7/19/2005 Case 1: Metastatic Hepatocellular Carcinoma


Clinical History:

This 57 year old man noticed pain in his neck beginning 6 months prior to the surgery which produced the specimen. The pain began after an amusement park ride and lasted about a day. Over several weeks prior to surgery he had progressive bilateral neck and shoulder pain and then additionally left arm weakness. Scans at an outside hospital showed pathological fracture of C4 plus a left vertebral artery dissection. At columbia cervical spine MRI showed a C4 compression fracture with fragments in the spinal canal with cord compression and deformity. In addition an abdominal CT showed a cirrhotic liver with mUltiple masses thought consistent with metastatic disease. The patient had a liver biopsy, and discectomies and spinal cord decompression in the C4 region.

Diagnostic Notes:

The slide showed dense fibrous tissue, bone fragments, cartilage consistent with disc tissue, and neoplastic tissue. The tumor had a solid epithelial growth pattern with foci suggestive 0f papillary growth and others with a gland- or duct-like pattern. The tumor cell nuclei were large, highly irregular, and with multiple nucleoli. Mitotic figures were at least focally numerous.

All present agreed this was cancer, and fairly clearly metastatic cancer. There were some votes for an adenocarcinoma, and some suggested hepatocellular carcinoma. There was some discussion about likely primary sites, with the usual suspects of lung, colon, and prostate (the latter especially since this was in spine). Melanoma was thought unlikely but prudent to exclude.

The additional information provided at the meeting included the facts that the liver biopsy was negative for tumor; that the tumor in the spine was positive for cytokeratin, for CEA (with a polyclonal antibody), for CDI0, for a hepatocyte marker, and for CDX2; it was negative for CK7, CK20, HMB45 , PSA, and TTFI. The final diagnosis was Metastatic Hepatocellular Carcinoma.

We were further told that current literature suggests that bone metastases of HCC occur in from 10% to 20% of all cases at some point in their course. Among these cases with bone spread, the spine is the most common site of involvement.

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