|LETTER TO THE EDITOR
|Year : 2015 | Volume
| Issue : 1 | Page : 118
Recurrent urinary tract infection masquerading as skeletal metastasis of hepatocellular carcinoma
A Gulia1, V Pai1, A Puri1, S Menon2
1 Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
2 Department of Pathology, Tata Memorial Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||3-Feb-2016|
Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Gulia A, Pai V, Puri A, Menon S. Recurrent urinary tract infection masquerading as skeletal metastasis of hepatocellular carcinoma. Indian J Cancer 2015;52:118
Classically, hepatocellular carcinoma (HCC) presents with the triad of right upper quadrant pain, mass, and weight loss. Unusual presentations are the norm in routine clinical practice and may lead to unexpected diagnosis and outcomes. We present an unusual case of a 60-year-old lady with a history of repeated episodes of urinary tract infection (UTI), where subsequent evaluation led to the diagnosis of metastatic HCC. She had a history of repeated episodes of UTI since eight months, and was being treated with prolonged courses of antibiotics and alternating urinary alkylating and acidifying agents. She did not respond to the conservative line of treatment. Localized burning micturition turned into a more generalized pain in the pelvic region. She was further evaluated with a radiograph and computed tomography (CT) of the pelvis, which revealed a lytic lesion in the right superior pubic ramus [Figure 1]a. She was referred to our center for further evaluation and management. The radiograph and CT of the pelvis were evaluated at our center and revealed a lytic lesion in the superior ramus of the right pubic bone with a wide zone of transition, cortical break, and associated extraosseous soft tissue component [Figure 1]b, which raised the suspicion of an aggressive lesion with a differential of bone metastasis from another primary or a primary sarcoma of the bone. An image-guided biopsy was performed from the lesion which showed a tumor with trabecular pattern and perithelial arrangement, comprising cells with moderate eosinophilic cytoplasm and central nuclei (hematoxylin and eosin, magnification × 200) [Figure 1]c. The tumor cells were positive for hepatocyte paraffin 1 monoclonal antibody (Hep Par 1) (inset, indirect immunoperoxidase, magnification × 100) which suggested metastatic deposit from HCC. Contrast enhanced computed tomography scan of the abdomen was ordered to assess the site of the primary disease involvement which revealed a 17 × 14 mm lesion in the left lobe of the liver with early enhancement on contrast administration which confirmed it as primary of the liver [Figure 1]d. The patient was treated with the best supportive care in the form of palliative radiotherapy to the site of bony metastasis in view of her advanced age and poor general condition.
|Figure 1: (a) Radiograph of pelvis with both hips showing an aggressive lytic lesion in right superior pubic ramus; (b) computed tomography of the pelvis showing lytic lesion in superior pubic ramus with cortical break and soft tissue component; (c) biopsy from the lesion showing tumor cells with moderate eosinophilic cytoplasm and central nuclei which are positive for hepatocyte paraffin 1 monoclonal antibody (Hep Par 1) (inset); (d) contrast enhanced computed tomography of the abdomen showing the primary lesion of hepatocellular carcinoma (HCC) in the left lobe of liver with early enhancement on contrast administration|
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HCC is the most common primary malignancy of liver in adults. It is an aggressive malignancy and typically presents in an advanced stage. Extrahepatic metastases occur in 13.5-41.7% of the patients. The common sites of extrahepatic metastases in patients with HCC are the lungs, regional lymph nodes, kidney, bone marrow, and adrenals. Incidence of bone metastasis in HCC is rare and ranges from 3-20% in various studies. Once a patient develops bony metastasis, the prognosis is dismal. Such advanced cases are treated with radiotherapy to the painful sites and with palliative chemotherapy. However, there are isolated case reports of long-term survival in these patients with solitary bone metastasis with surgical resection  or with sorafenib.
The present case had an unusual presentation of a metastatic HCC. Such an aggressive bony lesion in an elderly subject may have varied presentations, and the clinician should have a high index of suspicion for diagnosing these as metastatic disease of the bone. HCC is an aggressive malignancy and can present with distant metastasis even when the primary tumor is very small, thus emphasizing the importance of skeletal workup in HCC patients.
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