Appropriate referring.

Hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (iCCA) are the most common and second most common primary liver cancers, respectively. In contrast, double primary hepatic cancer (DPHC), the synchronous occurrence of these two tumors in different locations of the liver, is an uncommon pathology, occurring in less than 0.8% of all liver malignancies. A man in his 70s was referred to our department for the treatment of multiple liver tumors. He had previously been treated with a direct-acting antiviral agent for chronic liver disease due to hepatitis C virus infection and alcohol consumption. His carbohydrate antigen 19-9 (CA19-9) and des-γ-carboxy prothrombin levels were 36058 U/mL and 159 mAU/mL, respectively. Imaging studies revealed two separate lesions with different contrast features in segments VIII (SVIII, 2.5 cm in size) and IV/II/III (SIV/II/III, 3.5 cm). Therefore, the preoperative diagnosis was DPHC, consistent with HCC in SVIII and iCCA in SIV/II/III. The patient underwent an extended left hemihepatectomy with regional lymph node dissection and cholecystectomy, and DPHC was confirmed histologically. Accurate diagnoses and appropriate therapeutic strategies are essential for patients presenting with multiple liver tumors showing heterogeneous imaging features and elevated CA19-9 levels.