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Hematochezia From Metastasis of Hepatocellular Carcinoma to Colon in a Patient Who Underwent Liver Transplantation
IMAGE OF THE MONTH Hematochezia From Metastasis of Hepatocellular Carcinoma to Colon in a Patient Who Underwent Liver Transplantation Ruhail Kohli,* Andrei S. Purysko,‡ and Binu V. John§ *Department of Internal Medicine, ‡Department of Radiology, and §Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio
50-year-old woman was admitted to the hospital with a 3-day history of hematochezia. She had been diagnosed with cryptogenic cirrhosis and hepatocellular carcinoma (HCC) 4 years before presentation and underwent an orthotopic liver transplant. A 3-cm mass was discovered in the left lateral segment of the explant. Pathology showed poorly differentiated HCC with invasion of small vascular spaces and the liver capsule (Figure A). Immunohistochemistry demonstrated positivity for cytokeratin 7 and a canalicular staining pattern with CEA. CD10 and CD19 stains were negative. Three years after transplantation, she developed a 1.5-cm HCC recurrence in the right lobe of the liver. A magnetic resonance imaging scan of the abdomen showed the dominant hypervascular mass with central necrosis in the right lobe of the liver allograft compatible with recurrent HCC. There were no masses seen in the colon, but the study was likely limited by colonic gas. This liver lesion was treated with yttrium-90 radioembolization. Axial positron emission tomography/ computed tomography image obtained after yttrium-90 microsphere radioembolization showed accumulation of the isotope in the dominant right hepatic lobe mass (Figure B, arrow). On this admission, physical examination was remarkable for pallor. Hemoglobin was 8 g/dL from a
A
baseline of around 11 g/dL. A colonoscopy showed a friable, necrotic lesion with active bleeding at the splenic flexure that was causing an almost complete obstruction of the lumen (Figure C). A biopsy was taken, and the pathology was consistent with poorly differentiated neoplasm with significant tumor necrosis, similar to the patient’s original HCC. The alfa fetoprotein level was 43 ng/mL (normal, <11 ng/mL); the modest elevation was likely due to necrotic tumor. The patient subsequently developed worsening bleeding and therefore underwent a laparoscopic resection with an end colectomy for palliation. A 6.2 3.9 2.2 cm mass was resected. She had an uncomplicated postoperative course and was started on sorafenib, which was later discontinued because of intolerance. The most common site of metastasis for HCC is the lungs, followed by lymph nodes, bone, and adrenal glands.1,2 Gastrointestinal metastasis is rare, and in one series it was described in 11 of more than 2200 patients with HCC. Of those, the colon was involved in 4 cases.3,4 One previous case from Japan reported metastatic HCC to the ascending colon that caused hematochezia.5 HCC generally metastasizes through local invasion. Hematogenous metastasis is very rare and was the likely mechanism in this patient because the original tumor showed vascular invasion. Progression of metastatic HCC is more rapid in post-transplant patients on immunosuppressants.
Clinical Gastroenterology and Hepatology 2014;-:-–-
IMAGE OF THE MONTH, continued Although rare, bowel metastasis should be considered in the differentials for pretransplant or post-transplant patients with HCC.
4.
5.
References 1.
2.
3.
2
Katyal S, Oliver JH 3rd, Peterson MS, et al. Extrahepatic metastases of hepatocellular carcinoma. Radiology 2000; 216:698–703. Nakashima T, Okuda K, Kojiro M, et al. Pathology of hepatocellular carcinoma in Japan: 232 consecutive cases autopsied in ten years. Cancer 1983;51:863–877. Chen LT, Chen CY, Jan CM, et al. Gastrointestinal tract involvement in hepatocellular carcinoma: clinical, radiological and endoscopic studies. Endoscopy 1990;22:118–123.
Lin CP, Cheng JS, Lai KH, et al. Gastrointestinal metastasis in hepatocellular carcinoma: radiological and endoscopic studies of 11 cases. J Gastroenterol Hepatol 2000;15:536–541. Nozaki Y, Kobayashi N, Shimamura T, et al. Colonic metastasis from hepatocellular carcinoma: manifested by gastrointestinal bleeding. Dig Dis Sci 2008;53:3265–3266.
Acknowledgements The authors thank Lisa Yerian, MD, for assistance with the pathology images. Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2014.03.009
50-year-old woman was admitted to the hospital with a 3-day history of hematochezia. She had been diagnosed with cryptogenic cirrhosis and hepatocellular carcinoma (HCC) 4 years before presentation and underwent an orthotopic liver transplant. A 3-cm mass was discovered in the left lateral segment of the explant. Pathology showed poorly differentiated HCC with invasion of small vascular spaces and the liver capsule (Figure A). Immunohistochemistry demonstrated positivity for cytokeratin 7 and a canalicular staining pattern with CEA. CD10 and CD19 stains were negative. Three years after transplantation, she developed a 1.5-cm HCC recurrence in the right lobe of the liver. A magnetic resonance imaging scan of the abdomen showed the dominant hypervascular mass with central necrosis in the right lobe of the liver allograft compatible with recurrent HCC. There were no masses seen in the colon, but the study was likely limited by colonic gas. This liver lesion was treated with yttrium-90 radioembolization. Axial positron emission tomography/ computed tomography image obtained after yttrium-90 microsphere radioembolization showed accumulation of the isotope in the dominant right hepatic lobe mass (Figure B, arrow). On this admission, physical examination was remarkable for pallor. Hemoglobin was 8 g/dL from a
A
baseline of around 11 g/dL. A colonoscopy showed a friable, necrotic lesion with active bleeding at the splenic flexure that was causing an almost complete obstruction of the lumen (Figure C). A biopsy was taken, and the pathology was consistent with poorly differentiated neoplasm with significant tumor necrosis, similar to the patient’s original HCC. The alfa fetoprotein level was 43 ng/mL (normal, <11 ng/mL); the modest elevation was likely due to necrotic tumor. The patient subsequently developed worsening bleeding and therefore underwent a laparoscopic resection with an end colectomy for palliation. A 6.2 3.9 2.2 cm mass was resected. She had an uncomplicated postoperative course and was started on sorafenib, which was later discontinued because of intolerance. The most common site of metastasis for HCC is the lungs, followed by lymph nodes, bone, and adrenal glands.1,2 Gastrointestinal metastasis is rare, and in one series it was described in 11 of more than 2200 patients with HCC. Of those, the colon was involved in 4 cases.3,4 One previous case from Japan reported metastatic HCC to the ascending colon that caused hematochezia.5 HCC generally metastasizes through local invasion. Hematogenous metastasis is very rare and was the likely mechanism in this patient because the original tumor showed vascular invasion. Progression of metastatic HCC is more rapid in post-transplant patients on immunosuppressants.
Clinical Gastroenterology and Hepatology 2014;-:-–-
IMAGE OF THE MONTH, continued Although rare, bowel metastasis should be considered in the differentials for pretransplant or post-transplant patients with HCC.
4.
5.
References 1.
2.
3.
2
Katyal S, Oliver JH 3rd, Peterson MS, et al. Extrahepatic metastases of hepatocellular carcinoma. Radiology 2000; 216:698–703. Nakashima T, Okuda K, Kojiro M, et al. Pathology of hepatocellular carcinoma in Japan: 232 consecutive cases autopsied in ten years. Cancer 1983;51:863–877. Chen LT, Chen CY, Jan CM, et al. Gastrointestinal tract involvement in hepatocellular carcinoma: clinical, radiological and endoscopic studies. Endoscopy 1990;22:118–123.
Lin CP, Cheng JS, Lai KH, et al. Gastrointestinal metastasis in hepatocellular carcinoma: radiological and endoscopic studies of 11 cases. J Gastroenterol Hepatol 2000;15:536–541. Nozaki Y, Kobayashi N, Shimamura T, et al. Colonic metastasis from hepatocellular carcinoma: manifested by gastrointestinal bleeding. Dig Dis Sci 2008;53:3265–3266.
Acknowledgements The authors thank Lisa Yerian, MD, for assistance with the pathology images. Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2014.03.009