S2683 A Case of Patient With Stage VI Hepatocellular Carcinoma With Metastasis to the Spine Presenting With Acute Neurological Symptoms

Abstract

INTRODUCTION: Hepatocellular carcinoma (HCC) is the most prevalent primary malignant tumor of the liver. Hepatitis B and C infections are well known causes of HCC. Signs and symptoms of late stage HCC include abdominal pain, ascites, jaundice, unexplained weight loss and easy bruising or bleeding. The most common metastasis sites of HCC are the lungs, lymph nodes and bone. Here, we have a patient with previously undiagnosed HCC whose only symptoms at presentation were acute neurological deficits. CASE DESCRIPTION/METHODS: A 76-year-old female with a past medical history of chronic hepatitis B and C infection presented with six hours of lower extremity weakness and inability to walk. Physical examination of the lower extremities demonstrated decreased sensation throughout and 2/5 strength at the hips and knees. Spine magnetic resonance imaging revealed a T4 pathologic fracture with cord compression and mass effect (Image 1). Lesions were found also in the T9, L2 and L4 vertebral bodies. She had an emergent T4 corpectomy/laminectomy for tumor resection and T2-T6 posterior fusion with instrumentation by neurosurgery. Excisional biopsy of the T4 epidural tumor revealed extensive necrotic tissue with possibility of metastatic HCC. Liver imaging revealed numerous lesions. She was diagnosed with primary HCC after biopsy of one of those lesions was positive for HCC. She was later discharged to a skilled nursing facility for rehabilitation, and to radiation oncology for palliative chemotherapy. She unfortunately passed away two months later due to cardiac arrest secondary to hemorrhagic shock. A computed tomography scan of the abdomen at that time showed intraperitoneal hemorrhage due to tumor rupture. DISCUSSION: This patient presented with acute neurological symptoms due to pathological spinal fracture caused by metastatic HCC. Interestingly, this patient had no other signs and symptoms of stage VI HCC as stated above in the introduction. Similar to this patient, many others with HCC may be asymptomatic and remain undiagnosed till it progresses to the late stage. Successful intervention and treatment on these patients can become a challenge. Therefore, patients with histories of hepatitis B and C infections should be routinely screened to evaluate for progression into HCC. Early detection and treatment can prevent adverse health outcomes, increased healthcare cost and even death.Figure 1.: Magnetic Resonance Imaging revealed a T4 pathological fracture, with the epidural component compressing the cord and severely narrowing the thecal sac.