Case 13-2006: A Man with a Bone Mass and Lesions in the Liver
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《新英格兰医药杂志》
To the Editor: In the Case Records presented in the April 27 issue,1 which involved a patient with liver lesions and a bone mass in the right ulna, Hasserjian states that hepatocellular carcinoma "does not typically give rise to bony metastasis." In fact, bone metastases occur with regularity in hepatocellular carcinoma. Specifically, in a subgroup of 23 patients with metastatic hepatocellular carcinoma who received investigational thalidomide, bone lesions were present in 5 (22 percent) and were the third most common site of extrahepatic metastasis after lung and retroperitoneal lymph nodes.2 My colleagues and I noted bone metastases in 19 of 57 patients (33 percent) who had a recurrence of hepatocellular carcinoma after undergoing orthotopic liver transplantation. In this cohort, the presence of bone metastases was strongly associated with reduced overall survival relative to other sites of recurrence.3
Jonathan D. Schwartz, M.D.
Mount Sinai Medical Center
New York, NY 10029
jonathan.schwartz@mssm.edu
References
Case Records of the Massachusetts General Hospital (Case 13-2006). N Engl J Med 2006;354:1828-1837.
Schwartz JD, Sung M, Schwartz M, et al. Thalidomide in advanced hepatocellular carcinoma with optional interferon alpha2a upon progression. Oncologist 2005;10:718-727.
Roayaie S, Schwartz JD, Sung MW, et al. Recurrence of hepatocellular carcinoma after liver transplant: patterns and prognosis. Liver Transpl 2004;10:534-540.
The discussants reply: We agree with Dr. Schwartz that bone metastases are not uncommon during the course of hepatocellular carcinoma. One study suggests that the incidence of such metastases has increased from 4.5 percent (12 of 269) among patients who received a diagnosis of hepatocellular carcinoma between 1978 and 1987 to 12.9 percent (52 of 404) among patients who received a diagnosis between 1988 and 1997.1 The increase in incidence is probably attributable to the increased duration of survival among patients with this disease and the availability of more effective therapies to treat the primary tumor. Our statement was intended to reflect the fact that bone metastases would be an unusual initial presentation of hepatocellular carcinoma, since the condition was found to be the source of metastasis in only 5 of 64 patients (7.8 percent) who presented with skeletal metastases as a primary manifestation of cancer.2 The studies cited by Dr. Schwartz involved patients with advanced or recurrent disease, which would have a higher incidence of bony metastasis in general. Indeed, we hope that our case will lead oncologists and pathologists to consider hepatocellular carcinoma in the differential diagnosis of bony metastases with adenocarcinoma of "unknown primary."
Robert P. Hasserjian, M.D.
Andrew X. Zhu, M.D., Ph.D.
Massachusetts General Hospital
Boston, MA 02114
References
Fukutomi M, Yokota M, Chuman H, et al. Increased incidence of bone metastases in hepatocellular carcinoma. Eur J Gastroenterol Hepatol 2001;13:1083-1088.
Katagiri H, Takahashi M, Inagaki J, Sugiura H, Ito S, Iwata H. Determining the site of the primary cancer in patients with skeletal metastasis of unknown origin: a retrospective study. Cancer 1999;86:533-537.
Jonathan D. Schwartz, M.D.
Mount Sinai Medical Center
New York, NY 10029
jonathan.schwartz@mssm.edu
References
Case Records of the Massachusetts General Hospital (Case 13-2006). N Engl J Med 2006;354:1828-1837.
Schwartz JD, Sung M, Schwartz M, et al. Thalidomide in advanced hepatocellular carcinoma with optional interferon alpha2a upon progression. Oncologist 2005;10:718-727.
Roayaie S, Schwartz JD, Sung MW, et al. Recurrence of hepatocellular carcinoma after liver transplant: patterns and prognosis. Liver Transpl 2004;10:534-540.
The discussants reply: We agree with Dr. Schwartz that bone metastases are not uncommon during the course of hepatocellular carcinoma. One study suggests that the incidence of such metastases has increased from 4.5 percent (12 of 269) among patients who received a diagnosis of hepatocellular carcinoma between 1978 and 1987 to 12.9 percent (52 of 404) among patients who received a diagnosis between 1988 and 1997.1 The increase in incidence is probably attributable to the increased duration of survival among patients with this disease and the availability of more effective therapies to treat the primary tumor. Our statement was intended to reflect the fact that bone metastases would be an unusual initial presentation of hepatocellular carcinoma, since the condition was found to be the source of metastasis in only 5 of 64 patients (7.8 percent) who presented with skeletal metastases as a primary manifestation of cancer.2 The studies cited by Dr. Schwartz involved patients with advanced or recurrent disease, which would have a higher incidence of bony metastasis in general. Indeed, we hope that our case will lead oncologists and pathologists to consider hepatocellular carcinoma in the differential diagnosis of bony metastases with adenocarcinoma of "unknown primary."
Robert P. Hasserjian, M.D.
Andrew X. Zhu, M.D., Ph.D.
Massachusetts General Hospital
Boston, MA 02114
References
Fukutomi M, Yokota M, Chuman H, et al. Increased incidence of bone metastases in hepatocellular carcinoma. Eur J Gastroenterol Hepatol 2001;13:1083-1088.
Katagiri H, Takahashi M, Inagaki J, Sugiura H, Ito S, Iwata H. Determining the site of the primary cancer in patients with skeletal metastasis of unknown origin: a retrospective study. Cancer 1999;86:533-537.