Journal of Cancer Research and Therapeutics Medknow Publications on behalf of the Association of Radiation Oncologists of India (AROI) ISSN: 0973-1482 EISSN: 1998-4138 Vol. 7, Num. 1, 2011, pp. 81-83

Journal of Cancer Research and Therapeutics, Vol. 7, No. 1, January-March, 2011, pp. 81-83

Case Report

Muscle metastasis from hepatocellular carcinoma

Vasiliki Michalaki¹, Anna Zygogianni², Vassilios Kouloulias², Myrsini Balafouta², Dimitrios Vlachodimitropoulos³, Constantine G Gennatas¹

¹ Department of Oncology, Aretaieion University Hospital, 76 V. Sofias 11528, Athens, Greece
² Radiology Department, Kapodistrian, University of Athens, Athens, Greece
³ Laboratory Forensic Medicine and Toxicology, Evgenidion Hospital University of Athens, 76 V. Sofias 11528, Athens, Greece

Correspondence Address: Anna Zygogianni, Department of Radiology, Aretaieion Hospital, University of Athens, 76 V. Sofias, 11528, Athens, Greece, annazygo1@yahoo.gr

PMID: 21546750

DOI: 10.4103/0973-1482.80467

Abstract

Keywords: Hepatocellular carcinoma, subcutaneous metastases, treatment

Introduction

Hepatocellular carcinoma (HCC), is one of the most common primary hepatic malignancies worldwide. It is an extremely debilitating disease, frequently with a late stage of presentation. Typical patterns of dissemination include metastasis by hematogenous routes to the lungs, bone, adrenal glands, pancreas, and, rarely, other visceral organs. ^[1],[2]

Cutaneous / skin metastasis from HCC is unusual, but has been described in literature. ^[3],[4],[5] This report presents an unusual metastasis of HCC, which presented as a mass on the right humerus muscle.

Case Report

A 70-year-old male patient with underlying hepatitis B was referred to our center as a case of confirmed hepatocellular carcinoma. An extended right hepatectomy was performed in 2000. After completion of the surgery, the patient was assessed every six months for two years and then every year. At each follow-up visit, we provided a medical history. Alpha fetoproteine (AFP) was used as a tumor marker and abdomen ultrasononography with a chest computed tomography (CT) scan was used as a laboratory examination that suggested recurrent disease.

Six years following surgery, a chest CT scan revealed a small nodular lesion, less than 3 cm. Pneumonectomy was performed without complications. The pathology report disclosed the diagnosis of HCC metastasis with clear resection margins. The patient was regularly followed up and had regular scans that did not show evidence of recurrence for the next three years.

In June 2009, the patient presented with a painless subcutaneous mass in the medial aspect of his right humerus muscle. Clinically the mass measured 5.5 cm and was mobile, hard, and well-demarcated. The mass showed contrast enhancement and radiologically was in-keeping with subcutaneous metastasis. No underlying bony abnormality was seen. Staging investigations did not reveal any other suspicion of metastatic disease and the alpha-fetoprotein levels were normal. The mass was excised and the histopathology revealed a multinodular tumor with a microtrabecular pattern, consistent with metastatic hepatocellular carcinoma [Figure - 1] and [Figure - 2]. The patient had an uneventful recovery. A contrast-enhanced CT of the pelvis was performed after two months from the surgery and showed an aggressive destructive lesion occupying the left sacral ala. Further correlation with a Technetium-99m bone scan revealed an area of intense radio-pharmaceutical uptake in the left sacrum consistent in location to the lesion seen on CT. The rest of the skeleton on nuclear imaging was unremarkable.

Discussion

Hepatocellular carcinoma is a common malignancy for which chronic hepatitis B infection has been defined as the most common etiological factor. If untreated, HCC is a rapidly fatal disease with mortality rates approaching 95% within six months of diagnosis. The poor survival reflects its aggressive nature, associated with the propensity for hematogenous dissemination, and the extent of the disease at the time of presentation.

Extrahepatic metastasis ranges from 40 - 85% and is commonly to the lungs, regional lymph nodes, bone, and adrenal glands. ^[1],[2] Together, metastatic disease to the bones and muscle account for approximately 16% of all extrahepatic HCC metastases, and is found primarily with advanced disease. Although HCC skeletal metastases are well-described, metastasis to the skeletal muscle is an infrequent phenomenon. ^[3],[4]

This may be attributed to the contractility action of the muscle, its local pH environment, and the presence of tumor suppressors in the skeletal muscles. ^[5]

To our knowledge, there are only very few reports in the literature regarding intramuscular HCC metastasis thus far. Seeding of HCC to muscle and soft tissues after percutaneous liver biopsy has been well-reported, but this is different from the hematogenous spread of HCC, which has only been documented few times. ^[6],[7] Ming-Hsun et al., reported a case of known primary HCC presenting with a 5 cm tumor in the left psoas muscle, one year after a right trisegmectomy with thrombectomy for primary hepatoma. All the patient′s subsequent findings suggested that the psoas tumor was metastatic in origin. ^[7] Metastasis to the gastrocnemius muscle has also been reported, but only rarely. ^[8] Another unusual presentation of HCC metastasis to the right gluteal fold, has been described by Young et al. Except for the mass the patient had no other symptoms. The location as well as the size of the tumor differed between our patient and the patient described earlier. ^[9]

In the present case, the patient has had an indolent disease course of advanced HCC. His overall survival is largely enhanced by aggressive multiple resections of all the extrahepatic sites of recurrence. Although the management of extrahepatic recurrence remains controversial, an aggressive treatment strategy may be beneficial in terms of prolonging the survival, especially in patients with a well-controlled primary. However, there is no convincing evidence to suggest that aggressive surgical resection of metastases from primary HCC is beneficial to all patients with metastatic HCC, albeit some studies have suggested the benefits of such an approach in highly selected HCC patients with distant metastases. ^[10]

In conclusion, despite diagnostic and treatment advances, improving patient survival is highly dependent on maintaining a high degree of suspicion and early disease detection. Optimal management of any soft tissue mass comprises of complete clinical assessment, appropriate radiological investigations, and sampling of the mass for histological examination. Metastasis of HCC should be included in the differential diagnosis of rapidly growing lesions in unusual localizations, such as metastatic tumor, an angiomyolypoma, and an infection. Adherence to such protocols avoids inappropriate surgery and allows a planned radical excision of the tumors, such as in the case described.

In the absence of detectable distance metastases, excision of an isolated hepatoma metastasis can provide worthwhile disease-free survival duration and palliation. However, despite potentially curative local surgery, unusual sites of distant metastasis can occur.

References

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