Hepatocellular Carcinoma in a Case of Wilson's Disease Treated with Radiofrequency Ablation Therapy

A 37-year-old Japanese man was diagnosed with liver cirrhosis due to Wilson's disease in 2001 and treated with D-penicillamine. Thereafter, he was admitted to our hospital for further examination of a space occupying lesion in the liver. The patient was diagnosed with hepatocellular carcinoma (HCC) (7th segment, 2.5 cm in diameter) in May 2010 and treated with radiofrequency ablation therapy. Biopsy findings from a non-cancerous area revealed a fatty liver, though cirrhotic nodules were not found. Long-term treatment for Wilson's disease may improve hepatic fibrosis, and careful screening for HCC by abdominal imaging is needed in such cases.


Introduction
Wilson's disease (WD), a relatively rare disease with an incidence of approximately 1 in 40,000 births (1), is inherited as an autosomal recessive disease, based on mutations in the ATP-7b gene (2).WD is characterized by liver cirrhosis, neurological manifestations, and Kayser-Fleischer rings.These symptoms are caused by impaired copper secretion to bile juice due to defective copper transporting ATPase in the liver, which results in copper toxicosis (3).The disease is screened by assays of serum ceruloplasmin and copper, and urinary copper.WD is mainly diagnosed in children, while adult patients show manifestations of psychiatric/psychomotor symptoms and/or liver dysfunction.That with hepatic presentation is mainly found as liver cirrhosis.However, some patients are found to have a fatty liver or chronic hepatitis, thus the importance of screening for ceruloplasmin in patients with non-B, non-C liver disease has been reported (4).
A nationwide survey to investigate the etiology of liver cirrhosis in Japan revealed WD in 53 of 17,262 patients with liver cirrhosis, and in 2 of 16,117 patients with liver cirrhosis and a hepatocellular carcinoma (HCC) (5).An HCC is a common malignant hepatic tumor complicated in patients with hepatitis C virus (HCV) and hepatitis B virus (HBV) (6,7).Cheng et al reported that HCC in WD is extremely rare (8), whereas Sternlieb reported the opposite findings (9).It remains undetermined whether WD is a risk factor for HCC.Herein, we describe a case of WD with a small HCC treated by radiofrequency ablation (RFA) therapy.

Case Report
A 37-year-old Japanese man was diagnosed with WD at the age of 28 years old and was treated with Dpenicillamine.Thereafter, he was admitted to our hospital in May 2010 for further examination of a space occupying lesion (SOL).His history revealed a brother diagnosed with  WD and an alcohol intake of less than 20 g per day.Laboratory examination findings at the time of diagnosis of WD in November 2001 showed AST 23 IU/L (normal range, 10-40), ALT 29 IU/L (normal range, 5-45), total bilirubin 0.3 mg/dL (normal range, 0.2-1.2),albumin 4.2 g/dL (normal range, 3.9-4.9),ceruloplasmin 2.3 mg/dL (normal range, 25-45), ferritin 224.8 ng/mL (normal range, 27-320), and serum copper 47 μg/dL (normal range, 90-130).A Kayser-Fleischer ring was also observed (Fig. 1).Anti-HCV and hepatitis B surface antigen (HBsAg) were both negative, as was anti-HB core.Histologic examination of a biopsied specimen obtained at that time revealed liver cirrhosis (Fig. 2a).The patient was treated with D-penicillamine (600 mg/day).An abdominal ultrasonography examination showed multiple nodules smaller than 1 cm in diameter, while SOLs were not found by dynamic computed tomography (CT).Follow-up examinations including liver screening by dynamic CT or ultrasound were performed once or twice each year.
In February 2009, elevation of alpha-fetoprotein (AFP) was detected and dynamic CT revealed a hypovascular nodule (1.1 cm in diameter) in the 7th segment of the liver.In April 2010, the diameter of the nodule had increased to 2 cm and it was hypervascular in gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) magnetic resonance imaging (MRI) findings (Fig. 3).In addition, the   1).The tumor was suspected to be a typical HCC based on angio-CT results and was diagnosed as a moderately differentiated HCC based on biopsy findings at the time of RFA (Fig. 4).And results of a liver biopsy of a non-tumorous lesion on May 2010 showed improvement of cirrhosis (Fig. 2b, 2c).The patient was treated with RFA.After 11 months, there were no findings of recurrence of HCC shown by dynamic CT, and AFP and PIVKA-II were within normal ranges.

Discussion
In Table 2 (4, 8, 10-21), we summarize reported cases of WD combined with HCC written in English or with abstracts written in English, including the present case.In cases 10-16, the HBsAg and HCV antibodies were assayed and found to be negative in each patient (4,(17)(18)(19)(20)(21).In the present case, anti-HCV, HBsAg, and anti-HBc were all negative, and WD was thought to have an etiological relationship with the HCC.In all reports of past WD with HCC, HCC developed after liver cirrhosis.
Formerly, periodic screening for HCC by abdominal imaging was not performed for WD patients, thus the stage of HCC was advanced in many reported cases when the diagnosis of HCC was confirmed.However, imaging modalities have progressed and several institutions have begun to look for the occurrence of HCC in patients with WD, with some recent cases diagnosed in an early stage.In liver cirrhosis with WD, imaging examination should be considered in the same manner for viral cirrhosis.
With prolonged survival periods for patients with WD due to improved prognosis by administration of a chelator for copper, the frequency of HCC has been reported to be increased in WD patients (8).On the other hand, Sone et al reported that use of a copper-chelating agent reduced the risk of HCC in Long-Evans cinnamon rats, an animal model of WD (22).In addition, some studies have found that copper may prevent the occurrence of HCC (17,23).In the present case, the results of a liver biopsy conducted following RFA therapy showed improvement after administration of a copper chelator.The present results indicate that histological WD improves with long-term administration of a chelator, even in patients with liver cirrhosis.However, the long disease period might have played an important role in occurrence of HCC in the present case.Whether copper enhances or reduces the risk for HCC has yet to be determined.
RFA is performed worldwide for small HCC, because of its low invasiveness and good therapeutic effects (24)(25)(26).As shown in Table 2, HCC was diagnosed in an advanced stage in many of the WD patients with HCC, thus there are no reports of such cases with successful RFA treatment.Early detection for HCC in patients with WD may improve their prognosis as well as quality of life by allowing treatment with a low invasive therapy such as RFA.
In conclusion, treatment with a copper chelator for WD has prolonged the survival of affected patients, though an extended survival period may have a relationship with HCC occurrence those cases.Periodic screening by abdominal imaging is needed for the detection and diagnosis of HCC in the early stage, and additional reports of WD cases with HCC are important.

Figure 2 .
Figure 2. Microphotographs of biopsied liver specimens.a) November 2001.Findings of liver cirrhosis were observed.b, c) Second biopsy in May 2010 after treatments with D-penicillamine for 10 years.Histological findings were improved and cirrhotic nodules were not observed [Hematoxylin and Eosin (H&E) staining].

Figure 3 .
Figure 3. a) The tumor was revealed as hypervascular in the arterial phase in Gd-EOB-DTPA magnetic resonance imaging (EOB-MRI) findings.b) The tumor was shown as a defect in the hepatobiliary phase by EOB-MRI.c) The tumor was found to be ablated on May 2010 following radiofrequency ablation therapy.

Figure 4 .
Figure 4. Microphotographs of liver biopsy specimen from a nodule in the 7th segment obtained at the time of radiofrequency ablation in May 2010.The nodule was diagnosed as a moderately differentiated hepatocellular carcinoma (Hematoxylin and Eosin staining).

Table 1 . Laboratory and Endocrinology Data Obtained on Admission
levels of AFP and protein induced by vitamin K absence or antagonist-II (PIVKA-II) were elevated (Table