Abdominal ultrasound revealed enlarged dysmorphic liver, seat of multiple nodules saving no segment.

Computed tomography (CT) revealed multiple hepatic lesions, with the largest measuring 50 x 45 mm in the segment VIII of the liver. The lesions showed heterogeneous arterial enhancement with portal/delayed phase washout, consistent with multifocal multicentric HCC. The portal vein was dilated and multiple pulmonary metastases were present (Figure 1).

Tests for hepatitis B and hepatitis C were negative. Serum α-fetoprotein was more than 4000 UI/ml (normal range, <4 UI/ml).

The diagnosis of HCC due to alcoholic cirrhosis was formed.

During his hospital stay, the patient presented many episodes of hypoglycemia (33– 64 mg/dL) requiring continuous intravenous dextrose infusion.

The patient’s insulin level was <0.1 mIU/l and the blood cortisol level was elevated, thus excluding respectively the diagnosis of insuli­noma and adrenal insufficiency.

Further investigations showed insulin-like growth factor 1 (IGF1): <4 ng/ml (normal 71- 263), and IGF2: 561 ng/mL (normal 396- 1039). The ratio IGF2/IGF1 was very high (>140).

Therefore, the diagnosis of HCC and NICTH with production of IGF-2 was considered.

Initially, the patient was treated with continuous 10% dex­trose infusion. Due to the advanced disease stage and the general condition of the patient, he was not a candidate for surgical or other tumor-directed therapies.

He received only symptomatic treatment, including oral prednisolone 30 mg once daily in addition to frequent high complex carbohydrate meals with some improvement in the severity of hypoglycemia. Then, he opted to pursue home hospice and passed away.