Hardened Liver Due to Fibrolamellar Hepatocellular Carcinoma

A 48-year-old woman with no past medical history presented to the primary care clinic with right-sided abdominal pain, fatigue, and a 20-lb weight loss over 3 months. She described a short period of heavy alcohol use (a bottle of wine per day for 3 years), although she had been abstinent for 1 year before presentation. She has 2 daughters with Alagille syndrome. She had no other risk factors for liver disease. Initial evaluation revealed abnormal liver biochemical tests (alanine aminotransferase: 130 U/L, aspartate aminotransferase: 107 U/L, alkaline phosphatase: 622 U/L, total bilirubin: 0.9 mg/dL). Abdominal magnetic resonance imaging was performed, which revealed multiple well defined focal lesions throughout the liver (Figure A). A liver biopsy was pursued to secure the diagnosis. Remarkably, the 17-gauge needle used for the biopsy bent upon contact with the liver because of the extensive tumor burden (Figure B). Tissue was obtained and revealed moderately differentiated hepatocellular carcinoma consistent with the fibrolamellar or oncocytic variant (Figure C). Fibrolamellar hepatocellular carcinoma occurs more commonly in young patients and in those without underlying liver disease. When a tumor is extensive, as in the case of our patient, it can encase and harden the liver, creating an iecoris petram, or “rock liver.”