• Marlone Cunha-Silva, Eloy Vianey Carvalho de França, Clauber Teles Veiga, Raquel Dias Greca, Priscilla Brito Sena de Moraes, Daniel Ferraz de Campos Mazo, de AtaídeElaine CristinaECDepartment of Surgery; University of Campinas (Unicamp), Campinas, Brazil., Simone Reges Perales, Leonardo Trevizan Monici, and Tiago Sevá-Pereira.
• Division of Gastroenterology (Gastrocentro) - Department of Internal Medicine, University of Campinas (Unicamp), Campinas, Brazil.
• Medicine (Baltimore). 2022 Sep 2; 101 (35): e30315e30315.

RationaleLysosomal acid lipase deficiency (LAL-D) is a poorly diagnosed genetic disorder characterized by the accumulation of cholesteryl esters and triglycerides in many tissues, leading to dyslipidemia and cardiovascular complications. In the liver, deposits are found within hepatocytes and Kupffer cells, generating microvesicular steatosis, progressive fibrosis, and cirrhosis. Sebelipase alfa is the target therapy which can improve laboratory changes and reduce the progression of liver damage, but this is not yet widely available.Patient ConcernsWe are reporting a 15-year follow-up of a Brazilian man who was diagnosed with cirrhosis at age 43 and with LAL-D at age 53, but he has never been treated with sebelipase alfa for economic reasons. During the coronavirus disease 2019 (COVID-19) pandemic, he lost follow-up and missed three 6-month ultrasound exams for liver cancer screening.DiagnosisAt age 58, a remarkable deterioration in liver function was observed and he was diagnosed with hepatocellular carcinoma (HCC) outside the Milan Criteria (two nodules measuring 48mm and 25mm). Three other individuals with LAL-D and progression to liver cancer have been reported so far and none of them underwent enzyme replacement therapy: an 11-year-old girl with HCC, a 51-year-old male with cholangiocarcinoma, and a 21-year-old male with hepatocellular-cholangiocarcinoma. The latter had the same mutation in the gene LIPA as our patient, but a relationship between this variant and malignancies has not yet been established.LessonsWe emphasize how important is to treat LAL-D patients after diagnosis in order to avoid worsening liver function and progression to neoplasms. Untreated individuals should be considered at a higher risk but the most appropriate liver cancer screening program for this subgroup is still unknown.Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.

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