Solitary vertebral metastasis of primary clear cell carcinoma of the liver: a case report and review of literature

Abstract

Primary clear cell carcinoma of liver (PCCCL) is an uncommon variant of primary hepatocellular carcinoma. Though the literature describes a better prognosis in relation to the proportion of clear cells in the tumour when compared to the other variants, there is no general consensus in the management due to its rarity and unclear clinicopathological and prognostic factors. There is dearth of evidence with regard to the metastasizing nature of PCCCL and its management. In addition, the management of recurrent spinal tumours both primary and metastatic is not clear as the available evidence is mostly based on case reports. We describe an unusual presentation of PCCCL with solitary spinal metastasis and further complicated by tumour recurrence in a 71-year-old male. Such presentation has never been described before. He presented with low back pain and incomplete neurological deficits involving both lower limbs. On detailed evaluation, he was found to have a solitary metastasis at L3 vertebra secondary to PCCCL. He underwent radical excision of tumour and reconstruction for the solitary metastasis at L3 vertebral body and trans arterial chemo embolisation (TACE) for the hepatic lesion. Pt was asymptomatic until 9 months post operatively when he developed tumour recurrence at L3 vertebra. Patient subsequently underwent 2 stage palliative surgery followed by radiotherapy and chemotherapy. At his latest follow-up (1 year), the patient's overall general condition has improved with residual neurological deficits in the lower limb. PCCCL is a rare type of hepatocellular carcinoma which can present as "solitary metastasis" to the spine. Although the literature suggests a good prognosis for this histological type, this case did not have a good outcome. In addition to providing information for the management of similar cases in the future, this case report highlights that every patient has to be managed on a case-by-case basis.

Keywords: Clear cell; carcinoma; liver; metastasis; recurrence; resection; spine.

Figure 1

CT and MRI scans of the L3 vertebral metastasis. CT, computed tomography; MRI, magnetic resonance imaging.

Figure 2

Histology of tumour under light microscopy: (A) haematoxylin & eosin (original magnification ×200); (B,C) immunostaining for arginase-1 (B) and for HepPar1 (C) respectively (original magnification×200).

Figure 3

Radiographs of the lumbar spine at 6 months after tumour resection and spinal reconstruction.

Figure 4

MRI at 9 months’ post-operation showing tumour recurrence causing crowding of cauda equina and foraminal stenosis. MRI, magnetic resonance imaging.

Figure 5

Post-operative radiographs of the lumbar spine after the latest revision operation (12 months) with exchange of cage and extension of posterior instrumentation following debulking of tumour.