Wilson's disease (WD) is a rare autosomal recessive metabolic disorder with an incidence of 1:40,000.[1] The WD gene is located on chromosome 13 and codes for a copper transporting P-type ATPase-ATP7B.[2]
[3] Mutations of the WD gene cause impaired biliary copper excretion, resulting in copper accumulation in many vital organs, including liver, central nervous system, and cornea. Patients may therefore develop cirrhosis, neurological manifestations, and Kayser-Fleischer rings. A fair number of patients, however, may have only hepatic manifestations, and among these patients with liver disease some have normal laboratory results, such as normal levels of serum ceruloplasmin and 24-hour urine copper excretion.[4]
[5] In this subset of patients the diagnosis of WD becomes a challenge, and subsequent management is problematic.
The development of hepatocellular carcinoma (HCC) in WD is reported to be a rare but deadly complication. In contrary to early observations that copper accumulation may have a protective effect on hepatocarcinogenesis,[6]
[7] recent evidence suggests that accumulation of copper in the liver is a risk factor for HCC.[4]
[8] To date, there have been at least 20 reported cases of HCC associated with well-established WD.[4]
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[23] These tumors have been treated either surgically or with chemoembolization, both showing variable results.
Herein we report an unusual case of HCC being the first manifestation of undiagnosed WD; the HCC was successfully treated with liver transplantation and the diagnosis of WD was made upon review of the liver explant.
REFERENCES
1
Frydman M.
Genetic aspects of Wilson's disease.
J Gastroenterol Hepatol.
1990;
5
483-490
2
Tanzi R E, Petrukhin K, Chernov I et al..
The Wilson disease gene is a copper transporting ATPase with homology to the Menkes disease gene.
Nat Genet.
1993;
5
344-350
3
Vrabelova S, Letocha O, Borsky M, Kozak L.
Mutation analysis of the ATP7B gene and genotype/phenotype correlation in 227 patients with Wilson disease.
Mol Genet Metab.
2005;
86
277-285
7
Kamamoto Y, Makiura S, Sugihara S, Hiasa Y, Arai M.
The inhibitory effect of copper on DL-ethionine carcinogenesis in rats.
Cancer Res.
1973;
33
1129-1135
13
Guan R, Oon C J, Wong P K, Foong W C, Wee A.
Primary hepatocellular carcinoma associated with Wilson's disease in a young woman.
Postgrad Med J.
1985;
61
357-359
14
Polio J, Enriquez R E, Chow A, Wood W M, Atterbury C E.
Hepatocellular carcinoma in Wilson's disease: case report and review of the literature.
J Clin Gastroenterol.
1989;
11
220-224
18
Girard P F, Vachon A, Tommasi M, Paliard P, Rochet M, Barthe J.
Hepatolenticular degeneration and primary cancer of the liver.
Lyon Med.
1968;
219
1395-1400
19
Terao H, Itakura H, Nakata K et al..
An autopsy case of hepatocellular carcinoma in Wilson's disease [in Japanese].
Acta Hepatol Jpn.
1982;
23
439-445
21
Agret F, Vallet-Pichard A, Landau A, Carnot F, Pol S.
[Late presentation of Wilson's disease as cirrhosis complicating hepatocellular carcinoma].
Gastroenterol Clin Biol.
2003;
27
130-131
23
Savas N, Canan O, Ozcay F et al..
Hepatocellular carcinoma in Wilson's disease: a rare association in childhood.
Pediatr Transplant.
2006;
10
639-643
24
Miyamura H, Nakanuma Y, Kono N.
Survey of copper granules in liver biopsy specimens from various liver abnormalities other than Wilson's disease and biliary diseases.
Gastroenterol Jpn.
1988;
23
633-638
26
Ishida M, Nakagawara G, Imamura Y, Fukuda M.
Iron and copper deposition in chronic active hepatitis and liver cirrhosis: pathogenetic role in progressive liver cell damage.
Eur J Histochem.
1995;
39
221-236