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LETTER TO EDITOR  
Year : 2019  |  Volume : 62  |  Issue : 3  |  Page : 507-508
Hepatocellular carcinoma presenting as rib lesion: A diagnostic dilemma


Department of Pathology, AMRI Hospitals, Kolkata, West Bengal, India

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Date of Web Publication26-Jul-2019
 

How to cite this article:
Mitra S, Jhunjhunwala A, Chakraborty H. Hepatocellular carcinoma presenting as rib lesion: A diagnostic dilemma. Indian J Pathol Microbiol 2019;62:507-8

How to cite this URL:
Mitra S, Jhunjhunwala A, Chakraborty H. Hepatocellular carcinoma presenting as rib lesion: A diagnostic dilemma. Indian J Pathol Microbiol [serial online] 2019 [cited 2019 Oct 14];62:507-8. Available from: http://www.ijpmonline.org/text.asp?2019/62/3/507/263483




Editor,

Hepatocellular carcinoma (HCC) is the most frequent primary malignant tumor of the liver, the fifth most common malignancy worldwide, the third leading cause of cancer-related deaths, and is endemic in developing countries and Southeast Asia. HCC commonly metastasizes to regional lymph nodes and lungs and primary presentation with skeletal metastases is rare.[1],[2],[3]

A 60-year-old female patient presented with complaints of swelling on chest wall, cough, and fatigue since 1 month. Physical examination showed a palpable swelling overlying the right eight rib. Ultrasound examination revealed hepatomegaly and retroperitoneal lymphadenopathy, which was confirmed by contrast enhanced computed tomography (CECT), scan. CECT scan also showed an expansile lytic lesion in right eight rib with soft tissue mass and extrapleural extension in chest. A tiny cyst was seen in right lobe of liver.

TruCut biopsy of rib lesion was done for diagnosis, and the histopathology showed sheets of polygonal cells with clear or foamy cytoplasm and small to medium sized nuclei with variably prominent nucleoli. There was no obvious trabecular or pseudoglandular architecture. Mitoses were rare, and no hemorrhage or necrosis was evident. Immunohistochemistry showed strong positivity of tumor cells for HepPar1 and were negative for EMA, CK7, and CK20[Figure 1]. A diagnosis of moderately differentiated clear cell HCC was made.
Figure 1: (a and b) Sheets of large polygonal cells with clear cytoplasm (a: H and E, ×40; b: H and E, ×100). (c and d) Granular cytoplasmic HepPar-1 positivity in neoplastic cells (a: immunoperoxidase, ×40; d: immunoperoxidase, ×100)

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18F-FDG PET (positron emission tomography) scan detected an FDG (fluoro-2-deoxy-d-glucose) avid ill-defined hypodense lesion in liver, along with a hepatic cyst, and metabolically active mass lesions in breast and vertebra. Biochemical tests also showed elevated AFP (93.2 ng/mL) and CA-125 (54 U/ml) levels. CEA levels, routine biochemical parameters, and viral markers were normal. The patient received palliative radiotherapy and care. Patient was lost to follow-up after 1 year.

Metastasis of HCC occurs frequently by way of intrahepatic blood vessels, lymphatic permeation, or direct infiltration. Low survival rates for patients with HCC have resulted in low incidences of symptomatic extrahepatic metastases, such as lung and bone metastases (0%–5%). Few reports suggest that though uncommon, HCC should be considered in the differential diagnosis of patients presenting with bone metastases, and these can very rarely be the primary manifestation. Metastatic spread of HCC to the bones occurs in 13%–16% cases.[1],[3]

Other metastatic tumors, notably from the breast, kidney, and adrenal glands, may mimic HCC; and immunohistochemistry (IHC) is useful, especially in those cases with initial presentation of HCC as a metastasis. Morphological differentiation of clear cell HCC from clear cell renal carcinoma, which was a problem in the reported case, may not be possible without the aid of IHC. HepPar-1 (anti-hepatocyte-specific antigen) is highly sensitive for normal and neoplastic hepatocytes. A positive HepPar-1 (clone OCH1E5) by IHC is sufficient for a diagnosis of HCC-CC, if enough tissue is available.[4]

CA-125 and α-fetoprotein tumor markers are sensitive and specific, respectively, for HCC and are used for diagnosis and therapy monitoring. As a screening tool of extrahepatic metastasis of HCC, PET CT scan is invaluable for detection of lung metastases larger than 1 cm and bone metastases.[5]

The extent of intrahepatic lesions and liver performance status are important prognostic determinants in the majority of patients with HCC, rather than the presence of extrahepatic metastases. However, poor prognosis of patients with extrahepatic metastasis in HCC might not improve despite aggressive treatment.[6],[7]

This report underlines the importance of identifying typical histomorphological features of this rare metastatic lesion even in the absence of overt hepatic lesions or symptoms.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Sinha RT, Dey A, Agarwal S. Initial presentation of hepatocellular carcinoma as soft tissue swelling of the forearm: A rare cytomorphological diagnosis. J Cancer Res Ther 2015;11:1032.  Back to cited text no. 1
    
2.
Bae SY, Kim HJ, Oh HH, Kwon MK, Lee JH, Park M, et al. Multiple Bone metastases as the first manifestation of hepatocellular carcinoma in patient with noncirrhotic liver. Case Rep Oncol Med 2015;2015:512849.  Back to cited text no. 2
    
3.
Ferraz VR, Vitorino-Araújo JL, Sementilli L, Neto JF, Veiga JC. Lesion in scalp and skull as the first manifestation of hepatocellular carcinoma. Case Rep Neurol Med 2016;2016:2897048.  Back to cited text no. 3
    
4.
Murakata LA, Ishak KG, Nzeako UC. Clear cell carcinoma of the liver: A comparative immunohistochemical study with renal clear cell carcinoma. Mod Pathol 2000;13:874-81.  Back to cited text no. 4
    
5.
Lee JE, Jang JY, Jeong SW, Lee SH, Kim SG, Cha SW, et al. Diagnostic value for extrahepatic metastases of hepatocellular carcinoma in positron emission tomography/computed tomography scan. World J Gastroenterol. 2012;18:2979-87.  Back to cited text no. 5
    
6.
Lee LC, Tsuei YC. Metastasis of hepatocellular carcinoma to the scapula. J Formos Med Assoc. 2014;113:976-7.  Back to cited text no. 6
    
7.
Bansal N, Rastogi M. Clear cell hepatocellular carcinoma with associated tuberculosis-A case report. J Hepatol Gastroint Dis. 2017:3:146.  Back to cited text no. 7
    

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Correspondence Address:
Subhashis Mitra
Department of Pathology, AMRI Hospitals, Kolkata, West Bengal - 700 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_413_18

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