Hypervascular nodule in a fibrotic liver overloaded with iron: identification of a premalignant area with preserved liver architecture

A 55 year old man with idiopathic refractory anaemia was addressed for the cure of a recently appeared 3.3 cm hypervascular liver nodule. The nodule was not visible on the resected fresh specimen, but a paler zone was seen after formalin fixation. The surrounding liver was fibrotic (METAVIR score F3) and overloaded with iron. However, the paler zone, thought to be the nodule, had in fact a normal architecture, was less fibrotic, and contained some "portal tract-like structures" (but with arteries only); moreover, this paler area was devoid of iron, contained less glycogen and was characterized by foci of clear hepatocytes.In spite of the absence of architectural distortion, and a normal proliferative index, the possibility of premalignancy or malignancy should be considered in this type of hypervascular and hyposiderotic nodule, occurring in the context of an iron overloaded liver.The presence of a hypervascular nodule in a patient with liver disease is highly suggestive of a hepatocellar carcinoma (HCC) [1]. Increased iron stores in patients with HCC developed on a non-cirrhotic liver is well documented [2-5]; iron stores are seldom depleted at the time of the discovery of the HCC [6]. Few cases of premalignant nodules associated with HCC have also been reported under these circumstances [7,8]. In a fibrotic liver overloaded with iron, we report a case of a hypervascular and hyposiderotic nodule with premalignant features, but with a normal architecture.A 55 year old man with idiopathic refractory anaemia was addressed to our Unit for the cure of a recently appeared 3.3 cm hypervascular liver nodule in segment II (November, 2003). Physical examination was normal, including BMI. Liver function tests were as follows: ASAT = 53 IU/L (Normal = 40); ALAT = 58 IU/L (N = 50); Billirubin = 44 μmol/L (N = 17); PT = 70% (N = 70–100); V = 65% (N = 70–100); RBC = 2.9 × 106 cells/μl; Ht = 22.5% and Hb = 7.3 gm/dl; WBC = 4.6 × 103 cells/μl; and platelets = 210 × 109 /l. Ferritin