Metastatic Hepatocellular Carcinoma Presenting as Extensive Bone Metastasis

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The American Journal of Gastroenterology



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Hepatocellular carcinoma(HCC) is a primary malignancy of the liver and occurs mainly in patients with underlying chronic liver disease or cirrhosis. It is considered the third leading cause of cancer death worldwide. Here, we present a rare case of HCC with diffuse bone metastasis. 57 y.o. male with past history of Chronic Hepatits B & C presented with diffuse body aches associated with jaundice. Exam did not show any ascites or stigmata of cirrhosis. Relevant labs included: AST 62 ALT 53 Alk Phos 231 T Bili 1.6 INR 1.0 Alb 3.5 CEA 1.46 AFP 5.1. Multiple hepatic lesions seen on imaging were initially concerning for metastatic disease. Bone imaging revealed diffuse lytic lesions, with the largest in the right sacrum. No clear primary malignancy was identified, so patient underwent EGD and colonoscopy, which were negative. A sacral bone biopsy was performed, revealing atypical cells with abundant cytoplasm and abnormal nuclei (Image 1); further reticulin (Image 2), arginase, and heppar (Image 3) staining confirmed malignant hepatic cells. Patient was diagnosed with primary HCC with bone metastasis, Child Pugh score A. Due to the advanced nature of presentation, patient opted for Hospice care. HCC is often seen with early metastasis to lungs, abdominal lymph nodes, central nervous system, and bones—further decreasing median survival. Current treatment options for extra-hepatic HCC generalized to all metastatic types recommends palliative chemotherapy if Child Pugh A/B, and advises only symptomatic treatment if Child Pugh C. HCC with bony metastasis is rare, and is associated with even higher mortality rates and median survival of 3 months without treatment. Chemotherapy with Sorafenib can prolong median survival by on average 2 months, but with significant effect on standard of life due to side effects. Radiation therapy has shown improvement in pain without improved mortality. Other symptomatic treatment includes palliative stents, vitamin D, calcium, and pain control. In deciding care for HCC with bony metastasis, the net clinical benefit of each treatment must be considered by weighing the improvement in survival time versus quality of life. Interventions should focus on maximizing the individual's self-established quality-adjusted life years. Therefore, careful discussion is needed in each case to determine the best option for each patient.


Hepatology | Oncology