Although significant advances in the treatment of intrahepatic lesions, it is reported that the prognosis for patients with hepatocellular carcinoma (HCC) who have extrahepatic metastasis remains poor. We report a patient with lung, liver, brain, bone and subcutaneous metastasis from HCC who has survived more than 7 years maintaining relatively good performance status as a result of repeated therapies. A 55-year-old male patient with HCC underwent right lobectomy of the liver and cholecystectomy in September 2006. He received wedge resection for lung metastasis twice (July 2009, January 2011) and Gamma Knife stereotactic radiosurgery for brain metastasis (April 2011). Over the last 3 years, he has developed metastasis in subcutaneous tissues, muscle, and bone with pain. He has undergone 7 courses of radiotherapies for subcutaneous tissues, muscle, and bone metastasis and been prescribed sorafenib and he is still capable of all self-care.
Hepatocellular carcinoma (HCC) is the fifth most common cancer and the second most common cause of cancer deaths in Korea [
The aim of this report is to describe the case of a HCC patient with multiple extrahepatic metastases who has lived after seven courses of radiotherapy and review of the extrahepatic metastasis in literature.
A 55-year-old man with hepatitis B and C was diagnosed with HCC in September 2006, and subsequently underwent a right lobectomy of the liver and cholecystectomy. HCC was multiple and the largest lesion was 7 cm. HCC was Edmondson-Steiner grade 3/3 and complicated by cirrhosis. There wasn't vascular invasion and resection margin was clear. During follow-up, lung metastasis was found and wedge resection was undergone twice (right lower lobe, July 2009; left lower lobe, January 2011). In March 2011, he felt pain on a palpable mass of his left shoulder. He visited local clinic and a biopsy of the mass revealed metastatic HCC. He was referred to our hospital in March 2011 for further evaluation and treatment. His Eastern Cooperative Oncology Group performance status was 1. Soft tissue metastases in the left shoulder area and abdominal wall were showed on computed tomography and positron emission tomography/computed tomography (PET/CT). There was no intrahepatic lesion and α-fetoprotein (AFP) was normal. And Child-Pugh score was 5 (Class A).
Huge hard fixed masses were detected on his left pectoralis major, deltoid, and left teres minor muscles in which metastatic HCC was confirmed (
Due to about 6-cm sized painful abdominal mass, he underwent radiotherapy in another hospital. Radiotherapy was delivered 40 Gy in 16 fractions.
Though left pectoralis major and deltoid lesions nearly disappeared and pain was improved after radiotherapy, pain of left teres minor muscles area was aggravated and hard fixed mass was palpable again. A total dose of 30 Gy in 12 fractions for the left teres minor muscle area was delivered over a 3-week period.
Two painful recurred hard fixed masses were detected on abdominal wall. A total dose of 30 Gy in 15 fractions (
He felt pain on his left shoulder, new metastatic lesion in acromial angle was detected. He received radiotherapy of 20 Gy in 5 fractions. Pain was improved after radiotherapy.
A small scalp mass was detected, and excisional biopsy was performed on October 2012. The pathology of the lesion was metastatic HCC. He also felt a newly growing mass in his right arm. Radiotherapy was undergone for the tumor bed of his scalp and the right deltoid muscle area. A total dose of 35 Gy in 14 fractions was delivered for each lesion, and the pain was relieved.
A 5-cm sized rapid-growing hard fixed mass was detected with pain on his left anterior chest wall again. Radiotherapy of 35 Gy in 14 fractions was delivered, and pain was improved.
The patient underwent 7 courses of radiotherapy and took sorafenib orally (at starting dosage of 200 mg/day and a maintaining dosage of 600 mg/day) from April 2011 to July 2013. His hepatic function has been well preserved and the level of AFP has been normal. The brain metastasis had been also stable. Lung metastasis was suspicious on chest CT but that had not been progressed though intramuscular lesions were progressed after radiotherapy. He is still alive and is possible to carry on ordinary activities.
Extrahepatic metastasis occurs in about 15%-37% of patients with HCC, and it depends on HCC stages [
Despite significant advances in the treatment of intrahepatic lesions, the prognosis for patients with HCC who have extrahepatic metastasis remains poor. Natsuizaka et al. [
There is no standard treatment for extrahepatic metastases of primary HCC. Huang et al. [
Niibe et al. [
There has been little study regarding HCC with oligo-recurrence and no evidence of proper regimen of radiotherapy. We delivered 35 Gy in 14 fractions to this patient's shoulder for palliation of pain because of his previous history of multiple metastases. However, he needed re-irradiation for the same lesion, the dose was resultingly suboptimal. Moreover, the patient received treatments in three different hospitals and more effective multidisciplinary approach was difficult to apply.
Similarly to this case, there was a case report of long-term survival of a patient with multiple abdominal metastases from endometrial carcinoma treated with multi-portal conformal re-irradiation and chemotherapy [
No potential conflict of interest relevant to this article was reported.
(A) Two well-enhanced intramuscular masses (3.5 cm × 1.8 cm; 2.2 cm × 1.9 cm) in the left pectoralis major (arrow) and left deltoid muscles (curved arrow) were visualized on PET-CT (maxSUV 2.57, 2.30) in March 2011. (B) An intramuscular mass along the left teres minor muscle was also visualized on PET/CT (maxSUV 2.00) in March 2011. Radiotherapy of 35 Gy in 14 fractions was delivered. (C) After radiotherapy of 35 Gy in 14 fractions, these masses were decreased in size (1.5 cm × 1.2 cm) markedly. PET/CT, positron emission tomography/computed tomography.
(A) A hard fixed mass in left teres minor muscles area was palpable again on T1 gadolinium-enhanced magnetic resonance in October 2011. Subsequent radiotherapy of 30 Gy in 12 fractions was delivered over 3-week period. (B) Grossly the metabolism of the mass was decreased on the outside positron emission tomography/computed tomography in December 2012.
(A) A fluorodeoxyglucose (FDG)-avid well-enhanced conglomerated recurred muscular mass (5.0 cm × 2.7 cm) was detected in the right abdominal wall on PET/CT (maxSUV 2.84) in May 2012. (B) Since a total dose of 30 Gy in 15 fractions were delivered, the mass showed decreased metabolism grossly on outside PET/CT in December 2012. PET/CT, positron emission tomography/computed tomography.
(A, B) In July 2012, he felt pain on his left shoulder, there was newly developed well-enhanced lesion in his left acromion on T1 gadolinium-enhanced magnetic resonance (arrow). After receiving radiotherapy of 20 Gy in 5 fractions, his pain was relieved.
(A) In October 2012, about 1-cm sized painful scalp mass was detected. His previous T1 gadolinium-enhanced magnetic resonance showed about 0.3-cm sized well-enhanced nodule in the right posterior scalp area in July 2011. The excision was undergone. It was pathologically reported as metastatic hepatocellular carcinoma. (B) He also felt a newly growing mass in his right upper arm in May 2012. Positron emission tomography/computed tomography showed a hypermetabolic lesion in his right deltoid muscle (maxSUV 2.00). A total dose of 35 Gy in 14 fractions each was delivered for the tumor bed of his scalp and the right upper arm, and the pain was relieved.