Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 1997  |  Volume : 3  |  Issue : 1  |  Page : 49-52
Metastatic hepatocellular carcinoma with occult primary : A case report


1 Department of Oncology, King Fahad Hospital. Madinah Al Munawarah, Saudi Arabia
2 Department of Surgery, King Fahad Hospital. Madinah Al Munawarah, Saudi Arabia
3 Department of Pathology, King Fahad Hospital. Madinah Al Munawarah, Saudi Arabia
4 Department of Gastroenterology, King Fahad Hospital. Madinah Al Munawarah, Saudi Arabia

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Date of Submission28-Oct-1995
Date of Acceptance13-Apr-1996
 

How to cite this article:
Sabir AA, Banoo T, Al Haj OB, Fouad Sedky AA, Hamid TA, Mahrous AR. Metastatic hepatocellular carcinoma with occult primary : A case report. Saudi J Gastroenterol 1997;3:49-52

How to cite this URL:
Sabir AA, Banoo T, Al Haj OB, Fouad Sedky AA, Hamid TA, Mahrous AR. Metastatic hepatocellular carcinoma with occult primary : A case report. Saudi J Gastroenterol [serial online] 1997 [cited 2019 Dec 12];3:49-52. Available from: http://www.saudijgastro.com/text.asp?1997/3/1/49/33946


Hepatocellular carcinoma (HCC) is a common malignancy in the Third World countries mainly in sub­Saharan Africa and Far East [1] . In Saudi Arabia, the incidence of HCC is several times higher than in the western hemisphere. The disease was found to represent 12-30% of all the gastrointestinal malignancies [2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12] . HCC presents with hepatic involvement in majority and as metastatic disease in minority of patients [13],[14],[15] . Regional nodes are common site of secondaries whereas bone involvement is rare. Even many unusual presentations have been noticed [16],[17] which may lead to missed, overlooked or delayed diagnosis.

We report a case of hepatocellular carcinoma presenting primarily with bilateral symmetrical pelvic masses and bone metastasis with no evidence of primary in the liver. Such a rare presentation not reported earlier emphasizes the need for considering HCC as a differential diagnosis for any extrahepatic mass.


   Case report Top


A60-year-old Saudi male previously in good health started experiencing pain in the back and lower limbs which gradually increased over a period of three months. This also was associated with some limitation of movement particularly around right hip joint. He got some local treatment (cauterization) but there was no relief. After a fall he sustained a fracture of right iliac bone, and was admitted to the orthopedic department. Over this period, he also noticed loss of weight and appetite. There was no history of alcohol intake, liver disease or other relevant major illness in the past.

Examination revealed an average built man, conscious with stable vital signs and performance status of grade 2-3. There was no pallor, jaundice, lymphadenopathy or oedema. Multiple cauterization marks were noticed over the abdominal wall and right gluteal region. His chest and cardiac examination was unremarkable. On abdominal examination, there was no palpable upper abdominal mass. Liver and spleen were not palpable, there was no ascites. There were palpable masses in both iliac regions which were hard, fixed to underlying bone extending over iliac crests measuring 5 x 8 cm., 3x4 cm on right and left side respectively. There was tenderness over iliac crest and pelvic bone. On rectal examination, prostate was normal. Investigations revealed normal hemogram, renal functions electrolytes, coagulation and bleeding profile. His Bilirubin 4.9 mmol/L, AST 65 IU/L, ALT 94 IU/L. Total Protein 64.4 G/L, Albumin 38.9 G/L, Alk. Phosp 98 IU/L.

Test for Bence Jones Proteins in wine and other investigations for myeloma were negative. Screening done with Elisa method for HepatitisA,B, & C viruses were all negative. X-ray of chest showed no pulmonary metastases [Figure - 1] ana x-ray of peivus snowea large lytic lesion in iliac bones on both sides [Figure - 2].

Abdominal ultrasound did not reveal any hepatic lesion. CT scan of pelvis showed bilateral iliac soft tissue masses with destruction of iliac bones and pathological fracture right iliac bone [Figure - 3]. Bone scan showed multiple skeletal metastasis mainly in iliac bones and also in inferior pubic rami, 3, 4, 5, 6th ribs of left anterior chestwall, mid dorsal and lumbar spine [Figure - 4]. A primary extrahepatic malignancy with bony secondaries was suspected. Biopsy from right iliac bone and soft tissue mass showed a malignant neoplasm infiltrating the bone and mesenchymal tissues. The tumor composed of irregular cords and masses of cells with abundant acidophilic cytoplasm resembling liver cells. Both the individual cell and the arrangement was reminiscent of liver. Differentiation was so complete it almost resembled normal liver in many areas. Bile secretion was seen in some malignant acini [Figure - 5],[Figure - 6].

A histologic diagnosis of Metastatic Hepatocellular Carcinoma involving iliac bone mass was made. After biopsy report, an abdominal CT was carried out. Although there was a suspicious area in the anterior part of 4th hepatic segment [Figure - 7] ultrasound guided biopsy from this area did not reveal any evidence of hepatocellular carcinoma but showed only changes consistent with chronic persistent hepatitis. For painful bony metastasis, patient was referred to oncology service at King Faisal Specialist Hospital, Riyadh. On review of histopathological slides, diagnosis of metastatic hepatocellular carcinoma was reconfirmed. Tumor markers study showed CEA:6.1 ng/ml, CA 19.9:126.8 U/ml, AFP: 258000 IU/ml. Patient received palliative radiation therapy for pain relief and referred back to us for further supportive treatment.


   Discussion Top


HCC usually occurs in association with chronic liver disease most frequently with cirrhosis [14],[18],[19],[­20] or chronic Hepatitis B and C infection [21],[22],[23],[24],[25],[26] . Majority of patients are symptomatic and minority asymptomatic [14],[15],[27],[28] . The common presenting features are upper abdominal pain, malaise, abdominal distension, mass, fever, jaundice and weight loss [3],[13],[15],[20],[27],[29] . In cirrhotic patients, there may be sudden deterioration usually marked by hepatocellular failure or abrupt worsening of portal hypertension [30] . It may present as acute abdomen like hemoperitoneum or acute  Budd-Chiari syndrome More Details or as paraneoplastic syndrome [31],[32] . Occasionally, metastasis to bone or other sites may draw attention to the disease. An interesting feature of HCC is its varied and sometimes bizarre presentation [16],[17] . This report describes an unusual presentation of HCC. The patient presented with a pathological pelvic fracture, bilateral pelvic masses and bony metastasis without detectable primary in the liver. There was no radiological, clinical or laboratory suspicion of HCC. Metastatic HCC was only apparent on histologic examination of the right iliac bone mass. The histologic structure of HCC resembles that of a normal liver in that tumor parenchyma comprises a liver cell cord like (Trabecular) structure and a stroma consists of sinusoid like blood space lined by a single layer of endothelial cell. In histology of metastasis, the secondary tumor may produce the structure of the primary, even forming bile. Bile or glycogen in cells of metastasis suggests an hepatic primary [33] . These typical findings of histopathology were seen and confirmed by two histopathologists in bone biopsy of our patient. Subsequently a very high a- Fetoprotein was also documented.

Longmaid et al [17] reported seven cases of HCC presenting as extrahepatic masses. In similarity with our case no intrahepatic lesion was found in two of their cases. Dynamic IV contrast enhanced CT scan or CT after intraarterial Lipiodal injection was not done in any of these cases. Hence a small intrahepatic lesion cannot be excluded. A liver biopsy was nonconclusive in our case however a CT-guided biopsy was not done.

Extrahepatic spread of HCC occurs commonly. An unusual pattern of bulky extrahepatic disease with or without liver lesions should be recognized.

 
   References Top

1.Nubia Munox Bosch: Epidemiology of hepatocellular carcinoma. In: Okudak., Ishak K.G. Eds. Neoplasm of liver. Tokyo Springer. Veralag 1987;3-19.  Back to cited text no. 1    
2.Amer MH. Pattern of cancer in Saudi Arabia: A personal experience based on the management of 1000 patients. The King Faisal Specialist Hospital Medical Journal 1982;2:203-15.  Back to cited text no. 2    
3.Atiyeh, MMA Ali. Primary Hepatocellular Carcinoma in Saudi Arabia: A Clinico Pathological Study of 54 cases. Amer J Gastro 1980;74:25.  Back to cited text no. 3    
4.BedikianAY. Systemic & Regional Chemotherapy for advanced hepatobilliary carcinoma. The King Faisal Specialist Hospital Medical Journal 1983;3:105-10.  Back to cited text no. 4    
5.Stirling G, Khalil AM, Nauda GN. Malignant Neoplasm in Saudi Arabia. Cancer 1979;44:1543.  Back to cited text no. 5    
6.Ajarin DS. Cancer at King Khalid University Hospital, Riyadh. Ann Saudi Med 1992;12:76-82.  Back to cited text no. 6    
7.Koreich AM, Karawi M. Gastrointestinal Tract Malignancies: Pattern of disease at Riyadh Armed Forces Hospital (Abstract). Ann Saudi Med 1988;8:A75.  Back to cited text no. 7    
8.Khan AR, Hussain NK, AI Saigh AA, Malatani T, Shcika AA. Pattern of Cancer at Asir Central Hospital, Abha, Saudi Arabia. Ann Saudi Med 1991;11:285-8.  Back to cited text no. 8    
9.Al-Mofarrch MA, Afzal M, Al-Kraida AA. et al. Pattern of Primary Gastrointestinal tract malignancy among Saudi nationals: A retrospective study. Ann Saudi Mcd 1991;11:158.   Back to cited text no. 9    
10.Morad N, Khan AR, Al-Saigh A, Malatani T, Hussain N. Pattern of Primary Gastrointestinal tract cancer in the southern province. Ann Saudi Med 1992;12:259-63.  Back to cited text no. 10    
11.Abdul Al Aziz, Allam M, Khan K, Hawsawi Z. Pattern of cancer in Madinah Al Munawarah region. Ann Saudi Med 1995;15:350-3.  Back to cited text no. 11    
12.Tandon P, Pathak Ved P, Zaheer A, Chatterjee A, Walford N. Cancer in Gizan province of Saudi Arabia: An Eleven-year study. Ann Saudi Mcd 1995;15:14-20.  Back to cited text no. 12    
13.Anthony PP. Primary carcinoma of liver. A study of 282 cases in Ugandan Africans. J Pathol 1973;110:37-48.  Back to cited text no. 13    
14.Kew MC. Clinical, Pathologic & Etiologic heterogeneity in hepatocellular carcinoma: Evidence from South Africa. Hepatology 1981;1:366.  Back to cited text no. 14    
15.Wanebo Hi, Falkson G, Order SE. Cancer of hepatobilliary system. In Devita VT, Hellnan S, Rosenberg SA Eds. Cancer, Principals & Practices of Oncology Philadelphia. JB Lippincott 1989;836-74.  Back to cited text no. 15    
16.Benner EJ, Labby DH. Hepatoma: Clinical experience with a frequently bizarre tumor. Ann Intern Med 1961;54:620.  Back to cited text no. 16    
17.Longmaid HE, Seltzer SE, Costello P, Gordon P. Hepatocellular carcinoma presenting as primary extrahepatic mass on CT. Am J Rad 1986;146:1005-9.  Back to cited text no. 17    
18.Edomondson HA, Peters RL. Tumors of the liver: Pathologic features. Semin Roentgenol 1983;18:75-83.  Back to cited text no. 18    
19.Okuda K, et al. Hepatocellular carcinoma without cirrhosis in Japanese patients. Gastroenterology 1989;97:140.  Back to cited text no. 19    
20.Sherbini SS, Fakunle YM, Giangreco AB, et al. Hepatocellular carcinoma: A Clinico pathological Analysis of 118 cases from Riyadh Central Hospital. Ann Saudi Med 1992;12:8-12.  Back to cited text no. 20    
21.Anthony PP, Vogel CL, Barker LF. Liver Cell Dysplasia, A Pre­malignant condition. J Clin Pathol 1973;26:2 17.  Back to cited text no. 21    
22.Beasley RP. Hepatitis B virus as the etiologic agent in hepatocellular carcinoma epidemiologic consideration. Hepatology 19822:215.  Back to cited text no. 22    
23.Breachot C, Pourcell C, annelouise et al. Presence of intergrated hepatitis B virus sequences in cellular DNA of human hepatocellular carcinoma. Nature 1980;286:533.  Back to cited text no. 23    
24.Kew MC, Ronssow E, Peterson A, et al. Hepatitis B virus status of black women with hepatocellular carcinoma. Gastroenterology 1983;84:693-6.  Back to cited text no. 24    
25.Shobaski 0. the epidemiology of hepatitis B virus & primary hepatocellular carcinoma in Western Saudi Arabia (Abstract). Ann Saudi Med 1988;8:81A.  Back to cited text no. 25    
26.Al-Faleh FZ. Hepatitis B infection in Saudi Arabia. Ann Saudi Med 1988;8:474-80.  Back to cited text no. 26    
27.Al-Sarraf M, Kithierk, Vaitkevicius VK. Primary Liver Cancer, A review of clinical features, blood groups, serum enzymes therapy and survival of 65 cases. Cancer 1974;33:574-82.  Back to cited text no. 27    
28.Kingston M, Ali A, Lewall D. Hepatic tumors in Saudi Arabia: A practical approach to diagnosis. Cancer 1985;55:1579-85.  Back to cited text no. 28    
29.Ashraf SJ, Arya SC, El Saved M, et al. A profile of primary hepatocellular carcinoma, patient in the Gizan area of Saudi Arabia. Cancer 1986;92163-8.  Back to cited text no. 29    
30.Malt RA, Vroonhovcn TVJ, Kakumoto Y. Manifestation prognosis of carcinoma of the liver. Surg Gvnccol Obstet 1972;135:361-4.  Back to cited text no. 30    
31.Geddes EW, Falkson G. Differential diagnosis of primary malignant hepatoma in 569 Banto Mine Worker. Cancer (Suppl 5)1973;31:1216-21.  Back to cited text no. 31    
32.Ong GB, Taw JL. Spontaneous rupture of hepatocellular carcinoma. Br Med J 1972;4:146-9.  Back to cited text no. 32    
33.Leon Schiff, Eugene R. Schiff. In Diseases of the Liver 7 th Edition, vol 2-JB Lippincott 1993:1243-5.  Back to cited text no. 33    

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Correspondence Address:
Akbar Ali Sabir
Consultant Oncologist King Fahad Hospital, P.O. Box 5178. Madinah Al Munawarah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


PMID: 19864814

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