A rare and challenging case of extrahepatic costal metastases from an unknown primary hepatocellular carcinoma
Gastroenterology and Hepatology from Bed to Bench,
Vol. 17 No. 1 (2024),
7 January 2024
https://doi.org/10.22037/ghfbb.v17i1.2812
Abstract
Hepatocellular carcinoma (HCC) typically presents with a primary hepatic mass. Nevertheless, on rare occasions, the initial presentation can be exclusively related to extrahepatic metastases and the most common sites of metastases are the lungs, lymph nodes, bones, and adrenal glands. While, bone metastases are generally accompanied by multiple metastatic spreads elsewhere in the body or previously diagnosed HCC, cases of solitary bone metastases with no liver lesion at imaging have been reported. Indeed, two rare entities of HCC have been reported in the literature which are the ectopic hepatocellular carcinoma and the infiltrative type of hepatocellular carcinoma with a very challenging radiologic diagnosis and poor prognosis. In this article, we present a case of extrahepatic costal metastases of hepatocellular carcinoma, which was diagnosed through a bone biopsy, with no focal lesion on liver imaging including ultrasound, multiphase MRI, and CT scan except for the presence of a portal vein thrombosis. It is important to consider the possibility of HCC metastases when evaluating rapidly growing extrahepatic lesions in patients with chronic liver disease and to consider the tumor characteristics and imaging findings as well as limitations to make accurate and timely diagnosis leading to improved patient management. Our patient had probably an infiltrating HCC because of two prominent factors: the presence of portal vein thrombosis and a markedly elevated alpha-fetoprotein (AFP). A liver biopsy was crucial in order to confirm the diagnosis but unfortunately it could not be performed because of the unexpected death of the patient due to hemorrhagic shock. It is also worth noting in this case, that the elevated level of AFP raised the suspicion on an underlying HCC and contributed to more elaborate diagnostic tests.
- Hepatocellular carcinoma, extrahepatic costal metastasis, alpha-fetoprotein, spontaneous regression of HCC, ectopic HCC, infiltrative form of HCC.
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References
Chidambaranathan-Reghupaty S, Fisher PB, Sarkar D. Hepatocellular carcinoma (HCC): Epidemiology, etiology and molecular classification. Adv Cancer Res 2021;149:1–61.
Criss C, Nagar AM, Makary MS. Hepatocellular carcinoma: State of the art diagnostic imaging. World J Radiol 2023;15:56–68.
Uka K, Aikata H, Takaki S, Shirakawa H, Jeong SC, Yamashina K, et al. Clinical features and prognosis of patients with extrahepatic metastases from hepatocellular carcinoma. World J Gastroenterol 2007;13:414–20.
Katyal S, Oliver JH, Peterson MS, Ferris JV, Carr BS, Baron RL. Extrahepatic metastases of hepatocellular carcinoma. Radiology 2000;216:698–703.
Zhang J, Chen G, Zhang P, Zhang J, Li X, Gan D, et al. The threshold of alpha-fetoprotein (AFP) for the diagnosis of hepatocellular carcinoma: a systematic review and meta-analysis. PloS One 2020;15:0228857.
Hyun YS, Choi HS, Bae JH, Jun DW, Lee HL, Lee OY, et al. Chest wall metastasis from unknown primary site of hepatocellular carcinoma. World J Gastroenterol 2006;12:2139–42.
Asselah T, Condat B, Cazals-Hatem D, Hassani Z, Bernuau J, Groussard O, et al. Ectopic hepatocellular carcinoma arising in the left chest wall: a long-term follow-up. Eur J Gastroenterol Hepatol 2001;13:873–5.
Martinez CAR, de Resende HC, Rodrigues MR, Sato DT, Brunialti CV, Palma RT. Gallbladder-associated ectopic liver: A rare finding during a laparoscopic cholecystectomy. Int J Surg Case Rep 2013;4:312–5.
Li Z, Wu X, Wen T, Li C, Peng W. Multiple ectopic hepatocellular carcinomas in the pancreas. Medicine 2017;96:6747.
Jin R, Yu Q, Liang X. Ectopic hepatocellular carcinoma manifesting multiple abdominal masses: a case report. Medicine 2017;96:8968.
Adachi Y, Hayashi H, Yusa T, Takematsu T, Matsumura K, Higashi T, et al. Ectopic hepatocellular carcinoma mimicking a retroperitoneal tumor: a case report. World J Gastroenterol 2020;26:2268–75.
Pavlidis N, Pentheroudakis G. Cancer of unknown primary site. Lancet Lond Engl 2012;379:1428–35.
Sakamaki A, Kamimura K, Abe S, Tsuchiya A, Takamura M, Kawai H, et al. Spontaneous regression of hepatocellular carcinoma: a mini-review. World J Gastroenterol 2017;23:3797–804.
Dendy MS, Camacho JC, Ludwig JM, Krasinskas AM, Knechtle SJ, Kim HS. Infiltrative hepatocellular carcinoma with portal vein tumor thrombosis treated with a single high-dose Y90 radioembolization and subsequent liver transplantation without a recurrence. Transplant Direct 2017;3:206.
Çolaklar A, Altınbaş NK. Infiltrative non-mass-like hepatocellular carcinoma initially presenting with isolated malignant portal vein thrombosis: A case report and review of the literature. J Ultrason 2020;20:55–60.
Lee YK, Wang CC, Chiu YT, Tseng TC. A rare case of infiltrative hepatocellular carcinoma presented with neck mass. Adv Dig Med 2021;8:51–4.
Demirjian A, Peng P, Geschwind JFH, Cosgrove D, Schutz J, Kamel IR, et al. Infiltrating Hepatocellular Carcinoma: Seeing the Tree through the Forest. J Gastrointest Surg Off J Soc Surg Aliment Tract 2011;15:2089–97.
Mak LY, Cruz-Ramón V, Chinchilla-López P, Torres HA, LoConte NK, Rice JP, et al. Global epidemiology, prevention, and management of hepatocellular carcinoma. Am Soc Clin Oncol Educ Book 2018;:262–79.
Janevska D, Chaloska-Ivanova V, Janevski V. Hepatocellular carcinoma: risk factors, diagnosis and treatment. Open Access Maced J Med Sci 2015;3:732–6.
European Association for the Study of the Liver. Electronic address: easloffice@easloffice.eu, European Association for the Study of the Liver. EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma. J Hepatol 2018;69:182–236.
Marrero JA, Kulik LM, Sirlin CB, Zhu AX, Finn RS, Abecassis MM, et al. Diagnosis, Staging, and management of hepatocellular carcinoma: 2018 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatol Baltim Md 2018;68:723–50.
Hanna RF, Miloushev VZ, Tang A, Finklestone LA, Brejt SZ, Sandhu RS, et al. Comparative 13-year meta-analysis of the sensitivity and positive predictive value of ultrasound, CT, and MRI for detecting hepatocellular carcinoma. Abdom Radiol 2016;41:71–90.
Kim SY, An J, Lim YS, Han S, Lee JY, Byun JH, et al. MRI with liver-specific contrast for surveillance of patients with cirrhosis at high risk of hepatocellular carcinoma. JAMA Oncol 2017;3:456–63.
Hanif H, Ali MJ, Susheela AT, Khan IW, Luna-Cuadros MA, Khan MM, et al. Update on the applications and limitations of alpha-fetoprotein for hepatocellular carcinoma. World J Gastroenterol 2022;28:216–29.
Lee CW, Tsai HI, Lee WC, Huang SW, Lin CY, Hsieh YC, et al. Normal alpha-fetoprotein hepatocellular carcinoma: are they really normal? J Clin Med 2019;8:1736.
Adeniji N, Dhanasekaran R. Current and emerging tools for hepatocellular carcinoma surveillance. Hepatol Commun 2021;5:1972–86.
Melichar B, Voboril Z, Toupková M, Dvorák J. Hepatocellular carcinoma presenting with bone metastasis. J Exp Clin Cancer Res CR 2002;21:433–6.
Bukhari S, Ward K, Styler M. Hepatocellular carcinoma: first manifestation as solitary humeral bone metastasis. Case Rep Oncol Med 2020;2020:8254236.
Soto S, Artaza T, Gomez R, Camacho FI, Rodriguez I, Gonzalez C, et al. Rib metastasis revealing hepatocellular carcinoma. Scand J Gastroenterol 2000;35:333–6.
Daga D, Dana R, Kothari N. Hepatocellular carcinoma – an unusual metastatic presentation on the chest wall. Clin Exp Hepatol 2015;1:133–5.
Horita K, Okazaki Y, Haraguchi A, Natsuaki M, Itoh T. [A case of solitary sternal metastasis from unknown primary hepatocellular carcinoma]. Zasshi J Nihon Kyobu Geka Gakkai 1996;44:959–64.
Liu Q, Li J, Pan Y, Zheng X, Gao B. Challenge in diagnosis and treatment of ectopic hepatocellular carcinoma: a case report and literature review. Front Surg. 2022;9:827006.
Seo UH, Lee HJ, Ryu WS, Kwak JM, Shin BK, Kim WB, et al. Laparoscopic resection of a hepatocellular carcinoma arising from an ectopic liver. Surg Laparosc Endosc Percutan Tech 2008;18:508–10.
Alshareeda AT, Al-Sowayan BS, Alkharji RR, Aldosari SM, Al subayyil AM, Alghuwainem A. Cancer of unknown primary site: real entity or misdiagnosed disease? J Cancer 2020;11:3919–31.
Vernuccio F, Porrello G, Cannella R, Vernuccio L, Midiri M, Giannitrapani L, et al. Benign and malignant mimickers of infiltrative hepatocellular carcinoma: tips and tricks for differential diagnosis on CT and MRI. Clin Imaging 2021;70:33–45.
Reynolds AR, Furlan A, Fetzer DT, Sasatomi E, Borhani AA, Heller MT, et al. Infiltrative hepatocellular carcinoma: what radiologists need to know. RadioGraphics 2015;35:371–86.
Kneuertz PJ, Demirjian A, Firoozmand A, Corona-Villalobos C, Bhagat N, Herman J, et al. Diffuse infiltrative hepatocellular carcinoma: assessment of presentation, treatment, and outcomes. Ann Surg Oncol 2012;19:2897–907.
Çoban Ş, Yüksel O, Köklü S, Ceyhan K, Baykara M, Dökmeci A. Atypical presentation of hepatocellular carcinoma: a mass on the left thoracic wall. BMC Cancer 2004;4:89.
An C, Zuo M, Li W, Chen Q, Wu P. Infiltrative hepatocellular carcinoma: transcatheter arterial chemoembolization versus hepatic arterial infusion chemotherapy. Front Oncol 2021;11:747496.
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