Acute myeloid leukemia masquerading as hepatocellular carcinoma

Abstract

A 64-year-old Caucasian man developed progressive fatigue, abdominal distension, and 25 pounds weight loss (10% of his body weight) over a month period. His outpatient workup included an abdominal ultrasound that revealed a large liver mass. Magnetic resonance imaging confirmed a solitary 11 cm mass with central necrosis within segments 6 and 7 of the right hepatic lobe. The patient had no history of excessive alcohol intake, viral hepatitis, steatosis or liver cirrhosis. An alpha-fetoprotein (AFP) level was 7.9 ng/mL. Given the features of the liver mass on imaging, and despite the lack of cirrhosis and elevated AFP, a diagnosis of hepatocellular carcinoma (HCC) was presumed and the patient was considered for hepatobiliary surgery.In the interim, the patient had rapid functional decline. He was admitted for fever (39 ℃), confusion and back pain. The physical exam was notable for altered mental status and flapping tremor without meningismus, lower extremity weakness or focal neurologic findings. Laboratory studies revealed a white blood count (WBC) of 3.0×10 3 /µL, Abstract: Hepatocellular carcinoma (HCC) is often diagnosed on the basis of high quality imaging without a biopsy in the cirrhotic liver. This is a case of a 64-year-old Caucasian man with no history of liver disease or cirrhosis that presented with fatigue, weight loss, and abdominal distension and was found to have a large, isolated liver mass with arterial enhancement and portal venous washout on triple-phase computed tomography (CT) suspicious for HCC. The patient was initially referred for a surgical evaluation.Meanwhile, he developed fevers, pancytopenia, and worsening back pain, and a subsequent spinal MRI revealed a heterogeneous bone marrow signal suspicious for metastatic disease. A bone marrow biopsy that followed was diffusely necrotic. A core biopsy of the patient's liver mass was then performed and was diagnostic of acute monocytic-monoblastic leukemia. Findings from peripheral flow cytometry and a repeat bone marrow biopsy were also consistent with this diagnosis, and induction chemotherapy with cytarabine and idarubicin was initiated. This case describes a rare presentation of myeloid sarcoma (MS) as an isolated, hypervascular liver mass that mimics HCC in its radiographic appearance. Due to the broad differential for a liver mass, a confirmatory biopsy should routinely be considered prior to surgical intervention.

Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immunotherapy for the treatment of hepatocellular carcinoma

“…Other entities such as metastatic neuroendocrine cancers can similarly demonstrate Open access arterial enhancement on multiphase imaging. 31 Additionally, in rare instances, tissue biopsy may uncover certain genetic alterations that render a patient eligible for a tissue-agnostic therapy or a clinical trial.…”

Acute hepatitis-like presentation with cholestasis of CBFB–MYH11-positive acute myeloid leukemia in an adult male: a case report

“…The gastrointestinal tract is frequently involved, particularly the small intestine. Although MS can develop in any organ, liver infiltration is very rare, therefore it presents as a diagnostic challenge, especially in patients with no previous history of myeloproliferative neoplasm or acute leukemia, as happened in our patient [ 2 , 3 ].…”

Leukemia in gastrointestinal organs as cause of treatment failure: 378 cases analyzed

“…Liver involvement may present with pain or symptoms of cholestasis and very high lactate dehydrogenase levels. Nodules or masses as large as 11 cm have been reported, as well as sinusoidal infiltration and fulminant liver failure …”