Primary Hepatoma with Metastasis to a Long Bone

Abstract

Primary carcinoma of the liver occurs in two forms: one arising from the liver cells (hepatoma) and the other from the intrahepatic bile ducts. These types occur in a ratio of 92 to 8, respectively (14). Primary hepatoma rarely metastasizes to bone, and among those cases where such metastasis does occur, involvement of a long bone is an extreme rarity. The incidence of bone metastases in carcinoma of the liver, as reported in the literature, varies. Charache (5) found it to be 1.6 per cent in 1,125 cases. Greene (6), in a ten-year collective review, found that of 386 proved cases, 8 per cent had metastasized to bone. The figure of Hoyne and Kernohan (7) is intermediate between these two. In a series of 31 hepatomas among 16,303 autopsies, they discovered bone metastasis but once, an incidence of 3.22 per cent. Making every effort not to duplicate cases, the present writer found in the literature a total of 1,380 cases of hepatoma (1–4, 8–10, 12–14). To these he is adding 11 derived from 3,324 autopsies done at St. Vincent's Hospital, bringing the total number of cases to 1,391. Of this total, 45 (3.23 per cent) have shown long-bone involvement. The purpose of this paper is to report one such case. Case Report J. C., a 60-year-old white male of Hungarian nativity, was brought to St. Vincent's Hospital on March 2, 1948, after having fallen on a stairway. He was found to have a spiral comminuted fracture involving the proximal shaft of the right humerus. He gave a history of having been treated for hypertension and diabetes. The only physical findings of note, in addition to the fracture, were an apical systolic murmur and a blood pressure of 190/110. The fracture was treated by the insertion of a Kirschner wire through the olecranon process and the application of skeletal traction. On March 18, 1948, the roentgenologist reported the presence of a destructive lesion in association with the fracture. The Kirschner wire was removed and a hanging cast applied. The patient was then permitted to leave the hospital for three days. He was readmitted on April 6, 1948, for further study. Clinically there was no change in the appearance of the arm. The diabetes was well controlled. The serum calcium and acid and alkaline phosphatase determinations were normal. The patient was discharged to the Fracture Clinic on April 13. While he was attending the clinic, a spontaneous fracture was seen to have occurred proximal to the original fracture site. A mass measuring about 2 × 3 cm. was discovered in the left supraclavicular region. On readmission to the hospital, May 14, 1948, physical examination yielded no new findings other than the mass in the neck and a moderate degree of pretibial edema. One examiner believed the liver to be slightly enlarged, but this was not borne out by others. Aspiration biopsy of the neck mass led to a diagnosis of “thyroid adenoma.” At his request, the patient was discharged on June 2.