Carmen García-Bernardo

Germán Mínguez-Ruiz

Jimi Harold Jara-Quezada

Lino Vázquez-Velasco

M.ª Luisa González-Diéguez

Raquel Rodríguez-Uria

Mínguez Ruiz, Germán

García Bernardo, Carmen

Jara Quezada, J. H.

Rodríguez Uría, Raquel

González Diéguez, María Luisa

Vázquez Velasco, Lino

Repositorio Institucional de la Universidad de Oviedo

Letters to the Editor
1130-0108/2015/107/5/327-328
Revista española de enfeRmedades digestivas
CopyRight © 2015 aRán ediCiones, s. l.
Rev esp enfeRm dig (Madrid
Vol. 107, N.º 5, pp. 327-328, 2015
Primary hepatic neuroendocrine tumor in a 
patient with acute HBV hepatitis: An unusual 
neoplasia
Key words: Primary hepatic neuroendocrine tumor. Hepatitis 
B. Liver tumor.
Dear Editor,
We present the case of a 67-year-old woman with no previous 
medical history, with a flu-like clinic of 14 days, associated with 
arthralgia and jaundice. Additional tests showed hyperbilirubine-
mia (TB: 12.03 mg/dL) and liver enzymes with a hepatocellular 
injury pattern (AST: 1906 IU/L, ALT: 1611 IU/L). Studies were 
conducted, with viral markers: HBsAg: 1351; HBeAg: 12.39; 
HBc IgM: 27.17 and HBV DNA-426, and abdominal ultrasono-
graphic: Solid liver lesion (SLL) in segment IV adjacent to the 
portal vein of 21x17 mm. With the diagnosis of acute VHB hepa-
titis and SLL, diagnostic tests were extended. The abdominal CT 
(Fig. 1) and MRI showed the lesion described between segments 
III and IV suggestive of hepatocellular carcinoma.
Liver biopsy (FNA) was performed giving a result of peri-
portal and lobular chronic hepatitis, the SLL biopsy could not 
be performed due to its location. 
After the conversion to negative of HBsAg and HBc, the anti-
HBs positivity (acute hepatitis cured) and facing the suggesti-
ve HCC lesion, resection of segment IVa was performed, with 
intraoperative ultrasound that ruled out cirrhosis and other intra-
hepatic tumors. Highly favorable postoperative course, patient 
discharged on the fourth postoperative day. Pathology described 
a 3x3x2.5 cm tumor with poorly defined edges and free margins. 
Histological examination showed organoid architecture and tra-
vecular areas with cellular elements of round nuclei with clum-
ped chromatin, and immunohistochemical techniques showed 
synaptophysin +, chromogranin -, and a proliferation rate of 5% 
compatible with a nonfunctioning primary hepatic neuroendo-
crine tumor (PHNT). 
Given the findings, a PET-SCAN was made  without observing 
other injuries and chromogranin A was in normal range.
Two years after surgery, the patient has had no recurrence. 
Discussion
The primary location in the liver of neuroendocrine tumors 
is rare, because when the liver presents such tumors, the disease 
is usually metastatic (more than 80% are metastases) (1). The 
PHNT represents 0.3% of neuroendocrine tumors (2). They 
appear in middle-aged population (40-50 years) with no sex 
predilection. Usually at diagnosis, the tumors are large because 
Fig. 1. Abdominal CT, arterial phase contrast hyperenhancement PHNET 
of 25 x 20 mm and presence of feeder vessel (arrow).
328 LETTERS TO THE EDITOR Rev esp enfeRm Dig (maDRiD)
Rev esp enfeRm Dig 2015; 107 (5): 327-328
most are asymptomatic; if there are symptoms, these are strain 
or right upper quadrant pain, weight loss, fatigue and fever (3) 
and they do not usually have carcinoid syndrome (4).
Some authors have reported cases of PHNT in patients with 
previous liver disease (hepatitis B or cirrhosis), but an associa-
tion between the two has not been demonstrated (5,6). 
The differential diagnosis is made with hepatocellular carci-
noma and intrahepatic cholangiocarcinoma, showing negativity 
for markers such as AFP, CEA and CA 19-9 (3). Blood serotonin, 
chromogranin A, or 5-hydroxyindoleacetic acid in urine may be 
high (6). The imaging tests most commonly used are ultrasound, 
CT and MRI. The octreoscan and PET-CT with 18F-FDG can 
detect tumors up to 2 mm and occult foci (6). The final diagnosis 
needs histological confirmation with generally positive immu-
nohistochemistry for chromogranin A, neuro-specific enolase, 
and synaptophysin (7,8) and requires to fulfill another premise: 
exclude extrahepatic localization, since in that case it would then 
be a metastasis (3,5,9).
Surgery with complete resection is the accepted treatment 
for PHNT, with recurrences of 18% and survival at 5 years of 
74-78% (3,9,10).
Germán Mínguez-Ruiz1, Carmen García-Bernardo1, 
Jimi Harold Jara-Quezada1, Raquel Rodríguez-Uria1, 
M.ª Luisa González-Diéguez1 and Lino Vázquez-Velasco1
Departments of 1General Surgery and 2Digestive Diseases. 
Hospital Universitario Central de Asturias. Oviedo, Spain
References
1. Modlin IM, Sandor A. An analysis of 8305 cases of carcinoid tumors. 
Cancer 1997;79:813-29.
2. Fenoglio LM, Severini S, Ferrigno D, et al. Primary hepatic carci-
noid: A case report and literature review. World J Gastroenterol 2009; 
15:2418-22. 
3. Zhu H, Sun K, Ward SC, et al. Primary hepatic signet ring cell neu-
roendocrine tumor: A case report with literature review. Semin Liver 
Dis 2010;30:422-8. 
4. Modlin IM, Kidd M, Latich I, et al. Current status of gastrointestinal 
carcinoids. Gastroenterology 2005;128:1717-51.
5. Jia C, Zhang Y, Xu J, et al. Experience in primary hepatic neuroendo-
crine tumor. Turk J Gastroenterol 2012;23:546-51.
6. Huang YQ, Xu F, Yang JM, et al. Primary hepatic neuroendocrine 
carcinoma: Clinical analysis of 11 cases. Hepatobiliary Pancreat Dis 
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7. Dala R, Shoosmith J, Lilenbaum R, et al. Primary hepatic neuroen-
docrine carcinoma: An underdiagnosed entity. Ann Diagn Pathol 
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8. Erickson LA, Lloyd RV. Practical markers used in the diagnosis of 
endocrine tumors. Adv Anat Pathol 2004;11:175-89.
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10. Woodside KJ, Townsend CM, Evers BM. Current management of 
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Primary hepatic neuroendocrine tumor in a patient with acute HBV hepatitis: An unusual neoplasia

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Primary hepatic neuroendocrine tumor in a patient with acute HBV hepatitis: an unusual neoplasia

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Primary hepatic neuroendocrine tumor in a patient with acute HBV hepatitis: an unusual neoplasia

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