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  Table of Contents  
LETTER TO THE EDITOR
Year : 2016  |  Volume : 53  |  Issue : 1  |  Page : 85-86
 

Isolated hepatic tuberculosis masquerading as hepatic metastasis in a patient with Ewing's sarcoma of fibula


1 Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
2 Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India

Date of Web Publication28-Apr-2016

Correspondence Address:
A Gulia
Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.180838

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How to cite this article:
Gulia A, Pai V, Puri A, Chinnaswamy G. Isolated hepatic tuberculosis masquerading as hepatic metastasis in a patient with Ewing's sarcoma of fibula. Indian J Cancer 2016;53:85-6

How to cite this URL:
Gulia A, Pai V, Puri A, Chinnaswamy G. Isolated hepatic tuberculosis masquerading as hepatic metastasis in a patient with Ewing's sarcoma of fibula. Indian J Cancer [serial online] 2016 [cited 2019 Sep 15];53:85-6. Available from: http://www.indianjcancer.com/text.asp?2016/53/1/85/180838


Sir,

Oncologists have a natural tendency to suspect metastasis, in a patient with malignancy, who develops a visceral lesion. In a country like India, where tuberculosis is highly prevalent, it is imperative for doctors to exercise extreme caution, while evaluating an uncommon site of “visceral metastasis.” Here, we present a unique instance where an isolated hepatic lesion in a boy with Ewing's sarcoma was highly suspicious of a metastatic lesion.

A 14-year-old boy presented with a history of pain and swelling in the right leg of 3 months duration. He was further evaluated with radiograph and magnetic resonance imaging, raising the suspicion of Ewing's sarcoma of right proximal fibula. The histopathological diagnosis of Ewing's sarcoma was confirmed with a core needle biopsy. Whole body positron emission tomography-computed tomography (PET-CT) evaluation, done as part of staging protocol, revealed a hepatic caudate lobe lesion of size 2.4 cm × 1.4 cm with maximum standardized uptake value (SUVmax) of 6.75 (SUVmax of primary 10.54) [Figure 1]. This lesion although isolated was suspicious of hepatic metastasis. Multiple attempts by image-guided biopsy failed to demonstrate any evidence of malignancy. Hence, patient was given the “benefit of the doubt” and was labeled as nonmetastatic. He received 12 weeks of induction chemotherapy and subsequently underwent surgical excision of proximal fibula. Patient further received 26 weeks of adjuvant chemotherapy in accordance with the standard chemotherapy protocol of the institute for Ewing's sarcoma. A whole body PET-CT evaluation was carried out at the end of therapy, and this revealed the hepatic lesion to have significantly increased in size (3.7 cm × 3.2 cm with SUVmax of 15). There were no other suspicious lesions detected. Patient was subjected to a repeat image-guided biopsy of the hepatic lesion, which now revealed a granulomatous lesion suggestive of tuberculosis. The diagnosis of tuberculosis was further supported by a positive Quanti FERON-TB Gold test and positive Mantoux (25 mm × 25 mm). Patient was treated with standard antitubercular treatment for 9 months. Patient was last evaluated 6 months after completion of therapy for tuberculosis and continues to be in remission from the malignancy with a significant regression of the hepatic lesion.
Figure 1: (a and b) Positron emission tomography scan images showing metabolic active lesion (black arrow) with maximum standardized uptake value of 15 in the caudate lobe of the liver. (c) Computed tomography image showing a hypo dense lesion (3.7 cm × 3.2 cm) in caudate lobe of liver suspicious of metastasis from Ewing sarcoma

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Hepatic tuberculosis has various forms as classified by Levine.[1] These are miliary tuberculosis, pulmonary tuberculosis with hepatic involvement, the primary liver tuberculosis, focal tuberculoma or abscess, or tuberculous cholangitis. Hepatic involvement as part of miliary or pulmonary tuberculosis accounts for nearly 70% of the hepatic tuberculosis seen in clinical practice. Primary liver tuberculosis is rare and constitutes <1% of all cases.[2] Since imaging characteristics are nonspecific, diagnosis can be challenging, and many times biopsy may be warranted. Standard antitubercular treatment for a period of 9 months is recommended. Prognosis of primary hepatic tuberculosis, when diagnosed early and treated appropriately, is generally good.[3] On the contrary, when liver metastases are present in a patient with Ewing's sarcoma, prognosis is dismal and at instances may not be offered curative treatment in resource limited setting.[4] Review of literature revealed case reports where in primary hepatic tuberculosis has been confused with primary hepatocellular carcinoma as well as metastasis in a known case of carcinoma tongue and Klatskin tumor.[5]

The present case is an explicit example of a rare form of tuberculosis occurring with Ewing's sarcoma of bone and masquerading as a hepatic metastasis. The case also advocates the use of whole body PET-CT in evaluation of Ewing's sarcoma to detect non skeletal sites of metastasis or rare lesions like in the present case. As oncologists, it is only natural that the suspicion of metastases in a visceral lesion remains high. Although primary hepatic tuberculosis is extremely rare, this possibility should be considered in tuberculosis endemic areas while evaluating hepatic lesions in patients with malignancy.

 
  References Top

1.
Levine C. Primary macronodular hepatic tuberculosis: US and CT appearances. Gastrointest Radiol 1990;15:307-9.  Back to cited text no. 1
    
2.
Mert A, Ozaras R, Tabak F, Ozturk R, Bilir M. Localized hepatic tuberculosis. Eur J Intern Med 2003;14:511-12.  Back to cited text no. 2
    
3.
Tan TC, Cheung AY, Wan WY, Chen TC. Tuberculoma of the liver presenting as a hyperechoic mass on ultrasound. Br J Radiol 1997;70:1293-5.  Back to cited text no. 3
    
4.
Paulino AC, Mai WY, Teh BS. Radiotherapy in metastatic Ewing sarcoma. Am J Clin Oncol 2013;36:283-6.  Back to cited text no. 4
    
5.
Hsieh TC, Wu YC, Hsu CN, Yang CF, Chiang IP, Hsieh CY, et al. Hepatic macronodular tuberculoma mimics liver metastasis in a patient with locoregional advanced tongue cancer. J Clin Oncol 2011;29:e641-3.  Back to cited text no. 5
    


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