An Unexpected Source of Hemoptysis

Abstract

SESSION TITLE: Fellow Case Report Slide: Lung Cancer SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Sunday, October 23, 2016 at 03:15 PM - 04:15 PM INTRODUCTION: Most endobronchial lesions represent primary lung tumors or an infectious process. Endobronchial metastases (EBMs) are a very rare occurrence. Breast, colon, and kidney neoplasms are the more common types of cancers associated with EBMs. We present a rare case of endobronchial hepatocellular carcinoma presenting as hemoptysis. CASE PRESENTATION: 58 year old male with history of orthotopic liver transplant in 2012 for hepatocellular carcinoma (HCC) secondary to hepatitis C infection (HCV), with post-transplant recurrence of the HCV, admitted to our institution with submassive hemoptysis. Computed tomography (CT) of the chest showed mediastinal lymphadenopathy with bilateral pulmonary nodules. The patient underwent bronchoscopy and endobronchial ultrasound with fine needle aspiration (FNA) of the subcarinal lymph node. He was found to have two polypoid, friable, non-obstructive endobronchial lesions with spontaneous bleeding in bronchus intermedius and right middle lobe respectively. Successful hemostasis was achieved with Argon Plasma Coagulation (APC). FNA cytology of the subcarinal node showed polygonal tumor cells with large round nuclei, prominent nucleoli and abundant eosinophilic cytoplasm, as well as focal bile production consistent with metastatic HCC. The patient was started on Sorafenib and radiation therapy shortly after the diagnosis was made. DISCUSSION: EBM from hepatocellular carcinoma carry a poor prognosis, with mean overall survival 9-15 months after diagnosis1. Up until 2013 there were only seven cases described in the medical literature2. The presentation, bronchoscopic appearance, and imaging findings can make it hard to distinguish from bronchogenic carcinoma. Four types of EBM formation have been proposed: type I - direct metastasis to the bronchus, type II - bronchial invasion by a parenchymal lesion, type III - bronchial invasion by mediastinal or hilar lymph node metastasis and type IV - peripheral lesions extended along the proximal bronchus1. CONCLUSIONS: Most lung recurrences in HCC are associated with longer survival compared to liver recurrences3. Early diagnosis of metastatic HCC is crucial for initiation of therapy. Reference #1: Escartin A., et al, Recurrence of hepatocellular carcinoma after liver transplantation, Transplant Proceedings, 2007, 39(7):2308-10 Reference #2: Szumera-Cieckieqicz A., et al, Endobronchial Metastasis from Hepatocellular Carcinoma - a case description with literature review, International Journal of Clinical Exp Pathology, 2013, 6(9):1942-7 DISCLOSURE: The following authors have nothing to disclose: Claudia Onofrei, Damien Patel, Aliya Noor No Product/Research Disclosure Information