I have read the scientific letter by Leiva et al. entitled Hepatocellular carcinoma in intrathoracic ectopic liver tissue¹. I recall when we carried out the diagnostic process of this case in the Department of Anatomical Pathology in the same hospital were the authors work: the first diagnosis from a fine needle biopsy was “ectopic liver tissue with steatosis”, the diagnosis from the surgical specimen was “infiltrating hepatocellular on ectopic liver tissue with cirrosis and dysplastic nodules”, and finally as “metastasis of hepatocellular carcinoma” in the mandible biopsy, as the author has reported. I always emphasized that this was the most interesting case that residents in anatomical pathology would experience during their training, not only because of its rarity but also because of the way it was managed at the time of reporting and communicating the diagnoses.

If I may, I would like to add three comments or opinions in relation with this case:

1. It is worth mentioning that before the biopsy of the surgical specimen was available, the diagnosis of ectopic liver tissue was widely discussed, and questioned, among colleagues. This motivated the presentation of this case as a paper co-authored by the Department of General Surgery and the Department of Diagnostic Imaging at the hospital scientific meeting held in 2019². Perhaps, this paper could have been cited in the scientific letter published by Leiva et al.

2. An inquisitive reader could question the validity of the final diagnosis due to the absence of immunohistochemistry techniques certifying the hepatic lineage of the carcinoma. It should be noted that this determination of antigens was not necessary because the confirmation of lineage was provided by the large amount of non-neoplastic heterotopic liver tissue present in the sample.

3. Finally, I would like to point out that, in Medicine, there is still the tradition of recognizing contributions to scientific information. Even in the “Instructions for authors” of Revista Argentina de Cirugía, acknowledgements are defined as “contributions that require acknowledgement but do not justify authorship as a general endorsement of the chair or the department”. I consider that donation of bibliographic material and pictures deserves at least to be acknowledged. Photographic mapping of a tissue slide and of a macroscopic specimen, reviewing the literature and writing a legend of the histopathological examination that can be easily understood are not simple tasks. In this sense, the image E in Figure 2 of the scientific letter was carefully captured to show -and appreciate- the stromal (and vascular) infiltration, a sign that defines malignancy.

Ethics, like mankind, is always questioned, and disagreement can constitute progress rather than moral setback. José A. Mainetti

Julián Arévalo