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Fibrolamellar hepatocellular carcinoma (FL-HCC) is a rare variant of hepatocellular carcinoma (HCC) that typically arises in non-cirrhotic livers and affects younger individuals compared with conventional HCC. Because patients usually have preserved hepatic function, surgical resection may be feasible even in the presence of large tumors. However, diagnostic uncertainty and concerns regarding extrahepatic disease may limit initial surgical decision-making.

We report the case of a 48-year-old male patient who presented with epigastric discomfort, weight loss, and a palpable abdominal mass. Contrast-enhanced imaging demonstrated a large hepatic lesion involving segments II, III, and IV, with additional pulmonary and adrenal findings initially raising concern for metastatic disease. The patient had previously been declined surgical treatment at another institution. Further multidisciplinary evaluation, imaging reassessment, and histological confirmation by percutaneous biopsy supported the diagnosis of FL-HCC without confirmed metastatic disease. An open anatomical left hepatectomy was performed. Histopathology confirmed FL-HCC with negative surgical margins and no lymph node metastases. Follow-up 36 months after surgery demonstrated no evidence of recurrence.

This case highlights the importance of comprehensive staging and multidisciplinary reassessment in patients with suspected FL-HCC. Even when surgery has initially been declined, careful evaluation may identify candidates for potentially curative hepatic resection. Long-term surveillance remains essential due to the risk of recurrence following resection. Additionally, this report illustrates that FL-HCC can occur outside the typical age range, emphasizing the need to consider this diagnosis in compatible clinical and radiologic contexts.