A Case of Sacromatoid Hepatocellular Carcinoma Without Prior Anticancer Therapy

Abstract

Introduction: Sarcomatoid hepatocelluar carcinoma (SHCC), also referred as spindle cell carcinoma, pseudosarcoma, or carcinosarcoma is a rare histological type of hepatocelluar carcinoma (HCC). Incidence of SHCC is 1.8% in surgically resected, and 3.9% to 9.4% in autopsy cases. Previous chemotherapy use is presumed to promote sarcomatous change. We report a case of SHCC without prior anticancer therapy. Case Report: A 66-year-old Hispanic male presented with complaint of abdominal distension. The patient had past medical history of cirrhosis due to hepatitis C infection, portal hypertension, esophageal varices, recurrent ascites s/p therapeutic paracentesis (last done 3 months prior), diabetes mellitus, and hypertension. The patient had a 20-pack a year smoking history, but quit 20 years ago and denied alcohol or illicit drug abuse. He had no family history of any cancer. Vital signs on presentation, blood pressure 105/58 mm hg, pulse 74 per minute, and regular, respirations rate 20 per minute, temperature 97.8 F, BMI 25.2. On physical exam, the patient was found to have distended abdomen, dull on percussion. Labs showed hemoglobin 12.5 gm/dL, white count 5700/ul, platelet count 134,000/ul, prothrombin time 15.8 seconds, INR 1.2, sodium 130 meq/L, potassium 4.1 meq/L, chloride 100 meq/L, bicarbonate 28 meq/L, glucose 218 mg/dl, BUN 18 mg/dl, creatinine 0.9 mg/dl, calcium 8.2 mg/dl. albumin 2.6 G/DL, total protein 8.2 G/DL, bilirubin total 1.20 MG/DL, alkaline phosphatase 179 U/L, AST 34 U/L, ALT 20 U/L, and alfa-feto protein 4.3 ng/mL. CT abdomen showed a 4.3-cm rim-enhancing mass in the medial segment of the left lobe of the liver in periphery along the diaphragmatic crus. Biopsy of liver mass was done, which showed areas of moderately differentiated conventional HCC and other areas of high-grade spindle tumor. Immunohistochemical stains showed both components stained for keratin. The spindle component did not stain for desmin, CD31, CD34 but was positive for vimentin. The patient underwent upper and lower gastrointestinal endoscopy, which showed no evidence of malignancy. The patient refused any further treatment, and eventually died 8 months after diagnosis. Conclusion: SHCC, compared to ordinary HCC, has relative low serum AFP levels, higher incidence of intrahepatic and adjacent organ invasion, high tendency to large tumor size with central necrosis and hemorrhage in the tumor, delayed peripheral enhancement of the tumor on CT images, resistance to treatment, early recurrence after treatment, and a poorer prognosis, with approximate life expectancy less than 1 year after diagnosis. We should consider SHCC even when a patient has not undergone anticancer therapies.