S2787 A Rare Hepatic Malignancy Disguised by Unalarming Symptoms

Abstract

Introduction: Primary liver sarcomas are extremely rare, representing 0.1% to 0.2% of all hepatic tumors in adults. Most cases have been described in pediatric populations, with few occurring in adults. Prognosis is dismal, leading to death in the majority cases. Due to the tumor’s rapid growth and mortality, it is usually misdiagnosed resulting in an inappropriate treatment plan. Case Description/Methods: A 59-year-old Hispanic male with past medical history of hypertension and alcohol abuse who presented to the ER due to right upper quadrant pain and nausea. The patient had visited the ER a few weeks prior and was discharged on Omeprazole given diagnostic impression of GERD, however returned due to partial relief. Denied fever, chills, weight loss, diarrhea, or constipation. Labs showed an elevated alkaline phosphatase at 189 U/L, CEA and alpha-fetoprotein were normal. Physical examination revealed tenderness to palpation at the epigastric area and right upper quadrant, along with a new palpable, immobile mass. Abd-pelvic CT showed a large right hepatic lobe subcapsular complex, cystic mass with solid components displaying extracapsular extension. Interventional radiology service was consulted for biopsy prior to discharge. While awaiting results, patient’s abdominal pain increased significantly accompanied by early satiety, poor appetite, increased abdominal girth, and bilateral lower extremity edema. Imaging studies were repeated, revealing significant increase in previously described liver lesion, now measuring 24 x 16 cm compared to 20.8 x 13.9 cm less than three weeks prior. Biopsy confirmed the diagnosis of malignant spindle cell neoplasm with extensive necrosis and pleomorphism. Negative immunostains included pankeratin, CK7, CK20, desmin, arginase 1, S-100, c-kit, CD34, triple melanoma stain, HMB-45 and Melan-A consistent with Undifferentiated Sarcoma. PET CT disclosed only a severe hypermetabolic lesion confirming primary liver involvement. Therapy was started promptly with Doxorubicin and Ifosfamide. Discussion: Rapidly evolving pathologies are easily confused for other etiologies, such as infection. This sheds light on the importance of a holistic approach that brings together patient’s clinical presentation, labs and physical exam. This case highlights the fact that most common is not synonymous with accuracy. As a result, undifferentiated sarcomas should form part of the differential diagnoses when a patient simply presents with nausea, vomiting, and abdominal pain, as time is of the essence.