Manifestations of hypercholesterolaemia, hypoglycaemia, erythrocytosis and hypercalcaemia in patients with hepatocellular carcinoma: report of two cases

Paraneoplastic Syndromes in Hepatocellular Carcinoma, Epidemiology, and Survival: A Retrospective Seven Years Study

Background and Objectives: Liver cancer poses a significant global health threat, ranking among the top three causes of cancer-related deaths. Patients with hepatocellular carcinoma (HCC) often present with symptoms associated with neoplasms or unusual clinical features such as paraneoplastic syndromes (PNS), including hypoglycemia, hypercholesterolemia, thrombocytosis, and erythrocytosis. Our study aimed to investigate the prevalence, clinical characteristics, and survival outcomes associated with PNS in HCC patients and assess each PNS's impact on patient survival. Materials and Methods: We conducted a retrospective analysis of PNS clinical features and survival among consecutive HCC patients diagnosed at our department over seven years, comparing them with HCC patients without PNS. The study involved a retrospective data evaluation from 378 patients diagnosed with HCC between January 2016 and October 2023. Results: We obtained a PNS prevalence of 25.7%, with paraneoplastic hypercholesterolemia at 10.9%, hypoglycemia at 6.9%, erythrocytosis at 4.5%, and thrombocytosis at 3.4%. Patients with PNS tended to be younger and predominantly male. Multivariate analysis revealed a strong correlation between PNS and levels of alpha-fetoprotein and tumor size, with diabetes also showing a significant statistical association (p < 0.05). Subgroup analysis based on specific paraneoplastic syndromes demonstrated shorter survival in patients with PNS, albeit without significant statistical differences, except for hypoglycemia (p < 0.0001). Matched analysis indicated a shorter survival rate for patients with PNS, although no significant statistical differences were observed. Conclusions: PNS are frequently observed in HCC cases and are associated with unfavorable prognoses and decreased survival rates due to their correlation with increased tumor burdens. However, they do not independently predict poor survival. The impact of individual PNS on HCC prognosis varies.

Paraneoplastic syndromes in hepatocellular carcinoma: a review

INTRODUCTION

Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide, and a significant proportion (20-40%) of patients with HCC develop paraneoplastic syndromes (PNS). Despite this, there is a paucity of clinical evidence regarding PNS in HCC.

AREAS COVERED

A systematic search was performed to identify relevant case studies regarding PNS in HCC. Another search was conducted to identify studies that evaluated the impact of PNS on survival outcomes in HCC. Since there are currently no international guidelines for PNS in HCC, this review aims to provide comprehensive summaries and recommendations of PNS in HCC, including the pathophysiology, clinical features, diagnostic approach, and management, so that clinicians remain guided in caring for HCC patients with PNS. In general, PNS are associated with poorer survival outcomes and negative prognostic markers of HCC.

EXPERT OPINION

The presence of PNS has a significant influence on survival rates and clinical outcomes of patients with HCC. They contribute to significant morbidity, influencing patients' quality of life and fitness for curative and palliative therapies. Therefore, it is paramount for PNS to be integrated into routine investigations after diagnosing HCC to guide further management and prognostication of the disease.

Severe hyperlipemia-induced pseudoerythrocytosis - Implication for misdiagnosis and blood transfusion: A case report and literature review

BACKGROUND

Severe hyperlipemia (SHLE) has an impact on the results of many kinds of laboratory tests. Complete blood count (CBC) examination by automated blood cell counter (ABCC) is a quick and convenient measurement for screening abnormalities of blood cells that are triggered by various pathogenic insults in disease diagnosis and for monitoring changes in the treatment of existing hematological conditions. However, CBC results are frequently affected by many intrinsic and extrinsic factors from blood samples, such as in the setting of hypergammaglobulinemia and certain anticoagulants. SHLE could also affect CBC results.

CASE SUMMARY

A 33-year-old Chinese male presented with painful foot numbness and abdominal pain. He was initially misdiagnosed as having a myeloproliferative neoplasm (MPN) because of the marked abnormalities in CBC examination by the ABCC. Morphological evaluation of the bone marrow smears and biopsy showed no evidence of MPN. Gene mutations in Breakpoint cluster regions-Abelson murine leukemia viral oncogene homologue 1 (BCR-ABL1), Janus kinase 2 (JAK2), calreticulin (CALR), myeloproliferative leukemia virus (MPL), and colony-stimulating factor 3 receptor (CSF3R) were negative. Having noticed the thick chylomicron layer on blood samples and the dramatically fluctuating CBC results, we speculated that the fat droplets formed by shaking the blood samples in the setting of SHLE were mistakenly identified as blood cells due to the limited parameters of ABCC. Therefore, we removed a large part of the chylomicron layer and then reexamined the CBC, and the CBC results, as we expected, differed significantly from that of the sample before the chylomicron layer was removed. These significant differences had been validated by the subsequently repeated laboratory tests by measuring dual blood samples that the chylomicron layer was removed in one sample and was not in another, and comparing the CBC results. Computerized tomography reexamination of the upper abdomen revealed an exudative lesion surrounding his pancreas. After intensive consultation, definitive diagnosis was made as recurrent pancreatitis, hyperlipemia and pseudoerythrocytosis.

CONCLUSION

SHLE may become a potential cause of misdiagnosis of hyperlipemia-related diseases as MPNs and the resultant mistreatment. It may also lead to the misinterpretation of transfusion indications in patients with hematological disorders who critically need blood transfusion for supportive treatment.

The coexistence of hypercalcemia and hypoglycemia in a patient with a renal tumor and B cell lymphoma

Paraneoplastic syndromes are a heterogeneous group of malignant diseases caused by events which involve endocrine, immune and metabolic aspects and whose symptoms vary according to the substance produced and the primary tumor. Hypercalcemia is a frequent complication in cancer patients. Prognosis of cancer patients with hypercalcemia is usually poor. A factor called parathyroid hormone related peptide, whose actions are similar to those of the parathyroid hormone, is thought to be the most common cause of malignancy associated hypercalcemia. Non-islet hypoglycemic cell tumor consists of a rare syndrome characterized by the presence of a solid tumor and severe fasting hypoglycemia determined by an insulin-independent pathway. We report a case of a 59-year-old-man with a renal tumor and a T-cell rich large B cell lymphoma who was hospitalized due to severe hypercalcemia and hypoglycemia. The laboratory examination reported hypercalcemia with inhibited PTH and hypoglycemia with inhibited insulin secretion, arriving to the conclusion of tumoral peptide production. He received denosumab and corticoid therapy. The patient died one month later despite initial improvement after medical treatment. While a single paraneoplastic manifestation may be expected in most tumors, the coexistence of two or more of them is rare, except in hepatocellular carcinomas, and it has not yet been described in renal tumors.

Is hypoglycaemia a marker for increased long-term mortality risk in patients with coronary artery disease? An 8-year follow-up

BACKGROUND

No information is available regarding the association between low plasma glucose levels and cause-specific and all-cause mortality in patients with coronary artery disease (CAD). We aimed to investigate the relationship between hypoglycaemia and all-cause, cardiovascular and cancer mortality in a large population of patients with CAD.

DESIGN

Patients were recruited from the BIP (Bezafibrate Infarction Prevention) registry, a secondary prevention prospective multicentre randomized, placebo-controlled, double-blind trial aimed to assess the efficacy of bezafibrate in reduction of coronary events.

METHODS

The study included 14,670 CAD patients aged 45-74, divided into six groups: (1) hypoglycaemic (up to 69 mg/dl); (2) low normal (70-79 mg/dl); (3) euglycaemic (80-109 mg/dl); (4) impaired fasting glucose (IFG) (110-125 mg/dl); (5) borderline diabetics (126-139 mg/dl); (6) diabetics (> or 140 mg/dl).

RESULTS

Patients comprised 131 with hypoglycaemia (0.9%), 731 with low normal glucose (5%), 9308 euglycaemic (63.4%), 1577 with IFG (10.7%), 617 borderline diabetics (4.2%) and 2306 diabetics (15.7%). Over a mean 8-year follow-up, crude all-cause mortality was higher in both diabetic (31.8%) and hypoglycaemic groups (25.2%) as compared with euglycaemics (14.9%; P<0.0001); CAD mortality was higher in diabetic and borderline groups (17.8 and 13.3%, respectively, versus 7.9% in euglycaemics; P<0.0001). The highest prevalence of cancer mortality was documented in the hypoglycaemic group (6.1 versus 2.9% in euglycaemics; P<0.02). Actuarial survival curves showed the lowest mortality in euglycaemic and low normal groups; the highest was seen in diabetic and hypoglycaemic patients. Intermediate values were found in borderline and IFG patients. After adjustment for variables, a significantly higher mortality rate was seen in hypoglycaemics when compared with euglycaemics (P<0.0001). Hypoglycaemia was identified as a predictor of increased all-cause and cancer mortality with a hazard ratio (HR) of 1.84 [95% confidence interval (CI) 1.29-2.61] and 2.26 (95% CI 1.12-4.57), respectively, but not of increased CAD mortality, with HR 1.30 (95% CI 0.73-2.29).

CONCLUSIONS

Over a mean 8-year follow-up, hypoglycaemia emerges as a marker for substantially increased all-cause and cancer mortality among patients with CAD presenting with low fasting glucose levels.

Complete Tumor Resection for a Hepatocellular Carcinoma Secreting Parathyroid Hormone-related Peptide

Hepatocellular carcinoma (HCC) is the fifth most common cancer in Korea. Diverse paraneoplastic syndromes can occur in patients with HCC, but parathyroid hormone-related peptide (PTH-rP)-induced hypercalcemia is uncommon. Hypercalcemia due to PTH or particularly PTH-rP-secreting HCC is associated with poor outcomes. We report a 71-year-old man who presented with symptoms of vague abdominal discomfort, somnolence, lethargy, nausea, vomiting, and weight loss. Imaging studies revealed a large HCC without metastasis. The laboratory findings showed elevated serum calcium level, low intact parathyroid hormone (iPTH) level and elevated PTH-rP level. These results led to a diagnosis of a PTH-rP-secreting HCC and paraneoplastic hypercalcemia. After emergency management of the hypercalcemia, the patient underwent an extended right hemihepatectomy with cholecystectomy. One year after the surgery, he is alive with normal calcium, PTH-rP, and iPTH levels. This case demonstrates that the rare phenomenon of life-threatening hypercalcemia caused by HCC should not be overlooked. These symptoms offer a good opportunity to diagnose HCC early. Radical tumor resection makes it possible to cure patients with PTH-rP-secreting HCC.

Nanoparticle-formulated siRNA targeting integrins inhibits hepatocellular carcinoma progression in mice

Integrins play an important role during development, regulating cell differentiation, proliferation and survival. Here we show that knockdown of integrin subunits slows down the progression of hepatocellular carcinoma (HCC). Using nanoparticulate delivery of short interfering RNAs targeting β1 and αv integrin subunits we downregulate all integrin receptors in hepatocytes. Short-term integrin knockdown (two weeks) does not cause apparent structural or functional perturbations of normal liver tissue. Alterations in liver morphology accumulate upon sustained integrin downregulation (seven weeks). The integrin knockdown leads to significant retardation of HCC progression, reducing proliferation and increasing tumour cell death. This tumour retardation is accompanied by reduced activation of MET oncogene as well as expression of its mature form on the cell surface. Our data suggest that transformed proliferating cells from HCC are more sensitive to knockdown of integrins than normal quiescent hepatocytes, highlighting the potential of siRNA-mediated inhibition of integrins as an anti-cancer therapeutic approach.

Epidemiology and prognosis of paraneoplastic syndromes in hepatocellular carcinoma

Background. Paraneoplastic syndromes (PNS) such as hypercalcaemia, hypercholesterolaemia, and erythrocytosis have been described in hepatocellular carcinoma (HCC). Aims. (1) To examine the prevalence, clinical characteristics, and survival of PNS in HCC patients and (2) to evaluate the extent to which each individual PNS impacts on patient survival. Methods. We prospectively evaluated the prevalence, clinical characteristics, and survival of PNS among 457 consecutive HCC patients seen in our department over a 10-year period and compared them with HCC patients without PNS. Results. PNS were present in 127 patients (27.8%). The prevalence of paraneoplastic hypercholesterolemia, hypercalcemia, and erythrocytosis 24.5%, 5.3%, and 3.9%, respectively. Patients with PNS had significantly higher alpha-fetoprotein levels, more advanced TNM stage, and shorter survival. Among the individual PNS, hypercalcemia and hypercholesterolemia were associated with more advanced disease and reduced survival but not erythrocytosis. On multivariate analysis, the presence of PNS was not found to be an independent prognostic factor for reduced HCC survival. Conclusion. PNS are not uncommon in HCC and are associated with poor prognosis and reduced survival due to their association with increased tumor burden. However, they do not independently predict poor survival. Individual PNS impact differently on HCC outcome; paraneoplastic hypercalcemia in particular is associated with poor outcome.

Hypoglycemia, an atypical early sign of hepatocellular carcinoma

BACKGROUND

Hypoglycemia is extremely uncommon as the first presentation of hepatocellular carcinoma, and it occurs predominantly as a paraneoplastic manifestation.

METHODS

We report a case of a 38-year-old-man positive for hepatitis B surface antigen with high-serum viremia who presented with symptoms of acute severe hypoglycemia.

RESULTS

Laboratory tests confirmed hypoglycemia (serum glucose 1.54 mmol/L) with undetectable serum-C peptide (<0.5 µIU/mL) and slightly increased serum insulin concentration (35 µIU/mL). Alpha-fetoprotein serum level was 75,625 ng/mL. Abdominal ultrasonography and computed tomography revealed a big vascularized mass of 13 cm in diameter occupying most of the right lobe of the liver and an (18)F-fluoro-2-deoxy-D-glucose positron-emission tomography revealed a predominant uptake of glucose by the tumor mass.

CONCLUSIONS

These findings indicate that hepatocellular carcinoma-associated hypoglycemia may be due exclusively to increased glucose utilization by the tumor mass.

[Splenomegaly and thrombocytopenia in patients with liver cirrhosis]

BACKGROUND/AIM

Splenomegaly is a frequent finding in patients with liver cirrhosis and portal hypertension and may cause hypersplenism. The occurrence of thrombocytopenia in those patients can be considered as an event with multiple etiologies. Two mechanisms may act alone or synergistically with splenic sequestration. One is central which involves either myelosuppression because of hepatitis viruses or the toxic effects of alcohol abuse on the bone marrow. The second one involves the presence of antibodies against platelets. It also depends upon the stage and etiology of liver disease. The aim of the study was to investigate a correlation between the platelet count and spleen size and the risk factors for thrombocytopenia in patients with liver cirrhosis.

METHODS

We studied 40 patients with decompensated liver cirrhosis who were hospitalized in the Department of Gastroenterohepatology. The liver function was graded according to Child Pugh score. Spleen size was defined ultrasonografically on the basis of craniocaudal length. Suspicion of portal hypertension was present when longitudinal spleen length was more than 11 cm. Thrombocytopenia was determined by platelet count under 150,000/mL.

RESULTS

We did not find any significant correlation between hepatic dysfunction and spleen size (p = 0.9), and between hepatic dysfunction and thrombocytopenia (p = 0.17). Our study did not find any significant correlation between spleen size and peripheral platelet count (p = 0.5), but we found a significant correlation between thrombocytopenia and etiology of cirrhosis - decreased platelet count was more common among patients with cirrhosis of alcoholic etiology than in other etiologies of cirrhosis (p = 0.001).

CONCLUSION

According to our study, liver cirrhosis, portal hypertension and thrombocytopenia could be present even in the absence of enlarged spleen suggesting the involvement of other mechanisms of decreasing platelet account.

Successful Treatment in a Case of Massive Hepatocellular Carcinoma with Paraneoplastic Syndrome

Paraneoplastic syndromes of hepatocellular carcinoma (HCC) are not uncommon. However, the prognosis is poor and follow-up and improvement of paraneoplastic syndromes with treatment have been reported rarely. We report a successful case in an aged man of a massive HCC with paraneoplastic syndrome, treated by combined intraarterial chemotherapy and hepatic resection. Paraneoplastic syndrome (erythrocytosis and hyperlipidemia) was monitored throughout the treatment and erythropoietin (EPO) mRNA also was analyzed in the resected liver. The hemoglobin level and serum levels of EPO and total cholesterol (T-cho) decreased dramatically with treatment, along with a decrease in serum levels of alpha-fetoprotein and protein induced by vitamin vitamin K absence II (PIVKA-II). Semiquantitative reverse transcription polymerase chain reaction (RT-PCR) revealed that the residual cancer expressed EPO RNA but the nontumor tissue did not. This was a rare case of paraneoplastic syndrome of HCC that was treated successfully. This case indicates that paraneoplastic syndrome reflected tumor progression and that serum levels of both EPO and T-cho might be used as tumor markers.

An overview of hepatocellular carcinoma study by omics-based methods

Hepatocellular carcinoma (HCC) is one of the most deadly malignancies worldwide. Scientists have been studying the molecular mechanism of HCC for years, but the understanding of it remains incomplete and scattered across the literature at different molecular levels. Chromosomal aberrations, epigenetic abnormality and changes of gene expression have been reported in HCC. High-throughput omics technologies have been widely applied, aiming at the discovery of candidate biomarkers for cancer staging, prediction of recurrence and prognosis, and treatment selection. Large amounts of data on genetic and epigenetic abnormalities, gene expression profiles, microRNA expression profiles and proteomics have been accumulating, and bioinformatics is playing a more and more important role. In this paper, we review the current omics-based studies on HCC at the levels of genomics, transcriptomics and proteomics. Integrating observations from multiple aspects is an essential step toward the systematic understanding of the disease.

Hypoglycaemia in patients with liver diseases administered levothyroxine

OBJECTIVE

Experience of a few hypoglycaemic patients with liver disease and receiving levothyroxine suggested to us that the prevalence of hypoglycaemia might be higher in such patients. The purpose of this study was to ascertain whether the prevalence of hypoglycaemia this was actually the case.

METHODS

This study was a retrospective, cross-sectional analysis of a medical computerized database and/or written reports from our university hospital. Patients with primary liver disease who were admitted to our hospital between April 1998 and August 2000 were divided into two groups; the first group received levothyroxine and the second group did not. The patients in the second group were selected from three different time periods within the period shown. The prevalence of hypoglycaemia (blood glucose level <70 mg/dL) was compared between the two groups.

RESULTS

The prevalence of hypoglycaemia was significantly higher in the group receiving levothyroxine compared with the group not receiving levothyroxine (four of eight patients (50.0%) vs. three of 59 (5.1%), P = 0.003, Fisher's exact test).

CONCLUSIONS

The results suggest that levothyroxine may be a risk factor for hypoglycaemia in patients with liver disease. While a larger study, perhaps with an alternative study design is needed to confirm this, and to investigate possible mechanisms of effect, it would be prudent to monitor the blood glucose level of such patients closely.

Prevalence of Metastases in Hepatocellular Carcinoma: Risk Factors and Impact on Survival

The purpose of this study was to determine the prevalence and risk factors of metastases in hepatocellular carcinoma (HCC) patients and analyze the effects of different locations of metastases on survival. Retrospective analysis was performed on 347 HCC patients who received a metastatic workup including bone scan and computed tomography scans of chest, abdomen, and pelvis. Clinical and tumor characteristics were evaluated as risk factors for metastasis by univariate and multivariate methods. Survival was analyzed by Kaplan-Meier and Cox regression methods. One hundred forty-five patients had metastases: 71 had thoracic, 57 had abdominal, and 34 had bone metastases. Significant differences were noted with weight loss, hepatitis C, tumor grade, tumor multifocality, size, and alkaline phosphatase levels between the metastases group and the nonmetastases group by univariate analysis. Poor differentiation, multilobar spread, and size (≥5 cm) were strongest predictors of metastatic disease by logistic regression. Patients with thoracic metastases had significantly poorer survival. HCC metastasis is prevalent on initial presentation. Evaluation for liver transplantation or curative resection requires a full metastatic workup. Poor differentiation, larger tumors, and those with multilobar spread have increased risk for metastasis. Patients with thoracic spread have poor prognosis as compared to other locations of metastasis.

Paraneoplastic hypoglycemia associated with a hepatic hemangiopericytoma

Hepatic hemangiopericytomas are rare vascular tumors that may be associated with profound hypoglycemia. Although this tumor is more likely to arise in the lower extremities, pelvis, or retroperitoneum, it may very rarely arise in the liver. Unlike other vascular liver tumors, hemangiopericytomas are frequently large at the time of appearance and may have characteristic imaging features. We present the correlative imaging findings in a patient who had a large symptomatic hepatic hemangiopericytoma that produced intractable and ultimately terminal hypoglycemia. Although hemangiopericytomas seldom occur in the liver, the associated hypoglycemia that is known to occur may suggest the diagnosis and may help in differentiating the mass from other large vascular tumors of the liver.