S5627 Hepatocellular Carcinoma With Metastasis to the Pancreas: A Rare Occurrence

Introduction: Hepatocellular carcinoma (HCC) represents a primary liver malignancy originating in hepatocytes and is the most common liver tumor. The top 3 sites HCC typically metastasizes to are the lungs, regional lymph nodes, and bone. Rare sites of metastasis have been reported. This case details a rare occurrence in which HCC metastasized to the pancreas. Case Description/Methods: A 66-year-old man, with a history of diffuse large B-cell lymphoma in remission, presented with worsening abdominal pain and a 20-pound weight loss. Initial imaging revealed an 8 cm pancreatic head mass with multiple masses in the left lobe of the liver. Initial labs were notable for alkaline phosphatase 367 U/L, aspartate aminotransferase 300 U/L, alanine aminotransferase 56 U/L, and Lipase 196 U/L. CA 19-9 30, CEA <1.7, CA 125 846, AFP 47, 468. Endoscopic ultrasound with fine needle biopsy of both the pancreatic mass and one of the liver masses was performed. Pathology revealed HCC with metastasis to the pancreas. He had frequent admissions due to significant abdominal pain and was eventually stabilized to receive Cycle 1 of treatment with durvalumab and tremelimumab which he initially tolerated well. He re-presented 4 days later with significant abdominal pain and shock of unknown origin. Initial infectious workup was negative, imaging revealed significant interval enlargement of the hepatic lesions and retroperitoneal adenopathy. He continued to deteriorate and developed disseminated intravascular coagulation (DIC) with increasing vasopressor requirements. Despite supportive transfusions, vasopressors, and continuous renal replacement (CRRT) the patient expired shortly after readmission. Discussion: HCC imparts a significant disease burden and represents a leading cause of cancer-related deaths. HCC commonly presents in patients with underlying liver disease, such cirrhosis, and is typically asymptomatic at presentation. When symptomatic, it is usually due to sequelae of liver dysfunction or cancer related abdominal pain. Extrahepatic metastasis is present in 5-15% of cases at time of diagnosis. Pancreatic metastasis from HCC is a rare phenomenon with only a handful of case reports in the literature. With the presentation of masses in both the pancreas and liver, typically it is assumed that the primary malignancy is from the pancreas with metastasis to the liver. While rare, it is important to keep a high clinical suspicion for the potential of HCC as the primary malignancy in patients presenting with both hepatic and pancreatic lesions.