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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 12  |  Issue : 1  |  Page : 24-27

Hepatocellular carcinoma with initial presentation as metastatic spinal cord compression


Department of Medicine, University of Nigeria, Teaching Hospital, Enugu, Nigeria

Date of Submission28-Aug-2019
Date of Decision18-Oct-2019
Date of Acceptance10-Dec-2019
Date of Web Publication23-May-2020

Correspondence Address:
Dr. Belonwu Onyenekwe
Department of Medicine, University of Nigeria, Teaching Hospital, Enugu
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/NJGH.NJGH_8_20

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  Abstract 


Hepatocellular carcinoma (HCC) is the most common primary cancer of the liver. The burden of HCC is highest in the sub-Saharan Africa, South-East Asia and China. The recognized risk factors for HCC are chronic hepatitis B virus and hepatitis C virus infection, dietary aflatoxin, and alcoholic liver disease among others. HCC typically presents with symptoms related to the primary tumor; abdominal pain, weight loss, and abdominal swelling. Extrahepatic spread is present in up to 15% of patients with HCC at the time of diagnosis and may be the primary presentation. The most common site of extrahepatic metastasis by several authors is the lungs. Bone metastases in HCC are not as rare as previously reported and the most frequent site is the spine. Bone metastasis is mainly osteolytic and may result in pathologic fractures, hypercalcemia, and reduced quality of life. Spinal metastasis of HCC is recognized as a terminal stage of the disease and considerably worsens the prognosis. Presented is a case of a 35-year old man who came to the hospital primarily with metastatic spinal cord compression syndrome with paraplegia and was found to have advanced HCC. He succumbed to the disease within one month of presentation. While Pott's disease of the spine and metastatic prostatic tumor are the most common causes of nontraumatic myelopathy in sub-Saharan Africa, HCC should always be considered in the differential diagnosis of any patient with vertebral disease of uncertain origin.

Keywords: Extrahepatic metastasis, hepatocellular carcinoma, spinal cord compression


How to cite this article:
Onyenekwe B, Unigwe U. Hepatocellular carcinoma with initial presentation as metastatic spinal cord compression. Niger J Gastroenterol Hepatol 2020;12:24-7

How to cite this URL:
Onyenekwe B, Unigwe U. Hepatocellular carcinoma with initial presentation as metastatic spinal cord compression. Niger J Gastroenterol Hepatol [serial online] 2020 [cited 2020 Aug 8];12:24-7. Available from: http://www.njghonweb.org/text.asp?2020/12/1/24/284724




  Introduction Top


Hepatocellular carcinoma (HCC) is the most common primary cancer of the liver. It ranks as the third highest cause of cancer deaths, worldwide. It is the fifth most common type of cancer in men and the seventh in women.[1],[2],[3] The burden of HCC is highest in the Sub-Saharan Africa, Southeast Asia, and China.[1],[2],[3],[4]

In recent years, the incidence and mortality rates of liver cancer have been declining in Asian countries due to immunization against hepatitis B virus (HBV) and other population-based cancer prevention programs.[3],[5],[6] On the other hand, the incidence and mortality are increasing in countries previously with low incidence of liver cancer, such as Latin America (Brazil), Northern Europe (Norway, UK, and Denmark) and Western Europe (Germany), and the United States.[7],[8] This has been attributed to the large number of acquired hepatitis C virus (HCV) infection, the rising epidemic of obesity, diabetes, and nonalcoholic steatohepatitis.[7],[8] In sub-Saharan Africa, HCC develops in a much younger age group with a peak incidence in the fourth and fifth decades.[4],[9],[10],[11],[12],[13]

The recognized risk factors for hepatocellular carcinoma include chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infection, human immunodeficiency virus coinfection, exposure to dietary aflatoxin, fatty liver disease, alcoholic liver disease, cirrhosis, obesity, smoking, diabetes, and iron overload.[1],[2],[3],[4],[9],[10],[11],[12],[13] Overall, HCC displays a male predominance, occurring two to four times more in males than in females.[4],[12],[13] Typical presenting symptoms are abdominal pain, weight loss, and abdominal swelling. HCC in the Black African population carries an especially grave prognosis, with about 93% of the patients dying within 12 months of the onset of symptoms.[4] Late presentation is common to virtually all the liver cancer patients and over 60% would die in the course of the initial hospital admission.[12] Hepatic failure and intraperitoneal hemorrhage were the common causes of death.[10],[11],[12] Only symptomatic treatment could be offered in most cases.[9],[10],[11],[12],[13] Extrahepatic spread is present in 5–15% of patients with HCC at the time of diagnosis.[14] Extrahepatic metastases are more likely to occur in patients with more advanced intrahepatic tumor.[15] Although bone involvement is reported as uncommon in HCC, its incidence has significantly increased in the last decade due to improvement in diagnosis and overall survival of HCC patients.[16] In the series by Uka et al.,[17] 15.2% of the patients with HCC were found to have extrahepatic metastases. The most frequent site of extrahepatic metastases was the lungs (47%), followed by the lymph nodes (45%), bones (37%), and adrenal glands (12%). Wu et al.[18] reported similar findings; the lung followed by the bone, distant lymph nodes, and brain being the least. Most patients with extrahepatic metastases died of intrahepatic HCC or liver failure. In those with early intrahepatic tumor, extrahepatic metastasis then becomes an important cause of death. Patients with distant lymph metastasis had the best survival outcomes, while patients with brain metastasis fared the worst. In contrast, in the series by Chen et al., 12.2% of the cases had extrahepatic metastasis of which bone metastasis was the most frequent site (57%) followed by the lungs (22%), then lymph node, abdomen, omentum, adrenal gland, soft tissue, pelvic cavity, brain, stomach, intestine, retroperitoneum, diaphragm, ventriculus dexter, kidney, and umbilical region.[19] In their report, extrahepatic metastasis was an initial presentation of HCC in 22%. According to Santini et al., the spine was the most common site of bone metastasis (60%), followed by the hip (35%) and long bones (19%). In the spine, the most frequently involved site is the lumbosacral vertebrae, followed by the thoracic and cervical vertebrae. Osteolytic lesions predominated (82%) over mixed (10%) and osteoblastic (8%).[16] Osteolytic lesions result in significant morbidity from the associated skeletal-related events (SREs; defined as pathological fracture, the need for radiotherapy or surgery to the bone, spinal cord compression, and hypercalcemia).[16] Severe pain and neurological deficits (bowel and bladder incontinence) and loss of ambulation in metastatic spinal cord compression (MSCC) patients from primary HCC often lead to an unsatisfactory quality of life.[16],[17],[18],[19],[20] The clinical presentations of patients with extrahepatic metastatic HCC were mostly correlated with the manifestations of the primary tumor, and the metastatic presentation was a later event.[16] In addition, Child Score correlated with a greater tendency to biological osteotropism of HCC and bone metastatization.[16] Median survival was significantly shortened in the presence of bone metastasis, particularly spinal metastasis, and the occurrence of the first SRE.[16]


  Case Report Top


A 35-year-old male trader presented with a history of dull backache following a “give” at the back on strengthening from a bent posture 5 weeks previously. Three weeks later, he noted increasing weakness of both the legs. This progressed to a complete loss of power in both the lower limbs. He experienced some abdominal discomfort from time to time. He was a smoker and moderate drinker of alcohol. Significant findings on physical examination were that he looked well nourished and had bilateral pitting pedal edema, sacral bed sores, paraplegia (power grade 0), hypotonia, areflexia, and sensory loss of up to T6/7. Liver span was 21 cm and the liver was mildly tender and nodular with a blunt edge. The spleen was 4 cm enlarged. Rectal examination revealed lax anal sphincters. [Table 1] summarizes his test results at intake. Only symptomatic treatment could be offered. He subsequently succumbed to the illness as a result of massive intraperitoneal hemorrhage and hemorrhagic shock. Autopsy revealed hemoperitoneum, hepatomegaly of mixed nodularity, splenomegaly, and metastatic deposits in the lung. Histology was HCC.
Table 1: Test results

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  Discussion Top


Initial presentation with MSCC from HCC has been documented by several authors.[14],[19],[20],[21],[22],[23],[24],[25],[26] The incidence of MSCC caused by primary HCC has been increasing in recent years due to improved diagnosis and therapeutic modalities of primary HCC.[20] The most common symptoms in such patients were lower back pain, thoracic numbness, and lower limb weakness, as was evident in this case. Spinal metastasis of HCC is recognized as a terminal stage of the disease and is correlated with a shorter survival after development of the first SRE.[16] This patient died within <1 month of hospitalization. Many reviews of HCC in our region do not mention this phenomenon of spinal metastasis. Pott's disease of the spine and metastatic prostatic tumor are the most common causes of nontraumatic myelopathy in Sub-Saharan Africa, and anti-Koch's treatment might be initiated before investigation is concluded.[26] This case is also of interest because despite the terminal nature of the disease, indicative symptoms of the primary tumor (abdominal pain and swelling and wasting) were totally lacking. HCC should always be a differential when evaluating metastatic carcinoma with unclear origin in the spine or elsewhere. HCC patients with extrahepatic metastases should be offered treatment for intrahepatic HCC, and the selected patients with critical extrahepatic metastases could undergo treatment for extrahepatic metastases.[17] Systemic palliative treatment with sorafenib is considered at the first line in advanced HCC according to the guidelines.[27] Surgery is the treatment of choice to achieve immediate decompression and stabilization of the axial skeleton.[17],[20] Radiotherapy reduces pain and halts progression of motor dysfunction.[28] Other approaches include the use of denosumab, a human monoclonal antibody which is a bone-modifying agent. Bisphosphonates (zoledronic acid) are adjunctive therapy for cancer-related bone pain. Nonsteroidal anti-inflammatory drugs or opioids are also used in patients with bone metastases associated with severe pain.[29]


  Conclusion Top


Bone metastasis in HCC is not as rare as previously reported. Extrahepatic spread may be the first presentation of HCC. Spinal metastasis is associated with advanced liver disease, increased morbidity, and lower quality of life and carries a worse prognosis. HCC should always be considered in the differential diagnosis of any patient with vertebral disease or metastatic cancer of uncertain origin.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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