A Case of Hepatocellular Carcinoma Presenting with Pruritus as the Presenting Manifestation with Resolution after Trans Arterial Chemo Embolization

Abstract

Purpose: Pruritus secondary to high bile acid levels is well known (20%) in patients with advanced chronic hepatitis C. We report a case of patient presenting with pruritus as a possible paraneoplastic manifestation of hepatoma. Case Report: A 54 yr old Caucasian man with known diagnosis of Hepatitis C for 6 years was referred to our hepatology service because of a suspected large hepatocellular carcinoma. His only complaint at the time of presentation was severe pruritus. He had signs of portal hypertension and cirrhosis on a CT scan of his abdomen six years prior. A CT scan done almost one year before showed a 7.7 × 5.5 cm mass in the liver which showed early enhancement with late wash out consistent with hepatocellular carcinoma. A biopsy was not done at that time as his platelet count was profoundly low in the 20–30,000 range. His past medical history was unremarkable. Significant physical findings included skin excoriations from scratching, spider nevi, and a liver span of 12 cm with no discrete palpable masses or ascites. Laboratory Findings included hemoglobin 13.7 g/dl, platelets 33,000/UL, total bilirubin 1 mg/dl, alkaline phosphatase 208 U/L, ALT 99 U/L, AST 164 U/L and serum bile acid 81 Umol/L. A repeat CT scan showed again a large 9.3 × 7.4 × 10 cm mass in the right lobe of the liver without any evidence of biliary obstruction as well as several smaller subcentimeter lesions in the left lobe. The patient had tried multiple agents for pruritus including benadryl, cholestyramine, cyproheptadine & rifampin without much relief of his symptoms. In view of the large and multiple lesions he was deemed not to be a candidate for transplant, radiofrequency ablation, or surgical resection. He then underwent three cycles of Transarterial Chemoembolization (TACE) targeting the dominant lesions. After the first cycle, patient reported significant decrease in pruritus. Repeat CT scan showed significantly decreased amount of enhancing tumor. On a recent 6 month follow up the patient was still free of pruritus. Conclusion: Our case demonstrates association of pruritus with hepatocellular carcinoma. Although there have been rare reports of hepatocellular carcinoma presenting with pruritus, this is the first report where resolution was demonstrated after treatment of the cancer with TACE. Hepatocellular carcinoma should be considered in a patient with underlying cirrhosis and new onset pruritus.