Hepatocellular Carcinoma with Cervical Spine and Pelvic Bone Metastases Presenting as Unknown Primary Neoplasm

Seawon Hwang; Jieun Lee; Jung Min Lee; Sook Hee Hong; Myung-Ah Lee; Hoo Geun Chun; Ho Jong Chun; Sung Hak Lee; Eun Sun Jung

doi:10.4166/kjg.2015.66.1.50

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Hwang, Lee, Lee, Hong, Lee, Chun, Chun, Lee, and Jung: Hepatocellular Carcinoma with Cervical Spine and Pelvic Bone Metastases Presenting as Unknown Primary Neoplasm

Case Report

Korean J Gastroenterol 2015;66(1):50-54.

Published online: 4 October 2015

DOI: https://doi.org/10.4166/kjg.2015.66.1.50

Hepatocellular Carcinoma with Cervical Spine and Pelvic Bone Metastases Presenting as Unknown Primary Neoplasm

Seawon Hwang, Jieun Lee, Jung Min Lee, Sook Hee Hong, Myung-Ah Lee, Hoo Geun Chun, Ho Jong Chun¹, Sung Hak Lee², Eun Sun Jung²

Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

¹Department of Internal Medicine, Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

²Department of Hospital Pathology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

Correspondence to: Jieun Lee, Division of Medical Oncology, Department of Internal Medicine, The Catholic University of Korea, Seoul St. Mary's Hospital, 222 Banpo- daero, Seocho-gu, Seoul 197-701, Korea. Tel: +82-2-2258-6324, Fax: +82-2-594-6043, E-mail: befamiliar@naver.com

Received 20 November 2014 Revised 4 January 2015 Accepted 4 January 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

The occurrence of hepatocellular carcinoma (HCC) is closely associated with viral hepatitis or alcoholic hepatitis. Although active surveillance is ongoing in Korea, advanced or metastatic HCC is found at initial presentation in many patients. Metastatic HCC presents with a hypervascular intrahepatic tumor and extrahepatic lesions such as lung or lymph node metastases. Cases of HCC presenting as carcinoma of unknown primary have been rarely reported. The authors experienced a case of metastatic HCC in a patient who presented with a metastatic bone lesion but no primary intrahepatic tumor. This case suggests that HCC should be considered as a differential diagnosis when evaluating the primary origin of metastatic carcinoma.

Keywords: Hepatocellular carcinoma, Neoplams, unknown primary, Neoplasm metastasis

References

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Fig. 1.

Cervical MRI shows a 3 cm sized mass located at C5 spine (arrow).

Fig. 2.

Abdomen CT scan shows a 7.6 cm sized hypervascular mass at the right iliac bone (arrow).

Fig. 3.

Biopsy specimen of the iliac bone. H&E stain shows round, eosinophilic cytoplasm-rich cells with a trabecular arrangement, suggestive of hepatocellular carcinoma (A, ×100; B, ×400). The tumor cells showed focally positive immunoreactivity for hepatocyte surface antigen (C) and CD10 (D) with a canalicular staining pattern (arrows).

Fig. 4.

A hypervascular tumor mass on the iliac bone (transarterial chemoembolization).

Fig. 5.

Abdomen CT scan after 2 months of sorafenib shows partial regression of the tumor mass (arrows).

Table 1.

Motor Test of Upper Extremities

	Right	Left
Shoulder
Flexor	5	2
Extensor	5	4
Elbow
Flexor	5	3
Extensor	5	4

5, normal strength; 4, muscle holds the joint against a combination of gravity and moderate resistance; 3, muscle cannot hold the joint against resistance but moves the joint against gravity; 2, muscles moves the joint when gravity is eliminated; 1, flicker of movement; 0, no movement.

Table 2.

Laboratory Findings

Variable	Reference	Initial	After radiotherapy and TACE
HBsAg (index)	−	+	+
HBsAb (IU/L)	−	−	−
HBeAg/Ab (index)	−/−	+/−	+/+
HBV DNA PCR (copies/mL)	<34	1,890,769	373
AFP (ng/mL)	<10	5,013.1	47.3
PIVKA-II (mAU/mL)	<40	13,891	6,344

TACE, transarterial chemoembolization; HBsAb, hepatitis B surface antibody; HBeAg/Ab, HBeAg/antibody; PIVKA-II, protein induced by vitamin K absence or antagonist-II.

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