Metastatic hepatocellular carcinoma to the pelvis and vertebrae in a patient with chronic hepatitis ‘C’ with unknown primary

Correspondence to Dr Syed Hussain Abbas, [email protected]

Background

Hepatocellular carcinoma is the fifth most common cancer in the world and with hepatitis C as one of its aetiological agents, its incidence is on the rise in Pakistan.¹ Ours is a unique case in which a patient with chronic hepatitis C had a soft tissue mass in the right iliac blade and right ala of sacrum, which was found to be hepatocellular carcinoma on histopathological analysis without any primary lesion in the liver.

Case presentation

A 54-year-old man, a school teacher, who was diagnosed with hepatitis ‘C’ 6 years earlier, presented to us with pain in the right lower quadrant of the abdomen for the past 2 months. The pain was dull and continuous with radiation to the back and right thigh. On physical examination of the abdomen and pelvis, the site of right iliac fossa was tender. An ultrasound of the abdomen and pelvis along with CT scan and MRI of the abdomen and pelvis was performed, which depicted a large heterogeneously enhancing soft tissue mass involving the right iliac blade and right ala of sacrum (^{figures 1} and ²). Trucut biopsy of the mass was advised, which was then stained with two immunohistochemical stains having a very high sensitivity in detecting hepatocellular carcinoma, namely, Glypican-3 and Hep-par 1. The sample turned out to be positive. Before the diagnosis of hepatocellular carcinoma, the patient, being from a poor background, had refused testing for the genotype of hepatitis ‘C’ virus and could not afford the newer costly drugs.² He was treated for hepatitis ‘C’ using pegylated interferon and ribavirin,³ but the viral load constantly remained in the high range. Currently his viral load is still high at 9.2×10⁶ IU/mL.

Investigations

CT and MRI of the abdomen and pelvis depicted a large 13×10×20 cm heterogeneously enhancing soft tissue mass eroding the right ilium along with right sacral ala. The mass extended medially into the pelvis and lower abdomen, pushing the iliopsoas muscle, common iliac and external iliac vessels medially with extension posterolaterally into the soft tissues of the gluteal region (^{figures 1} and ²). The liver revealed smooth margins and normally enhancing parenchyma with no focal lesions except hypertrophy of the left...