Title : Isolated duodenal metastasis of hepatocellular carcinoma- a rare
presentation
Abstract:
Hematogenous metastasis to the duodenum from any primary tumor is rare.
Hepatocellular carcinoma[HCC] frequently metastasizes to lung and regional
lymph nodes. Involvement of small intestines by HCC is mostly via direct invasion
of the contiguous neoplasm. We report a case of isolated non contiguous
duodenal metastasis of hepatocellular carcinoma because of its rarity.
Introduction:
Hepatocellular carcinoma is the most common primary tumor of the liver.
Metastasis is frequent in these aggressive tumors and is commonly to the lungs,
regional lymph nodes and or bones. Involvement of small intestine is generally by
direct invasion and spread. Isolated non contiguous metastatic involvement of the
duodenum is very rare.
Case report:
A 52 year old male presented to the out patient department with icterus, pallor,
pedal edema, abdominal distension, hepatomegaly upto 8cm below the costal
margin and splenomegaly. He had been a chronic alcoholic and smoker for the
past 15 years. Laboratory investigations revealed a raised bilirubin level
[3.15mg/dl] and SGOT level[89U/l]. His viral markers were negative. Alfa feto
protein[AFP] level was high[ 5225.9ng/ml, normal value being<20ng/ml].
Ultrasound abdomen done showed cirrhosis of liver with portal vein thrombosis,
ascites and splenomeagaly.
Upper gastrointestinal endoscopy revealed grade I oesophageal varices with an
ulcer at D1D2 junction. Biopsy from the duodenal ulcer showed small intestinal
mucosa with sub mucosal collection of tumour cells arranged in a sinusoidal
pattern. The tumor cells were large with abundant granular eosinophilic
cytoplasm with vesicular mildly pleomorphic nuclei .[Fig.1,2,3]. There was no
evidence of mitosis or necrosis. The overlying small intestinal mucosa was
ulcerated and the adjacent mucosa was free of dysplasia or carcinoma. The
differential diagnosis considered by H&E features were, Neuroendocrine tumors
(Carcinoid) and metastatic HCC. By immunohistochemistry the sinusoidal pattern
was highlighted by CD34 [fig.4]. Stains for S100,synaptophysin and chromogranin
were negative. Histopathological and immunohistochemical features with the
markedly elevated levels of AFP in a cirrhotic patient were in favour of duodenal
metastasis of hepatocellular carcinoma. Further radiological investigation was
suggested.
A contrast enhancing computer tomography[CECT] abdomen showed multiple
hypodense lesions in both lobes of liver showing enhancement in arterial phase
with early washout in the venous phase[fig.5]. The portal vein was dilated at the
hilum and showed echogenic thrombus within. There was mild splenomegaly,
moderate ascites and multiple splenorenal, perigastric and gall bladder
collaterals. The radiological features were that of multicentric hepatocellular
carcinoma. There was no direct invasion of the small intestine by the lesion. No
other primary lesion was identified on thorough endoscopic and radiological
investigations.
Since the patient had portal vein thrombosis chemoembolisation was not
recommended and the patient was put on palliative chemotherapy with cisplatin
and 5 fluorouracil. He responded to the treatment and the first follow up
radiological investigation showed reduction in the size of hepatic lesions.
Discussion:
Hematogenous metastasis to the duodenum from any primary malignancy is rare.
The usual primary tumours include carcinoma of the lung, breast and malignant
melanoma.[1-3] However most of these cases had metastatic deposits in other sites
also.
Hepatocellular carcinoma is the most common primary tumor of the liver
worldwide. This aggressive neoplasm frequently metastasizes to lungs and
regional lymphnodes. Involvement of the small intestine is usually by direct
invasion and spread by the primary tumour.[4-8] Hematogenous or lymphatic
metastasis is very rare. Even among those rare instances of isolated metastatic
lesions of duodenum the primary origin from liver appears to be exceedingly
rare. [9]
With the histopathological picture of sub mucosal collection of tumor cells in
nests, a differential diagnosis of carcinoid tumor was considered. The
immunohistochemical markers for the neuroendocrine neoplasm, namely
synaptophysin, chromogranin and S100 were negative.
The sinusoidal pattern highlighted by CD34 by immunohistochemistry, raised AFP
levels and radiological picture of hepatic lesions in a cirrhotic back ground favors
the diagnosis of duodenal metastasis of hepatocellular carcinoma. With no
involvement of other organs by radiological study this is a unique presentation of
HCC with isolated non contiguous duodenal metastasis. Involvement of the
duodenum indicates advanced nature of the disease with a very grave prognosis.
Conclusion:
Isolated non contiguous duodenal metastasis of HCC is rare and an unique
presentation. This condition poses differential diagnostic problems and should be
kept in mind. Close clinical and radiological correlation is very essential for the
correct diagnosis of this rare presentation.
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Legends:
Figure1:
Figure1: Shows small intestinal mucosa with sub mucosal collection of tumour
cells. H&E x100
Figure 2:
Figure2: Tumour cells arranged in a sinusoidal pattern H&Ex100
Figure 3:
Figure3:Tumour cells have abundant granular eosinophilic cytoplasm and
vesicular mildly pleomorphic nuclei .H&E x400
Figure 4:
Figure4: IHC for CD34 highlights the sinusoidal pattern IHC x100
Figure 5:
Figure 5: CECT Abdomen shows multiple hypodense lesions in both lobes of liver