LIVER CANCER ASSOCIATED WITH HEPATITIS B VIRUS INFECTION IN A CHILD: A CASE REPORT

Background: Two-thirds of primary liver tumors in children are malignant. Hepatoblastoma (HBL) accounts for 40-60 percent of pediatric liver tumors and is the most common malignant liver tumor. Hepatocellular Carcinoma (HCC) is the second most common malignancy in children, accounting for approximately 20% of cases. Both malignant liver tumors have similar clinical and imaging features, but different prognosis and treatment. Purpose: This report aims a case of liver cancer related to hepatitis B virus infection in a child. Case analysis: A 15-year-old girl presented with a two-month history of right upper quadrant pain along with abdominal distension, weight loss, back pain, anorexia, nausea, weakness and fatigue for 5 months prior to admission. Physical examination revealed a hard, firm mass with a bumpy surface in the right upper quadrant of the abdomen and splenomegaly. Laboratory test showed an increase in Lactate Dehydrogenase (LDH), Gamma-Glutamyl Transpeptidase (GGT), Alpha Feto Protein (AFP), quantitative Hepatitis B Virus (HBV) DNA, and HBsAg reactive. Abdominal Multi-Slice Computed Tomography (MSCT) revealed malignant solid mass with necrotic component inside, indistinct borders, irregular margins and kissing spleen. Result: The diagnosis of liver cancer in this patient suggested HCC associated with chronic hepatitis B infection. Conclusion: Routine follow-up of all children with chronic hepatitis B infection is crucial because of the risk of developing liver cancer in adolescence and adulthood.

Introduction

Pediatric liver cancer often develops in otherwise healthy livers and generally carries a poor prognosis. This liver cancer may be associated with congenital abnormalities, genetic syndromes or metabolic conditions. Hepatoblastoma (HBL) and Hepatocellular Carcinoma (HCC) are two major neoplasms accounting for 0.5 - 1.5% of all pediatric neoplasms. These two neoplasms also account for 4% of all Orthotopic Liver Transplants (OLT) in children. Hepatoblastoma accounts for 67-80% of all childhood liver cancers worldwide, while HCC accounts for 20-33%. The incidence of HCC depends on geographic and demographic factors and is related to the incidence of hepatitis B in the population(Khanna & Verma, 2018). Childhood HCC has a poor prognosis, with less than 30% disease-free survival compared to HBL, which has over 80% disease-free survival(Digiacomo et al., 2023).

Hepatocellular Carcinoma (HCC) is the second most common primary liver malignancy in children after HBL, accounting for approximately 27% of cases. The remaining pediatric promary liver malignancy cases are vascular tumors and sarcomas. Overall primary liver malignancies are extremely rare, accounting for only 1% of all pediatric malignancies, with less than 1.5 cases per million in children under age of 18. Hepatoblastoma accounts for more than two-thirds of these cases, with HCC and the very rare embryonal sarcoma of the liver accounting for the other cases. Hepatocellular Carcinoma occurs mostly in older children and adolescents, either in a noncirrhotic liver or associated with various fibrosing diseases or cirrhosis of varying etiology(Ranganathan et al., 2020).

A total of 257 - 291 million people worldwide are chronically infected with Hepatitis B Virus (HBV), but may remain asymptomatic for many years. However, they can potentially transmit the infection to others by perinatal, percutaneous, and sexual exposure or by close person-to-person contact. Complications such as cirrhosis, liver failure, and HCC, which are the leading causes of HBV-related death, are estimated to occur in 15 - 40% of HBV-infected patients(Lim et al., 2020),(Tajiri et al., 2016)World Health Organization (WHO) has committed to eliminating HBV, but this is difficult to achieve due to social barriers, including stigma, embarrassment, denial, isolation, and depression, that cause chronic HBV patients to conceal their infection and not seek treatment(Roma et al., 2024). This report aims to discuss a case of liver cancer associated with hepatitis B virus infection in a child. Serious complications from hepatitis B in children are well established, therefore early prevention of hepatitis B should be implemented.

Case study

A 15-year-old girl presented to the Pediatric Outpatient Clinic with Right Upper Quadrant (RUQ) pain for 2 months and other symptoms, including abdominal distention, back pain, weight loss, anorexia, nausea, general weakness, and fatigue for 5 months prior to admission. Data revealed that the patient’s maternal grandmother had died several years ago from liver cancer, and the patient's biological mother had also suffered from HBV infection, with seropositive results on HBsAg blood examination. Previously, the patient had been taken to the local regional hospital, where a serological examination also revealed positive serology HBsAg results. The family has been advised to seek further management. However, due to the pandemic, the patient’s family postponed the follow-up. The patient’s physical examination showed abdominal distension, splenomegaly without venous dilatation. In the right upper quadrant of the abdomen, a hard, solid mass with an irregular surface pas palpable.

Result

The complete blood count revealed anemia (Hb 7.6 g/dL, Hct 22.6%, leucocyte 8.81x10³/μL, thrombocyte 526x10³/μL). Liver function tests showed elevated Aspartate Aminotransferase (AST) 348 U/L, normal Alanine Aminotransferase (ALT) 29 U/L, elevated Lactate Dehydrogenase (LDH) 252 U/L, HBsAg reactive >1.000, Alkaline phosphatase (ALP) 171 U/L, Gamma-Glutamyl Transpeptidase (GGT) 215 U/L, Alpha Feto Protein (AFP) >1.000 IU/ml, and HBV DNA 364 copies/ml (Log 2.56). Abdominal ultrasound showed a normal-sized liver with a hypoechoic lesion measuring 6.2 x 5.2 x 7.1 cm in segments 5 - 6 of the right lobe, vascularization within the lesion (+), and suspicion of a right lobe hepatoma in segment 5 - 6 can be seen inFigure 1. After admission, chest x-ray was performed due to shortness of breath. Rough nodules were seen on both lungs, suggesting metastatic process to the lungs can be seen inFigure 2.

A real-time Multi-Slice Computed Tomography (MSCT) scan of the abdomen revealed a liver enlargement with a mean craniocaudal length of approximately 25.56 cm, resulting in a kissing spleen. A solid mass (38 - 41 HU) with a necrotic component in the interior (25 HU), ill-defined margins, irregular borders ± 13.7 x 17.2 x 25.56 cm was identified in the right lobe. In segment II of the left lobe, the largest size of approximately 2.2 x 2.1 x 3.5 cm showed contrast enhancement (93 HU). The lesion seemed to be nourished by the right and left hepatic artery. Additionally, a mass was found pressing the right kidney posteriorly, no thrombus or AV fistula was observed (Figure 3). Based on the patient’s history, physical examination, laboratory findings and radiological results, HCC was suspected. Liver biopsy was not performed due to the clinical condition. Supportive care was initiated with packed red blood cell transfusion and oxygen supplementation.

Figure 1.Abdominal ultrasonography showed hypoechoic lesion

Figure 2.Chest radiograph showed rough nodules on both lungs

Figure 3.Multi Slice Computed Tomography (MSCT) scan of the abdomen revealed a liver enlargement with solid mass

Discussion

Liver tumors account for approximately 1% of all