|
Advertisement |
|
|
||
 |
|
|||||
|
|||||
|
 |
||||||
|
||||||
|
||||||
|
Journal of Clinical Oncology, Vol 25, No 13 (May 1), 2007: pp. 1805-1806 © 2007 American Society of Clinical Oncology. DOI: 10.1200/JCO.2006.09.9036
Hepatocellular Carcinoma Presenting As RadiculopathyDivision of Orthopedics, Department of Surgery, Far Eastern Memorial Hospital and Medical Center, Taipei, Taiwan, Republic of China A 36-year-old man with no previous medical history came to our clinic with complaint of intermittent left sciatica for 3 weeks, which was associated with weakness, numbness, and a limping gait of his left lower limb. Physical examination revealed the patient to be in good general condition with no yellowish discoloration of his skin or sclerae nor any palpable abdominal masses. However, neurological examination revealed positive sensory change over his left S1 dermatome, with a decreased ipsilateral ankle jerk reflex and a positive straight leg raising test of approximately 30° on the same limb. Under the impression of a ruptured disc over the left L5-S1 level, plain lumbar spine radiograph and magnetic resonance imaging studies were performed. Findings from both revealed no soft tissue lesions or bony lesions. Due to the persistent and progression of the left sciatica, a lumbar spine myelogram and detailed computed tomography scan (CT) were done. A small soft tissue nodule (arrow) beside the left S1 root was detected, as shown on the last two images of the CT scan (Fig 1). Other laboratory data were within normal limits except for slightly elevated AST (39) and ALT (49) levels. An exploratory laminectomy was advised and performed. Intraoperative findings revealed a small grayish adipose-like nodule measuring approximately 0.5 x 0.5 x 0.5 cm in size on the foramen of the left S1 root. The lesion was excised and sent for pathological examination. The dura and surrounding bony structures were intact. Unfortunately, the pathologic report revealed a metastatic hepatocellular carcinoma (HCC; Fig 2, magnification x20). Immunohistochemistry of the tumor cells were positive for alpha fetoprotein. Patient family history was then reviewed and revealed the patient's father and uncle both died of HCC. Postoperative abdominal sonogram and CT scan were performed and both revealed a tumor lesion of approximately 5 cm in diameter (arrow) over the right hepatic lobe (Fig 3). Whole body scan was also performed and excluded any bony metastases. Further laboratory work-up revealed an elevated alpha fetoprotein (136.3), with positive hepatitis B surface antigen (5371), negative anti-hepatitis C virus (0.22), and an elevated carcinoembryonic antigen (5.72). The patient was referred to the oncology service and at 2 weeks postoperation, he received transarterial embolization and lumbosacral radiotherapy. The patient tolerated the treatment well and was later discharged in stable condition. He has had regular follow-up at the oncology, orthopedics, and gastrointestinal clinics for 1 year, and work-ups show no recurrence of the hepatic and lumbar spine lesions.
HCC, also called hepatoma, is the most common primary cancer of the liver cell with a mean survival of shorter than 1 year after primary diagnosis.1 In Taiwan, the incidence of HCC is relatively high compared with Western countries like the United States. This can be attributed to the high prevalence of hepatitis B carriers in Taiwan and along with its association with chronic hepatitis and cirrhosis of the liver.2,3 Risk factors of HCC include the Asian and African race, male sex, cirrhosis of the liver (alcoholic-related cirrhosis), chronic hepatitis B surface antigen carrier, hepatitis C antigenemia, and aflatoxin found in peanuts infected with Aspergillus flavus.4,5 Extrahepatic spread of HCC occurs commonly to the lungs (37% to 70%) and regional lymph nodes (23% to 45%).1 Reported bone metastasis is comparatively low (2% to 20%),1 although initial presentation as spinal cord compression has been reported. Initial presentation as a single root radiculopathy has not been documented. To the best of our knowledge, our case is the first in Taiwan of HCC initially presenting as low back pain with a single root radiculopathy, and treated successfully with complete excision of the spinal lesion followed by TAE and lumbar radiotherapy. The overall outcome of chemotherapy as compared with transarterial embolization for treatment of primary HCC lesion is both similar and poor. Current chemotherapy with single-agent drugs, such as cisplatin, doxorubicin, and fluorouracil, show a response rate of 10%, while studies using combination chemotherapy regimens, such as cisplatin-based combinations, reveal improved response rates at approximately 20%. To date there is no clear impact on overall survival for both groups as compared with supportive care. The response rate of transarterial embolization for HCC is approximately 60% to 80%.6 Although the response rates of HCC to systemic chemotherapeutic agents is poor, they are still given to patients with advanced stage cancers, in order to reduce the size of the tumor for salvage surgery. The following are indications for systemic therapy for HCC: patient with advanced HCC, age younger than 70 years, Karnofsky performance score more than 70%, platelet count more than 100 x 109/L, WBC count more than 3 x 109/L, total bilirubin less than 50 nmol/L, and creatinine clearance more than 50 mL/min.7 In addition to the aforementioned chemotherapeutic agents, biologic and new biochemical agents are being given to patients with advanced HCC. These include a combination of interferon and different schedules of fluorouracil and single-agent thalidomide whose mechanism until now is poorly understood, but some believe that it exerts its therapeutic properties through antiangiogenic activity and modulations of cytokines, including tumor necrosis factor-  , interferon, interleukins 10 and 12, cyclooxygenase-2, and nuclear factor B.8 AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The authors indicated no potential conflicts of interest.
REFERENCES 1. Doval DC, Bhatia K, Vaid AK, et al: Spinal cord compression secondary to bone metastases from hepatocellular carcinoma. World J Gastroenterol 12:5247-5252, 2006[Medline] 2. Chen CJ, Chen DS: Interaction of hepatitis B virus, chemical carcinogen, and genetic susceptibility: Multistage hepatocarcinogenesis with multifactorial etiology. Hepatology 36:1046-1049, 2002[CrossRef] 3. Romeo R, Colombo M: The natural history of hepatocellular carcinoma. Toxicology 181-182:39-42, 2002[CrossRef][Medline] 4. Chang SS, Luo JC, Chao Y, et al: The clinical features and prognostic factors of hepatocellular carcinoma patients with spinal metastasis. Eur J Gastroenterol Hepatol 13:1341-1345, 2001[CrossRef][Medline] 5. Bhart K, Rayees N, Henry F, et al: Case report: Spinal cord compression due to metastatic hepatocellular carcinoma. Am J Med Sci 306:233-235, 1993[Medline] 6. Hepatic Carcinoma, Primary: E-Medicine from webMD. http://www.emedicine.com/med/topic2664.htm 7. Lau WY, Ho SKW, Yu SCH, et al: Salvage surgery following downstaging of unresectable hepatocellular carcinoma. Ann Surg 240:299-350, 2004[CrossRef][Medline] 8. Zhu AX: Systemic therapy of advanced hepatocellular carcinoma: How hopeful should we be? Oncologist 11:790-800, 2006
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|||||||||||
|
|||||||||||
|
|
Copyright © 2007 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
|
