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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 16  |  Issue : 2  |  Page : 137-140

HCC presenting as left breast swelling in a young patient: A case report


1 Department of Internal Medicine, Ahmadu Bello University Zaria/Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Department of Medicine, Bayero University Kano/Aminu Kano Teaching Hospital, Kano, Nigeria

Date of Submission07-Dec-2017
Date of Decision09-Jan-2018
Date of Acceptance12-Feb-2018
Date of Web Publication19-Nov-2019

Correspondence Address:
Dr. Ahmad K Bello
Department of Internal Medicine, Ahmadu Bello University Zaria/Ahmadu Bello University Teaching Hospital, Zaria
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njbcs.njbcs_39_17

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  Abstract 


Hepatocellular carcinoma (HCC) is a leading cause of cancer-related deaths seen more in males than females. Risk factors include hepatitis B viral infection and aflatoxin contaminated food products. Metastatic lesions are common to the lungs, skull, para-aortic lymph node, bone, and adrenal glands. Breast metastasis are rare with few reported cases worldwide. We present a case of HCC with metastasis to the left breast. HCC should be considered as a differential in patients with unilateral gynaecomastia, particularly in patients with risk factors for chronic liver disease.

Keywords: Breast swelling, case report on HCC, HCC in a young Nigerian, metastasis


How to cite this article:
Bello AK, Borodo MM. HCC presenting as left breast swelling in a young patient: A case report. Niger J Basic Clin Sci 2019;16:137-40

How to cite this URL:
Bello AK, Borodo MM. HCC presenting as left breast swelling in a young patient: A case report. Niger J Basic Clin Sci [serial online] 2019 [cited 2019 Dec 8];16:137-40. Available from: http://www.njbcs.net/text.asp?2019/16/2/137/271003




  Introduction Top


Hepatocellular carcinoma (HCC) is a primary tumor of the liver which develops in a setting of cirrhosis. It is the world's most common cancer in males, probably only rivalled by cancer of the prostate, the third leading cause of cancer-related deaths, and the fifth most common cancer worldwide.[1] HCC is prevalent in Africa and Asia where the incidence is up to 500 cases per 100,000 population. This is because of the high rate of infection with hepatitis B in these regions. The peak age of incidence is in the 5th to 6th decades of life in USA and Europe but occurs 10 to 20 years earlier in Asia and Africa.[1] Risk factors for HCC are development of liver cirrhosis from any cause, infection with hepatitis B virus, hepatitis C virus, and aflatoxin contaminated foodstuff. Others are obesity, use of contraceptive pills, nonalcoholic steatohepatitis (NASH), and diabetes mellitus (DM).

HCC is usually diagnosed late due to the absence of pathognomonic symptoms, and the large functional reserve of the liver at which symptoms only appear after significant liver destruction has occurred or is only diagnosed after the appearance of a distant metastatic lesion.

Clinical presentation is usually with malaise, progressive weight loss, right upper quadrant pain, abdominal swelling, anorexia, early satiety, and nodular, tender hepatomegaly in advance stage, among others.

The diagnosis of PLCC can be made with imaging such as abdominal ultrasound, abdominal CT scan, and angiography. The Korean liver cancer study group showed high sensitivity and specificity in accuracy of clinical diagnostic criteria for HCC.[2] Liver biopsy is also used with better yield when ultrasound guidance is employed, though the fear of seeding and excessive bleeding into the liver because of deranged clotting factors may limit its use. In Nigeria, most patients present late, usually with hemorrhagic ascitis, hepatic encephalopathy, prolonged prothrombin time, thrombocytopenia, or with metastatic lesions.

Tumor markers are also used with varying sensitivity, such as alfa-feto protein (α-FP), which is the most readily available and is also used for diagnosis with varying sensitivity. Others are CD 34, anti-P53, and glypican.

Metastatic lesions are common to the lungs, skull, para-aortic lymph node, bone, adrenal glands, etc. Unilateral breast swelling is neither a feature of hepatic malignancy nor is it a common metastatic site. We, therefore, present a case of PLCC in a young Nigerian with metastasis to the left breast.


  Case Report Top


A 29-year-old university undergraduate presented to us with a 3-month history of a left breast swelling which progressively increased from the size of a pea to a sizable swelling [Figure 1]. There was no history of pain over the mass, nipple discharge, rash, or retraction. He had no history of radiation therapy or family history of breast cancer. He had not given much attention to the breast mass until recently when its size was socially embarrassing. There was no history of jaundice, right-sided abdominal pain or swelling, no history of surgery nor of blood transfusion, and no alcohol ingestion. He had traditional circumcision, and scarification marks on his face done by traditional barbers during childhood. He had lost some weight in the past one month despite good appetite. Three years previously he had tested positive to HBsAg, with normal liver function tests at the university clinic on routine screening without follow-up.
Figure 1: Unilateral breast swelling in the young man

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On examination, he was afebrile (temperature, 36.6°C), wasted, anicteric, with no peripheral stigmata of chronic liver disease.

The left breast was enlarged, firm, nontender, measuring 6 cm × 4 cm in size, no skin discoloration, no tethering, no nipple retraction or discharge, and not fixed to underlying tissues [Figure 1].

The abdomen was full, soft, with mild tenderness over the right hypochondrium on deep palpation. Liver was enlarged 2 cm below the right costal margin, firm in consistency, mildly tender, but no bruit. Spleen and kidneys were not palpably enlarged, and there was no ascitis. Examination of the other systems was unremarkable.

HBsAg was reactive, with HBV DNA level of 241,000 copies/ml. Anti-HCV was not reactive. Liver function test was minimally deranged [AST – 16 IU/L (0–12) IU/L, ALT – 21 IU/L (0–12) IU/L, total bilirubin <17 umol/L]. His clotting profile was deranged, with prothrombin time of 17 s (control, 12 s), KCCT - 39 s (control, 35 s). Complete blood count showed HCT 32.2%, Platelet count 200 × 109/L, WBC 5.6 × 109/L, lymphocytes 30.5%, granulocytes 62.7%. He was found to have α-fetoprotein (AFP) level of 953 ng/mL. Abdominal ultrasound revealed mild hepatomegaly measuring 16.5 cm, with increased echogenicity. There was an echogenic mass seen in segment VI, measuring 5.62 cm × 4.15 cm in dimension with a right pleural effusion. Abdominal CT scan [Figure 2] showed an irregular isodense mass in the right lobe of the liver with inhomogeneous enhancement measuring 5.8 cm × 4.6 cm in dimension. The left lobe of the liver appeared preserved. The gallbladder, spleen, pancreas, kidneys, ureters, and urinary bladder appeared normal. No ascites or lymphadenopathy was noted. There was a right-sided pleural effusion, with a conclusion of liver cell tumor (PLCC) with right pleural effusion. Left breast ultrasound [Figure 3] showed increase in the size of the fibroglandular tissue which was hypoechoic at the centre, measuring 7.83 cm × 3.2 cm with axillary lymph nodes. Mammography [Figure 4] revealed a dense well-defined hypoechoic mass within the left breast, but no microcalcification were seen within the mass. The right breast tissue appears grossly normal. The conclusion was that of a mastopathic breast in a male (BRADS 2) from systemic disease.
Figure 2: Abdominal CT scan showing the liver mass

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Figure 3: Left breast ultrasonography

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Figure 4: Mammogram of the left breast

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  Discussion Top


The Korean Liver Cancer Study Group and the National Cancer Center (KLCSG/NCC) and National Comprehensive Cancer Network (NCCN)[2] guidelines showed high sensitivity and specificity of clinical diagnostic criteria in HCC diagnosis in HBV endemic areas. The method of diagnosis of HCC in this case from Nigeria, an area of HBV high endemicity was the use of KLCSG/NCC guidelines of typical abdominal ultrasound features, CT scan features, together with the high α-FP level. In addition, the patient had deranged liver function test, high HBV viral load, and deranged clotting factors. He, however, declined liver and breast biopsy for histologic examination.

Studies from tropical Africa have reported that HCC occurs in the age range of 20–49 years and that liver cancers are more common in males than in females with a M:F of 2:1.[3],[4],[5] These are the age range and gender group the index case belonged to.

Many risk factors are associated with the development of HCC, among which are chronic HBV infection, HCV infection, and aflatoxin B from contaminated food substances (nuts, grains, vegetables, etc.). Of these, chronic hepatitis B was established in the index case, but he had no HCV or history of alcohol ingestion. Although exposure to aflatoxin was not noted, there are several studies in the geopolitical zone of the index case where this risk factor is known to exist at high levels. Nigerian studies have shown high levels of aflatoxin B in vegetables, grains, and spices greater than 20 ug/kg which is far beyond the safe level allowed.[6],[7],[8],[9] Aflatoxin, together with HBV, are known additive factors in HCC development.

AFP, a tumor marker used in both screening and diagnosis of HCC, is elevated in up to 80% of HCC cases. A serum AFP level of greater than 400 ng/ml has a 95–100% specificity for HCC when associated with imaging (ultrasound, CT scan) evidence of liver masses.[10],[11],[12] In the index case, AFP level was 953 ng/ml together with ultrasound and CT scan evidence of liver masses, and high HBV viral load are considered supportive of the diagnosis of HCC.

HCC is a highly invasive tumor, with distant metastasis being important mode of presentation. The most common sites of metastasis being the lungs, lymph node, skull, kidney, and adrenals.[13] HCC spreads to distant sites hematogenously through the hepatic or portal vein, or via lymphatic involvement or by direct invasion of adjacent tissues. The pleural effusion seen in this case may have been because of direct infiltration of the adjoining diaphragm with spread to the pleura. The involvement of the left breast, as seen in the reported case, may have been via thoraco-epigastric veins which drain in to the axillary vein or through the lymphatics. Chung et al., in their imaging findings of metastatic disease to the breast, reported well-defined, noncalcific mass with axillary node involvement in some of their hematogenous and lymphangitic metastasis cases similar to what was found in our case.[14]

The breast is a rare site of metastasis from HCC, with only few studies reporting breast metastasis from HCC worldwide. It usually presents as a rapidly growing, firm mass, which is well-circumscribed, painless, and mobile. To our knowledge, this is the first case report on breast metastasis from HCC in Nigeria.


  Conclusion Top


HCC presents late and usually at an advanced stage. It should be noted that metastasis may also occur at unusual sites such as the breast. We, therefore, recommend that evaluation of patients with breast swelling should also include abdominal ultrasound, AFP, and hepatitis viral screening, especially where no clinical features of or risk factors for breast cancer exist.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Parkin DM. The global health burden of infection-associated cancers in the year 2002. Int J Cancer 2006;118:3030-44.  Back to cited text no. 1
    
2.
Yoon JH, Park JW, Lee JM. Noninvasive Diagnosis of Hepatocellular Carcinoma: Elaboration on Korean Liver Cancer Study Group-National Cancer Center Korea Practice Guidelines Compared with Other Guidelines and Remaining Issues. Korean J Radiol 2016;17;1:7-24.  Back to cited text no. 2
    
3.
Vhriterhire RA, Ngbea JA, Ojo BA, Jegede OO, Manasseh AN, Ayuba MD, et al. Hepatocellular carcinoma sub-types in North-Central Nigeria: A Histological Review of Liver Biopsies. Br J Med Med Res 2016;12:1-8.  Back to cited text no. 3
    
4.
Seleye-Fubara D, Jebbin NJ. Hepatocellular carcinoma in Port Harcourt, Nigeria: Clinicopathologic study of 75 cases. Ann Afr Med 2007;8:554-57.  Back to cited text no. 4
    
5.
Sylvester CN, Uchenna NI, and Olive O. Liver Cancer in Enugu, South East Nigeria. Insight Bioinformatics 2011:1;1;1-5.  Back to cited text no. 5
    
6.
Makun HA, Apeh DO, Adeyemi HRY, Tahir N, Okeke JO, Mustapha AS, et al. Determinants of Aflatoxin in Sesame, Rice, Millet, and Acha fron Nigeria using HPLC. Chem Sci Trans 2014;3:1516-24.  Back to cited text no. 6
    
7.
Atehnkeng J, Ojiambo PS, Donner M, Ikotun T, Sikora RA, Cotty PJ, et al. Distribution and toxigenicity of Aspergillus species isolated from maize kernels from three agro-ecological zones in Nigeria. Int J Food Microbiol 2008:122;74-84.  Back to cited text no. 7
    
8.
Adetunji MC, Atanda OO, Ezekiel CN, Dipeolu AO, Uzochukwu SV, Oyedepo J, et al. Distribution of Mycotoxins and Risk Assessment of Maize Consumers in Five Agro-ecological Zones of Nigeria. Eur Food Res Technol 2014:239:287-96.  Back to cited text no. 8
    
9.
Shehu K, Bello MT. Effect of environmental factors in the growth of Aspergillus species associated with stored millet grains in Sokoto. Niger J Basic Appl Sci, 2011;19:218-23.  Back to cited text no. 9
    
10.
Tatsuya M, Ryosuke T, Masyuko K, Ryoo N, Naoto F, Sato M, et al. Serum Alpha-fetoprotein has High Sensitivity for the early Detection of Hepatocellular Carcinoma after Hepatitis C Virus Eradication in Patients. Med 2015;94:1-6.  Back to cited text no. 10
    
11.
Colli A, Frequelli M, Casazza G, Massivoni S, Collucci A, Conte D, Duca P. Accuracy of Ultrasonography, Spiral CT, MRI, and Alpha-Fetoprotein in Diagnosing Hepatocellular Carcinoma: A Systemic Review. Am J Gastroenterol 2006;101:513-23.  Back to cited text no. 11
    
12.
Eldad SB, Adrian MD. Diagnosis of Hepatocellular Carcinoma. HPB 2005;7:26-34.  Back to cited text no. 12
    
13.
Annalisa KB, Tso DK, Alison CH, Mayfair D, Chang SD. Extrahepatic Metastasis of Hepatocellular Carcinoma: A Spectrum of Imaging Findings. Can Assoc Radiol J 2014;65:60-66.  Back to cited text no. 13
    
14.
Chung SY, Ki K. Oh. Imaging Findings of Metastatic Disease to the Breast. Yonsei Med J 2001:42:497-502.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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