# A Rare Case of Non-cirrhotic Hepatocellular Carcinoma in a Female Adolescent: Diagnostic and Multimodal Treatment Challenges in a Low-Resource Setting

## TL;DR

A rare case of liver cancer in a teenage girl was treated with surgery and chemotherapy in a setting where liver transplants are not available.

## Contribution

This case highlights multimodal treatment strategies for pediatric HCC in low-resource settings without transplant access.

## Key findings

- A 15-year-old female with non-cirrhotic HCC was treated with neoadjuvant chemotherapy and liver resection.
- Bile duct injury after surgery was successfully managed with endoscopic techniques.
- Aggressive multimodal therapy can offer curative potential in the absence of liver transplant options.

## Abstract

Hepatocellular carcinoma (HCC) is rare in children and adolescents, particularly in non-cirrhotic livers. Pediatric HCC often presents with aggressive behaviour and requires individualized, multidisciplinary care. Liver transplantation is a potential curative option, but this procedure is not readily accessible in many regions. In this case, a 15-year-old female patient presented with vague right-sided abdominal pain, fatigue, and abdominal distension. Imaging revealed a large heterogeneous hepatic mass with right portal vein thrombosis and mass effect on the inferior vena cava. Laboratory investigations revealed elevated transaminases and negative viral hepatitis markers. Histology was suggestive of HCC with possible hepatoblastoma features. Despite the tumour’s size potentially qualifying her for a liver transplant according to the Milan and University of California, San Francisco criteria, we opted for neoadjuvant chemotherapy and a resectional approach due to inherent limitations. She underwent four cycles of neoadjuvant sorafenib-based chemotherapy, followed by extended right hepatectomy and right hemi-diaphragmatic resection. A postoperative bile duct injury was successfully managed with the endoscopic retrograde cholangiopancreatography rendezvous technique for biliary stenting. In settings without readily accessible transplant capability, aggressive multimodal therapy including neoadjuvant chemotherapy and liver resection can offer curative potential. This case highlights the importance of adapting treatment strategies to available resources while maintaining oncologic intent.