P0785 - Abscess or Metastasis? Hepatocellular Carcinoma Metastatic to the Spine Presenting as an Epidural Abscess

Michael Conner, MD, Amber Hardeman, MD, MBA, MPH, Kaylor Wright, MD, John Affronti, MD
Tulane University School of Medicine, New Orleans, LA

Introduction: Hepatocellular carcinoma (HCC) is one of the most common causes of cancer-related death worldwide. Historically, metastatic disease was not frequently identified. As a result of improved screening for HCC, metastasis is becoming increasingly prevalent.

Case Description/Methods: A 37 year old man with a history of hypertension, untreated HCV, and IV drug use presented with 2 months of excruciating lower back pain radiating to his feet associated with paresthesia and intermittent fevers. On exam he was afebrile, tachycardic, hypertensive and in distress due to back pain. His abdomen was distended and diffusely tender to palpation with hepatomegaly. He had palpable swelling overlying the left side of his thoracic spine and no focal neurologic deficits.

Labs: WBC 8.9 × 103/μL, ESR 28 mm/hr, CRP 12.3 mg/dL. AFP >3000 ng/mL. Serology: positive HBcAb, HBsAg, and HBeAb. HCV RNA PCR >3.7million copies. HBV DNA PCR 2,458 IU/mL. HBcAb IgM and HIV negative. AFP >3000 ng/mL.

Neurosurgery drained purulent fluid and removed what was thought to be an phlegmon, measuring 4.3 x 4.1 x 2.6 cm. Epidural cultures were pan negative. Pathology later confirmed T12 spinous process metastatic HCC. Patient was started on tenofovir 25mg/day for flare prophylaxis during chemotherapy. He completed 10 radiation treatments prior to discharge and was set up to complete a 28 day cycle of lenvatinib chemotherapy. Depending on overall prognosis after chemotherapy completion, he may start outpatient treatment for Hepatitis C.

Discussion: In this case, we describe an unusual presentation in which spinal metastases are initially disguised by an epidural abscess. HCC diagnoses in the United States have more than tripled since 1980, which should raise concern for HCC in patients with spinal disease. Early diagnosis and treatment of HCC is vital. Due to the rarity of metastatic HCC to the spine, there is a limited amount of data on treatment options and patient outcomes. A systematic review of metastatic HCC to the spine by Goodwin et al. compared median survival rate in observation alone (0.7 months), surgery alone (7 months), medical management alone (chemotherapy and/or radiation) (6 months), and surgery combined with medical management (13.5 months). Although the combination of surgery and medical management was shown to have the longest survival rates, the study was not able to determine the improvement in patient quality of life or the rate of prevention of complete paralysis with the goal of preserving ambulatory status.


Figure: A: Triple phase CT of the abdomen demonstrating diffuse involvement of HCC. B: T2 MRI demonstrating T11-L1 posterior extradural mass.


Disclosures:
Michael Conner indicated no relevant financial relationships.
Amber Hardeman indicated no relevant financial relationships.
Kaylor Wright indicated no relevant financial relationships.
John Affronti indicated no relevant financial relationships.


Michael Conner, MD, Amber Hardeman, MD, MBA, MPH, Kaylor Wright, MD, John Affronti, MD. P0785 - Abscess or Metastasis? Hepatocellular Carcinoma Metastatic to the Spine Presenting as an Epidural Abscess, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.