World J Oncol

World Journal of Oncology, ISSN 1920-4531 print, 1920-454X online, Open Access

Article copyright, the authors; Journal compilation copyright, World J Oncol and Elmer Press Inc

Journal website http://www.wjon.org

Case Report

Volume 5, Number 5-6, December 2014, pages 214-219

Relapsing Episodes of Loss of Consciousness in a Patient With Hepatocellular Carcinoma

Figure 2. Microscopic appearance of hepatocellular carcinoma. Note the trabecular pattern of growth (H&E, × 10).

Figure 3. Hepatocellular carcinoma (arrow). In the adjacent liver parenchyma incomplete cirrhotic nodules (star) and fatty changes were observed (H&E, × 4).

**Table 1.** Non-islet Cell Tumors Associated With Hypoglycemia
Tumor	% of total
Data extracted from Zapf (1993), Frystyk et al (1998), Marks and Teale (1998), Fukuda et al (2006) and Tsuro et al (2006) [3-7].
Tumors of mesenchymal origin	41
Mesothelioma	8
Hemangiopericytoma	7
Solitary fibrous tumor	7
Leiomyosarcoma/gastrointestinal stromal tumor	6
Fibrosarcoma	5
Others	8
Tumors of epithelial origin	43
Hepatocellular	16
Stomach	8
Lung	4
Colon	4
Pancreas (non-islet cell)	3
Prostate	2
Adrenal	2
Undifferentiated	2
Kidney	1
Others	1
Tumors of neuroendocrine origin	1
Tumors of hematopoietic origin	1
Tumors of unknown origin	14

Table 1. Non-islet Cell Tumors Associated With Hypoglycemia

Tumor

% of total

Data extracted from Zapf (1993), Frystyk et al (1998), Marks and Teale (1998), Fukuda et al (2006) and Tsuro et al (2006) [3-7].

Tumors of mesenchymal origin

Mesothelioma

Hemangiopericytoma

Solitary fibrous tumor

Leiomyosarcoma/gastrointestinal stromal tumor

Fibrosarcoma

Others

Tumors of epithelial origin

Hepatocellular

Stomach

Lung

Colon

Pancreas (non-islet cell)

Prostate

Adrenal

Undifferentiated

Kidney

Others

Tumors of neuroendocrine origin

Tumors of hematopoietic origin

Tumors of unknown origin

**Table 2.** Laboratory Tests
Laboratory test	Results	Units	Reference values
WBC	7.420	10³/µL	7.000 - 11.000
HG	14.40	g/dL	12 - 18
Ht	42.3	%	36 - 48
PLT	222	10³/µL	150.000 - 400.000
PT	13.6	s	Normal
INR	1.03	-	0.8 - 1.2
Glu	30	mg/dL	70 - 125
Ur	18	mg/dL	11 - 54
Cr	0.6	mg/dL	0.6 - 1.2
BILIRUBIL	0.6	mg/dL	0.1 - 1
BILL-DIRECT	0.16	mg/dL	0.01 - 0.2
AST	91	IU/L	10 - 35
ALT	42	IU/L	10 - 35
γGT	233	IU/L	10 - 52
ALP	97	IU/L	Adults 30 - 125 IU/L
Total protein	6.7	g/dL	6 - 8.4
Albumin	2.8	g/dL	3.4 - 5
LDH	392	U/L	115 - 230
Calcium	8.8	mg/dL	8.2 - 10.6
Sodium	144	mEq/L	135 - 153
Potassium	3.23	mEq/L	3.5 - 5.3

Table 2. Laboratory Tests

Laboratory test

Results

Units

Reference values

WBC

7.420

10³/µL

7.000 - 11.000

14.40

g/dL

12 - 18

42.3

36 - 48

PLT

222

10³/µL

150.000 - 400.000

13.6

Normal

INR

1.03

0.8 - 1.2

Glu

mg/dL

70 - 125

mg/dL

11 - 54

0.6

mg/dL

0.6 - 1.2

BILIRUBIL

0.6

mg/dL

0.1 - 1

BILL-DIRECT

0.16

mg/dL

0.01 - 0.2

AST

IU/L

10 - 35

ALT

IU/L

10 - 35

γGT

233

IU/L

10 - 52

ALP

IU/L

Adults 30 - 125 IU/L

Total protein

6.7

g/dL

6 - 8.4

Albumin

2.8

g/dL

3.4 - 5

LDH

392

U/L

115 - 230

Calcium

8.8

mg/dL

8.2 - 10.6

Sodium

144

mEq/L

135 - 153

Potassium

3.23

mEq/L

3.5 - 5.3

**Table 3.** Glucagon Stimulation Test
Time (min)	Glucose (NR: 70 - 125 mg/mL)	Insulin (NR: 1.9 - 23 µIU/mL)
NR: normal ratio.
10 before	30	0.6
0	89	0.7
15	155	1.1
30	146	0.6
45	141	0.5

Table 3. Glucagon Stimulation Test

Time (min)

Glucose (NR: 70 - 125 mg/mL)

Insulin (NR: 1.9 - 23 µIU/mL)

NR: normal ratio.

10 before

0.6

0.7

155

1.1

146

0.6

141

0.5

**Table 4.** Workup of Hypoglycemia
Modality	Results	Conclusion
Serum glucose levels	30 mg/dL (70 - 125)	Hypoglycemia
Clinical manifestations	Hepatomegaly, palmar erythema spider nevi	Hepatic disease
Complete blood count	Normal	-
Serum chemistry	Normal	Child Pugh A
Coagulation test	Normal	Child Pugh A
AFP	7.794 ng/mL (<9 ng/mL)	MCC
TSH	1.56 µIU/mL (0.34 - 5.6)	Normal, exclusion of hypothyroidism
Serum cortisol	26 mg/dL (6.7 - 22.6)	Adequate response, exclusion of adrenocortical insufficiency
Insulin	0.5 µIU/mL (1.9 - 23 µIU/mL)	Suppressed levels during hypoglycemia (excludes insulinoma)
Glucagon test	Positive	Paraneoplastic insulin-like secretion
IGF-I	29.4 ng/mL (51 - 297)	Low
IGF-II	485 ng/mL (288 - 736)	Normal
IGF-II/IGF-I ratio	> 10:1	Consistent with non-islet cell tumor hypoglycemia
Immunohistological stains of IGF-II	Not defined	-
CT scan abdomen	Positive	Large tumor volume

Table 4. Workup of Hypoglycemia

Modality

Results

Conclusion

Serum glucose levels

30 mg/dL (70 - 125)

Hypoglycemia

Clinical manifestations

Hepatomegaly, palmar erythema spider nevi

Hepatic disease

Complete blood count

Normal

Serum chemistry

Normal

Child Pugh A

Coagulation test

Normal

Child Pugh A

AFP

7.794 ng/mL (<9 ng/mL)

MCC

TSH

1.56 µIU/mL (0.34 - 5.6)

Normal, exclusion of hypothyroidism

Serum cortisol

26 mg/dL (6.7 - 22.6)

Adequate response, exclusion of adrenocortical insufficiency

Insulin

0.5 µIU/mL (1.9 - 23 µIU/mL)

Suppressed levels during hypoglycemia (excludes insulinoma)

Glucagon test

Positive

Paraneoplastic insulin-like secretion

IGF-I

29.4 ng/mL (51 - 297)

Low

IGF-II

485 ng/mL (288 - 736)

Normal

IGF-II/IGF-I ratio

> 10:1

Consistent with non-islet cell tumor hypoglycemia

Immunohistological stains of IGF-II

Not defined

CT scan abdomen

Positive

Large tumor volume