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Advisor(s)
Abstract(s)
O Carcinoma Hepatocelular (CHC) é a neoplasia do fígado mais comum e uma das mais letais. Apesar de avanços ao nível do diagnóstico, é frequentemente diagnosticada em estadios avançados, com cerca de 1/3 dos doentes a apresentar metastização óssea. No entanto, a metastização óssea é infrequentemente descrita como manifestação inicial do CHC.
Apresenta-se o caso, de um doente com lesões ósseas líticas espinhais, com investigação etiológica, a culminar nos diagnósticos de CHC e Mieloma Múltiplo (MM).
Homem, 54 anos, melanodérmico, sem antecedentes pessoais relevantes, com história de 6 semanas de dor lombar intensa e fadiga. Boa performance status com exame objetivo com dor à palpação no hipocôndrio direito. Na avaliação analítica apresentava hemoglobina 11,7 g/dL, enzimas hepáticas aumentadas e bilirrubina séria, creatinina e cálcio normais. Serologia para o vírus da Hepatite B (HBV) compatível com Hepatite B Crónica e níveis séricos de α-fetoproteina (943 ng/ml) muito elevados. Eletroforese de proteínas com banda nas regiões β e γ, e componente biclonal IgA lambda na imunofixação sérica.
No Mielograma revelou-se um aumento de plasmócitos que constituíam 20% da celularidade total. Nos estudos imagiológicos, revelaram-se múltiplas lesões líticas nos corpos vertebrais de D6 a L2. Na tomografia computorizada abdominal, fígado ligeiramente aumentado, com margens irregulares e múltiplas área nodulares parenquimatosas, confluentes, a sugerir CHC.
Com diagnósticos de CHC e MM estabelecidos para discriminar a etiologia das lesões líticas, realizou-se biópsia óssea guiada por TC. Os resultados histopatológicos e imuno-histoquimicos foram compatíveis com metástases de CHC.
Este caso ilustra o desafio diagnóstico etiológico de lesões ósseas líticas, entre duas doenças com potencial envolvimento ósseo. A coexistência de CHC e MM poderá refletir uma etiopatogénese comum. O vírus da hepatite B, para além de hepatotrópico, é hipotetizado a sua associação com o aumento do risco para o MM, por estimulação antigénica crónica.
Hepatocellular carcinoma (HCC) is the most common type of liver tumor and one of the most lethal cancers. Despite advances in diagnosis, it is frequently diagnosed at an advanced stage and about 1/3 of these patients have bone metastasis. However, bone metastasis are infrequently described as HCC first clinical manifestation. We herein present a patient with lytic lesions of the spine in whom the etiological investigation led to HCC and multiple myeloma (MM) diagnoses. A 54-year-old black man with uneventful personal history presented with 6-weeks history of severe low back pain and fatigue. The patient performance status was good and on clinical examination he had right hypocondrium tenderness. Blood tests showed hemoglobin 11.7 g/dL, elevated liver enzymes and normal serum bilirrubine, creatinine and calcium. Hepatitis B virus (HBV) serology was compatible with chronic hepatitis B and serum α-fetoprotein (943 ng/ml) was very elevated. Serum protein electrophoresis revealed one band in β and γ regions and serum immunofixation showed a biclonal component IgA lambda. Bone marrow aspirate smear revealed increased plasma cells with 20% of total celullarity. Spine imaging studies showed multiple lytic lesions on vertebral bodies from D6 to L2. On abdominal computed tomography (CT) scan, the liver was slighty enlarged, with irregular edges and multiple confluent parenchymal nodules suggesting HCC. HCC and MM diagnoses were established and in order to discriminate the bone lesions etiology, a lumbar spine CT-guided biopsy was done. Histopathological and immunohistochemistry findings were compatible with HCC metastasis. This case illustrates the challenge on etiologic diagnosis of lytic bone lesions when two diseases with potencial bone involvement are present. The coexistence of HCC and MM may reflect a common etiopathogenesis. In addition to being a hepatotropic virus, it was hypothesized that HBV could be associated with increased risk of MM due to chronic antigenic stimulation.
Hepatocellular carcinoma (HCC) is the most common type of liver tumor and one of the most lethal cancers. Despite advances in diagnosis, it is frequently diagnosed at an advanced stage and about 1/3 of these patients have bone metastasis. However, bone metastasis are infrequently described as HCC first clinical manifestation. We herein present a patient with lytic lesions of the spine in whom the etiological investigation led to HCC and multiple myeloma (MM) diagnoses. A 54-year-old black man with uneventful personal history presented with 6-weeks history of severe low back pain and fatigue. The patient performance status was good and on clinical examination he had right hypocondrium tenderness. Blood tests showed hemoglobin 11.7 g/dL, elevated liver enzymes and normal serum bilirrubine, creatinine and calcium. Hepatitis B virus (HBV) serology was compatible with chronic hepatitis B and serum α-fetoprotein (943 ng/ml) was very elevated. Serum protein electrophoresis revealed one band in β and γ regions and serum immunofixation showed a biclonal component IgA lambda. Bone marrow aspirate smear revealed increased plasma cells with 20% of total celullarity. Spine imaging studies showed multiple lytic lesions on vertebral bodies from D6 to L2. On abdominal computed tomography (CT) scan, the liver was slighty enlarged, with irregular edges and multiple confluent parenchymal nodules suggesting HCC. HCC and MM diagnoses were established and in order to discriminate the bone lesions etiology, a lumbar spine CT-guided biopsy was done. Histopathological and immunohistochemistry findings were compatible with HCC metastasis. This case illustrates the challenge on etiologic diagnosis of lytic bone lesions when two diseases with potencial bone involvement are present. The coexistence of HCC and MM may reflect a common etiopathogenesis. In addition to being a hepatotropic virus, it was hypothesized that HBV could be associated with increased risk of MM due to chronic antigenic stimulation.
Description
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2020
Keywords
Carcinoma hepatocelular Vírus da hepatite B Metastização Lesões ósseas Mieloma múltiplo