CASE 09
NON-CIRRHOTIC HEPATOCELLULAR CARCINOMA MANAGED WITH CURATIVE HEPATIC RESECTION
Introduction
A 47-year-old female was investigated for persistent abdominal pain. Initial ultrasonography identified a solitary hepatic lesion, leading to further radiological and histopathological evaluation.
This case highlights the management of a solitary hepatocellular carcinoma (HCC) arising in a non-cirrhotic liver with preserved liver function, where surgical resection remains the treatment of choice and offers the best chance of long-term disease-free survival.
Pre-operative Assessment
Ultrasound Findings
Ultrasound examination demonstrated:
* Fairly well-defined heterogeneous hypoechoic lesion
* Located within the liver
* Measuring approximately 7.0 × 4.4 × 5.0 cm
* Internal vascularity present
* No cystic areas
* No calcifications
Contrast Enhanced CT Findings
* Preserved liver contour and dimensions
* Solitary focal lesion involving Segment V of the right hepatic lobe
* Heterogeneous low contrast enhancement throughout all phases
* Size approximately 5.8 × 4.2 cm
* No calcifications
* No radiological evidence of metastatic disease
* No significant lymphadenopathy
Histopathological Diagnosis
Ultrasound-guided core biopsy was performed.
Microscopy revealed:
* Liver core tissue predominantly replaced by neoplastic tissue
* Thick trabecular architecture
* Hepatocyte-like tumour cells with abundant eosinophilic granular cytoplasm
* Round central nuclei
* Nuclear inclusions
* Frequent binucleation
* Mild to moderate nuclear pleomorphism
* Occasional mitotic figures
* Absence of normal portal tract structures
* Presence of unpaired arteries and arterioles
Immunohistochemistry
CD34:
* Strong diffuse sinusoidal staining pattern throughout tumour tissue
* Adjacent normal liver tissue negative
Reticulin Stain
* Demonstrated thickened trabecular architecture
Histological Conclusion
Features consistent with Well Differentiated Hepatocellular Carcinoma (HCC).
Biochemical Assessment
* Liver function tests within normal limits
* Liver enzymes within normal limits
* AFP < 1.8 ng/ml
Teaching Point
Normal AFP does not exclude hepatocellular carcinoma.
Approximately 30–40% of HCCs may present with normal AFP values, particularly well-differentiated tumours.
Surgical Decision Making
The patient had:
Solitary lesion
No radiological evidence of metastatic disease
Preserved liver function
Clinically non-cirrhotic liver
Adequate future liver remnant
Therefore, surgical resection was considered the optimal curative treatment.
Operative Procedure
Open hepatic tumour resection with cholecystectomy.
1.Exposure
A Reverse “L” abdominal incision was utilized to provide optimal exposure of the liver and hepatoduodenal ligament.
2.Intra-operative Assessment
Findings included:
* Solitary tumour involving Segments V and VI
* No additional hepatic lesions
* No portal triad lymphadenopathy
* No obvious peritoneal disease
* No bowel, gastric or pelvic lesions
* Liver appeared clinically non-cirrhotic
3.Operative Steps
Liver Mobilization
Complete liver mobilization was performed to facilitate safe access to the lesion and vascular inflow structures.

4.Portal Triad Control
The hepatoduodenal ligament was carefully dissected.
Portal triad structures were identified and controlled, allowing immediate inflow control if required during parenchymal transection.
5.Cholecystectomy
Cholecystectomy was performed to facilitate access and improve exposure during hepatic resection.
6.Hepatic Resection
A non-anatomical wedge resection was planned.
Rationale,
* Solitary tumour
* Adequate margin achievable
* Preserved liver parenchyma desirable
A parenchymal-sparing strategy was selected.
Intra-operative ultrasound was utilized throughout the procedure to:
* Confirm tumour location
* Mark resection planes
* Identify major vascular structures
* Maintain adequate margins
Parenchymal Transection
Transection was performed using:
* CUSA
* Ligasure device
* Surgical clips
* Electrocautery
* Selective hemostatic suturing
A macroscopic margin of approximately >1 cm was achieved.
CUSA (Cavitron Ultrasonic Surgical Aspirator), which is a highly precise surgical device used by surgeons to remove liver tumors while safely preserving surrounding blood vessels and bile ducts.
How the CUSA Device Works.
The CUSA does not "cut" like a traditional knife or scalpel. Instead, it uses ultrasonic vibrations to selectively target and clear away tissue based on its water content
1.Cavitation & Fragmentation: The tip of the handpiece vibrates at an incredibly high frequency (ultrasonic waves). When touched to the liver, it causes the water-rich liver cells (hepatocytes) to expand, burst, and fragment.
2.Irrigation and Aspiration: The device continuously injects sterile saline to wash the area and simultaneously uses a vacuum to suction away the fragmented cellular debris.
3.Vessel Preservation: Tissues with high collagen and elastin—such as the liver's dense network of blood vessels and bile ducts—are highly resistant to these ultrasonic vibrations. The CUSA leaves these critical structures completely intact, exposing them so the surgeon can safely seal them off.
Why It Is Used in Liver Tumor ResectionsThe liver is one of the most vascular organs in the human body, making bleeding a primary concern during surgery. Surgeons utilize the CUSA because it provides distinct tactical advantages.
1.Reduced Blood Loss: By cleanly isolating blood vessels rather than cutting blindly through them, intraoperative bleeding is drastically minimized.
2.Precision Near Vital Structures: Because it selectively destroys soft liver tissue, surgeons can safely extract tumors that are located right next to, or even touching, major hepatic veins or the portal triad.
3.Maximizing Healthy Liver Tissue: It allows for a highly controlled, precise boundary (resection margin), ensuring the tumor is entirely removed while saving as much healthy, functioning liver tissue as possible
4.Hemodynamic Strategy
Central Venous Pressure (CVP) was deliberately maintained at a low level throughout transection.
Importance
Low CVP anesthesia significantly reduces:
* Hepatic venous bleeding
* Blood loss
* Transfusion requirements
and remains a key principle in major liver surgery.
5.Completion
Following tumour excision:
* Raw hepatic surface inspected carefully
* No active bleeding
* No bile leakage identified
* Hemostatic sutures reinforced where necessary
Tisseel fibrin sealant was applied to the transection surface.
A drain was placed adjacent to the resection bed.
Immediate Outcome
The patient tolerated the procedure well.
* Hemodynamically stable
* No immediate complications
* Transferred to ICU for monitoring
* Uneventful recovery
The specimen was submitted for definitive histopathological analysis.
Key Surgical Principles Demonstrated
1. Careful Patient Selection
The ideal candidate for hepatic resection remains:
* Solitary tumour
* Preserved liver function
* Absence of extrahepatic disease
* Adequate future liver remnant
2. AFP Alone Should Not Guide Management
Normal AFP levels do not exclude HCC.
Histology and imaging remain crucial.
3. Importance of Liver Mobilization
Adequate mobilization provides:
* Exposure
* Vascular control
* Safer parenchymal transection
4. Intra-operative Ultrasound is Essential
It improves:
* Margin planning
* Vessel identification
* Detection of occult lesions
and should be considered standard practice whenever available.
5. Low CVP Liver Surgery
Maintaining low central venous pressure remains one of the most effective strategies for minimizing blood loss during hepatic transection.
6. Parenchymal Preservation Matters
In patients with preserved liver function, non-anatomical resection can achieve oncological clearance while maximizing future liver reserve.
Key Learning Points
✓ Solitary HCC in a non-cirrhotic liver remains an excellent indication for surgical resection.
✓ Normal AFP does not exclude hepatocellular carcinoma.
✓ Thorough staging is mandatory before proceeding to surgery.
✓ Reverse “L” incision provides excellent exposure for open hepatic resections.
✓ Portal triad control should always be established before parenchymal transection.
✓ Intra-operative ultrasound significantly improves operative safety and oncological precision.
✓ Low CVP anesthesia is a cornerstone of modern liver surgery.
✓ Adequate oncological margins can be achieved with parenchymal-sparing resections in selected patients.
Take Home Message
Successful liver surgery is not simply tumour removal. It is the balance between oncological clearance, preservation of functional liver parenchyma, meticulous vascular control, and prevention of postoperative liver failure.
Patient identity protected. Images shared for educational purposes with appropriate consent.
