The map of liver cancer distribution throughout the world, depicted below, indicates the high concentrations of the disease among male populations in parts of Africa and China. The distribution for females is similar.

Case Report

A Case Report of Liver cancer following meloma

by Professor Hussein Khaled Vice-Dean, NCI, Cairo

A male patient aged 54 years and known to have chronic, viral C hepatitis presented in March 1996 with a low backache. After an initial work-up, which included laminectomy and excision of a lesion found in the sacral region, he was diagnosed as having a solitary plasmacytoma. The lesion was treated with radiotherapy, which was completed in 1996. Follow-up included bone marrow aspiration, serum protein immuno-electrophoresis, serum immunoglobulin estimation, serum ß2 microglobulin, and Bence Jone's proteins in urine, which remained within normal limits except for a very mild increase in the level of IgG (1585 mg/dl, normal range 770-1520 mg/dl), which persisted in the course of the next year, and a very minimal increase in ß2 microglobulin level ( 3.5 µg/dl, normal range 0-3.4 µg/dl).

In November 1998 the patient developed severe headache. A work-up included brain CT and MRI scans, MRI cervical spine, ophthalmologic, ENT, and dental consultations, but no abnormalities were found. One year later, the patient developed a painful swelling in the right temporal region. Brain CT revealed a right temporal bone lesion, suspicious for neoplasia, and a suspected osteolytic lesion in the midline of the occiput. Another compete work-up revealed the following: (1) a deposit in the right alum of the sacrum, (2) a monoclonal band in the gamma region, with a concentration of 2.7 g/dl (3) an increase in the IgG concentration, exclusively associated with kappa light chains, (4) a ß2 microglobulin level of 7.8 µg/dl, and (5) a high serum uric acid level (1.8 mg/dl). A fine needle aspiration of the temporal bone lesion revealed the presence of plasmacytoma.

The patient was treated with 3-4 cycles of the VAD regimen and Aredia, given as an infusion of 90 mg every month, to be followed by high dose therapy and autologous peripheral blood stem cell transplantation if he obtained a CR. While on the VAD therapy, however, the patient developed steroid induced diabetes mellitus, which was controlled by insulin therapy, and elevations in liver enzymes. Given his history of viral C hepatitis, a trial of interferon, 6 million units per day was initiated, but due to severe side effects, which included persistent fever, generalized bone pain and depression, the drug was stopped after 10 days. The patient went on to receive 4 cycles of VAD chemotherapy, but his multiple myeloma progressed. Further investigations at this point revealed the presence of a portal vein thrombosis that involved the main portal trunk, its bifurcation and both right and left branches. In addition, a large hypoechoic area of about 10 cm in diameter was found in the right hepatic lobe of the liver and there was minimal ascites. A panel of serum tumor markers demonstrated elevated alpha fetoprotein (84 ng/ml, normal up to 10 ng/ml), and carcinoembryonic antigen ( 204 u/ml , normal up to 37 u/ml ). It was felt very likely that the patient had developed a second malignancy in the liver (hepatocellular carcinoma), but a CT-guided biopsy of the hepatic lesion was considered a high risk procedure and therefore not undertaken. The patient traveled abroad and a PET scan performed in June 2000 was felt to be compatable with the diagnosis of hepatocellular carcinoma. It also revealed bone lesions at D8 and L1. The patient was treated with palliative therapy, including supportive care and tamoxifen, 20 mg/day.