Hepatocellular Carcinoma with Multiple Soft tissue Metastasis-A Rare Case Report

Ananthkumar S

Abstract

Hepatocellular carcinoma represent the 5th most common cancer in men worldwide. Most cases of HCC present at an advanced stage and extrahepatic metastasis commonly occur in lung, bone, peritoneum and intra-abdominal lymphnodes. The first sign of liver cancer may be an extrahepatic metastasis. We report a 46 years old man with HCV hepatitis and had a metastatic HCC with multiple soft tissue metastasis, bony metastasis and adrenal metastasis. In view of disseminated disease, it was planned to start on Sorafenib therapy. Introduction Primary cancers of liver represent the 5th most common cancer in men worldwide Нere is an increase in the incidence of Hepatocellular cancer (HCC) in areas endemic for chronic viral hepatitis. Most cases of HCC present at an advanced stage and extrahepatic metastasis commonly occur in lung, bone, peritoneum and intra-abdominal lymphnodes We report a case of multiple soÑ– tissue and bony metastasis in a patient with HCC, who presented with a mass in the right scapular region. Case Report A 46 year old man presented to us with painless swelling in the right scapular region which gradually increased in size over 1 month and dull aching right upper quadrant pain for 20 days duration. He also gave history of loss of appetite and loss of weight. History of passing high colored urine was there, but no history of clay colored stools or generalized pruritis. Figure 1: Swelling in the right scapular region. Нere was history of similar lump in his abdomen which was excised 4 years back, but records were not available. During the course of workup, he developed sudden onset painless loss of vision in the leÑ– eye. He was a chronic alcoholic and smoker but had no co morbidities. On evaluation, he was icteric. Нere was an 8 × 8 cm well de Ù½ned Ù½rm non tender swelling over the right scapular region and the skin overlying was normal. Abdomen examination revealed hepatomegaly 10 cm below right costal margin with irregular nodular surface and mild ascites (Figure 1). Laboratory investigations showed normal complete hemogram and no coagulation disorders. Serum HCV was positive. Liver function test showed Bilirubin total-1.6 mg/dL and direct-0.9 mg/dL. AST-71 IU/L, ALT-60 IU/L, ALP-1224 IU/L and GGT- 421IU/L. Serum alpha fetoprotein level was normal (3.68). A Fine Needle Aspiration Cytology (FNAC) was done from the right scapular swelling, which was reported as metastatic hepatocellular carcinoma with the cellular smear showing cohesive clusters and sheets of atypical hepatocytes . Figure 2: Clusters of atypical hepatocytes. A triple phase CT was done which showed multifocal HCC in the background of cirrhosis with ascites and multiple metastatic lesions in the vertebra. Нere was a small enhancing focal lesion in the stem of leÑ– adrenal gland. Нere were no lung lesions Discussion Hepatocellular carcinoma is the 5th most common malignancy in men and 9th in women and the 2nd most common cause of cancer death [1], which occurs in the background of cirrhosis, commonly caused by Hepatitis B or C infection or alcohol consumption. Untreated HCC has a dismal prognosis with a 5 year survival rate below 10%. Нe median survival was 4.9 months (0 to 37 months). Нe incidence of extrahepatic metastasis from HCC vary from 13.5 to 42%. Dissemination of malignancy occurs through hematogenous routes and frequently involve the lungs (47%), bone (37%), intra-abdominal lymphnodes (45%) and adrenal glands (12%) [2]. Natsuizaka et al. reported that patients with advanced HCC develop extrahepatic metastasis more frequently than those with less advanced HCC [3]. 6oÑ– tissue metastasis from HCC is unusual. It usually originates from needle tracts or surgical wound contamination. Non iatrogenic metastasis from HCC is very rare and there does not seem to be a clear predisposing factor that contributes to the incidence [4]. To our knowledge, there are only a few case reports in the literature regarding soÑ– tissue metastasis from HCC. Only one case has been reported with HCC patient developing monocular blindness due to skull base metastasis [5]. Systemic therapy should be the mainstay of care in metastatic disease and localized cutaneous or soÑ– tissue metastatic lesions can be palliated with either surgical resection or radiotherapy. Radiation treatment was found to have satisfactory results with low toxicity pro Ù½le in patients with soÑ– tissue metastasis [6]. A low risk and 2 This work is partly presented at 31st Annual Congress on Vaccines, Clinical Trials & B2B, July 27-28, 2018 Vancouver, Canada Vol.3 No.1 Extended Abstract Journal of Vaccines & Clinical Trials 2019 e ٴو ectLYe treatment modality is required for good palliation of such metastatic lesions as the expected survival is measured in months. Our patient was a 46 years old man with HCV hepatitis and had a metastatic HCC with multiple soÑ– tissue metastasis, bony metastasis and adrenal metastasis. In view of disseminated disease, it was planned to start on Sorafenib therapy. Conclusion Нe Ù½rst sign of liver cancer may be an extrahepatic metastasis. Metastatic HCC should be a consideration in patients presenting with unexplained rapidly growing soÑ– tissue lesions with a history of HCC or risk factors for the disease [7] and should be evaluated with appropriate radiologic investigations and sampling of the mass for histopathological examination. Keywords: Hepatocellular carcinoma; 6oÑ– tissue metastasis