Embolization of an unusual metastatic site of hepatocellular carcinoma in the humerus

Abstract

Hepatocellular carcinoma (HCC) is the fifth most common cancer in the world. This case documents an unusual metastatic presentation of HCC in the humerus. Preoperative palliative arterial embolization of the tumor was performed to arrest severe tumor bleeding caused by the biopsy. Embolization turned out to be useful also in limiting/preventing potential uncontrolled bleeding during subsequent amputation.

Figure 1

Liver sonography (A) and CT imaging of hepatocellular carcinoma (HCC) (B-D). A: Round but inhomogeneous tumor with hyper- and hypo-echoic appearance in the sonography (diameter 6 cm, arrow); B: Axial multidetector CT contrast image at the arterial phase demonstrated a tumor lesion in the right upper lobe (arrow). Dimension 7 cm × 6.5 cm × 60 cm with hyperdense periphery and hypodense centre (latter areas of necrosis); C: Additional 1.4 cm × 1 cm × 1 cm hyperintense lesion in segment VII of the liver (arrow); D: Partial thrombosis of the portal vein (arrow).

Figure 2

X-Ray (A, B) and MR imaging (C, D) of HCC metastasis at the humerus. A and B: Destructive lesion in the left humerus associated with a bulging soft tissue component, 5.5 cm × 4 cm in dimension; C: Coronal noncontrast PD-weighted (TR/TE, 1920/12) image demonstrating a soft tissue tumor (coronal dimension 6.2 cm × 5 cm) with complete destruction of the humerus, the tumor reached the surface with ulceration (arrow); D: Axial noncontrast TIRM sequences (TR/TE, 7400/92) show the edematous tumor in the centre of the extremity and the lateral tumor branch to the surface (arrow). In this region, a biopsy was taken which was followed by massive hemorrhage.

Figure 3

Catheter angiography of the tumor before (A, B) and after embolization (C), X-Ray after final treatment with amputation of the left upper extremity (D). A: Catheter angiography of the axillary artery reveal a round hypervascular tumor; B: Selective angiography of a tumor feeding vessel as side of application of Bead Block (size 300-500 μm, Terumo Europe, Leuven, Belgium) for embolization; C: After embolization of main parts of the tumor, at this status no areas of bleeding detectable but small parts of the tumor still perfused; D: Final treatment with amputation of the left upper extremity.

Figure 4

Neoplastic cells of HCC metastasis were diffusely stained by hepatocellular antigen (for instances, see arrowheads), destroyed bone areas within the tumor are visible (arrows).