veins. (B) 2D echocardiogram showing the presence of a right atrial thrombus. (C) Liver biopsy showing large polygonal tumor cells with eosinophilic granular cytoplasm surrounded by abundant fibrous stroma in parallel lamellae. (D) Liver biopsy showing cytologic features that include large nuclei with a single prominent nucleolus and pale pink globules in the cytoplasm.

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Fibrolamellar hepatocellular carcinoma (FLHCC) differs from traditional hepatocellular carcinoma (HCC) in patient demographics (mean age 25 years, equal sex distribution), and absence of underlying cirrhosis or usual risk factors. 1 Our patient presented with rare manifestations that included secondary Budd-Chiari syndrome and significant clot burden causing lower extremity edema and ascites, bilateral pulmonary emboli causing shortness of breath, and a right atrial thrombus. 2 He had both tumor thrombus and bland thrombus, with the latter likely related to a hypercoagulable state. Alpha-fetoprotein levels are usually normal. On imaging a heterogeneous mass characterized by hypervascularity and a central scar in the background of normal liver parenchyma is appreciated. Metastatic tumor burden, hepatic adenoma, focal nodular hyperplasia, traditional HCC, and hemangioma are in the differential diagnosis. In contrast to the central scar of focal nodular hyperplasia (FNH), the central scar has low attenuation on T2 images. 3 On biopsy, the presence of large polygonal tumor cells with vesicular nuclei and large nucleoli, eosinophilic granular cytoplasm, and abundant fibrous stroma in thin parallel lamellae around tumor cells support the diagnosis. 1, 4 Immunohistochemistry shows staining for both hepatocellular (Heppar-1) and biliary differentiation (cytokeratin-7 and epithelial membrane antigen), with the latter contrasting FLHCC and HCC. 4

There are limited data on survival stratified by treatment modalities or by disease stage for FLHCC as compared to HCC arising in noncirrhosis livers. In a multicenter study of patients without metastatic disease undergoing resection, the 5-year survival of patients with FLHCC was similar to those patients with HCC without underlying cirrhosis but higher than patients with HCC and concomitant cirrhosis (62% versus 58% versus 27%). 5 Chemotherapeutic options are limited. Given its increased expression in FLHCC, selective targeting of epidermal growth factor receptor may play a role. Modest 5-year survival rates (35%-50% survival rates) after transplantation have been reported. 6

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