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Table 1: Routine blood investigations
Investigation Value
Hemoglobin (g/dL) 13
9
Total leukocyte count (×10 /L) 9.2
Platelet count (×10 /L) 260
9
Serum creatinine (mg/dL) 0.6
Blood urea level (mg/dL) 22
Serum bilirubin (mg/dL) 1.0
SGOT (mg/dL) 125
SGPT (mg/dL) 168
Alkaline phosphatase (U) 360
HIV Negative
HBsAg Positive
HCV Negative
Serum AFP (ng/dL) 34,300
SGOT: serum glutamic-oxaloacetic transaminase; SGPT: serum
glutamic pyruvic transaminase; HCV: hepatitis C virus; HIV:
human immunodeficiency virus; AFP: alpha fetoprotein; HBsAg:
hepatitis B surface antigen
Figure 1: Prominent sternal mass on presentation
infiltration. Both lung fields were clear, and there was no
mediastinal adenopathy. Trucut biopsy showed moderate
to large-sized polygonal cells with abundant eosinophilic
cytoplasm and pleomorphic nuclei with a few cells
showing characteristic inclusion bodies suggestive of
metastatic carcinoma likely from an HCC [Figure 2].

Further, CT scan of the abdomen revealed a 9 cm × 7 cm
heterogeneously enhancing mass in the arterial phase in
segment VIII and IV of the liver with early washout in the
venous phase, suggestive of HCC [Figure 3]. Serum alpha
fetoprotein (AFP) was greatly elevated at 34,300 ng/dL. In view
of raised AFP, characteristic liver mass and biopsy of sternal
mass, the diagnosis of HCC with sternal metastasis was
confirmed. The patient was treated with local radiotherapy
to sternal metastasis (20 Gray, divided into 10 fractions) Figure 2: Hematoxylin and Eosin staining section (×40) showing moderate-
and was started on entecavir, 0.5 mg daily for hepatitis B to-large sized polygonal cells with abundant eosinophilic cytoplasm,
pleomorphic nuclei, with few cells showing characteristic inclusion bodies
and sorafenib, 400 mg daily for HCC. One month after the (black arrow)
start of treatment, there was a mild reduction in the size of
the sternal mass. The patient is currently under follow-up.

DISCUSSION

HCC is the most common primary malignant tumor
of the liver and is one of the most frequently occurring
malignancies in Asia. The incidence exceeds 30 cases
in 100,000 people per year in the East Asian region.
[3]
The course of clinically apparent disease is generally
very rapid, and, if untreated, most patients die within 3-6
months after diagnosis. HCC shows both intra-hepatic
and extra-hepatic metastasis, with intra-hepatic metastases
occurring more frequently. Extra-hepatic metastasis has
been reported in 18% of cases. The mode of extra-
[4]
hepatic spread is generally hematogenous, less commonly
via lymphatics or direct spread. The most common sites Figure 3: Computed tomography scan of abdomen showing heterogeneous
enhancing mass in segment VIII and IV in liver in the arterial phase
of extra-hepatic involvement are lungs, lymph nodes,
adrenals, and bones. Bony metastasis has been reported generally multiple. An isolated bony metastasis as an
[4]
in 3-10% of cases. The most common bones involved
[5]
are vertebrae, pelvis, ribs, long bones, skull and, very initial presentation of HCC, as in our case, is rarely
rarely, sternum. Further, bony metastases in HCC are seen. [7]
[6]
42
Journal of Cancer Metastasis and Treatment ¦ Volume 2 ¦ Issue 1 ¦ January 15, 2016 ¦