This is a 72-year-old male patient diagnosed with liver cirrhosis secondary to HCV infection in close follow-up in Hepatology clinics of our center since 2000.
He was infected with genotype 1b and had not received antiviral treatment in the past because the patient refused to receive interferon therapy.
Among its other most relevant medical history, surgical intervention in childhood of a patent ductus arteriosus, the presence of a paroxysmal atrial fibrillation, placement of two conventional coronary stents in 2004 indicated for aortic valve replacement in 2013 stood out.
In addition, he had presented in 2007 and 2013 episodes of acute cerebrovascular accidents without subsequent sequelae and was diagnosed with chronic obstructive pulmonary disease with moderate impairment.
In May 2014, in the context of a screening test for hepatocellular carcinoma, a liver magnetic resonance was performed, which found a 25 x 17 mm lesion in the hepatic segment VI suggestive of hepatocellular carcinoma.
Radiofrequency ablation was chosen as treatment, achieving a complete radiological response on magnetic resonance imaging performed four weeks after treatment.
The patient was then submitted to clinical and radiological follow-up, performing imaging tests every three months with no evidence of tumor recurrence.
In May 2015, the patient started treatment with ledipasvir/antiviral magnetic resonance imaging (MRI) 2 90/400 mg once daily for 12 weeks, after documenting the absence of tumour disease.
The patient completed treatment without presenting adverse events or complications and achieved virological response at 12 and 24 weeks after the end of treatment.
In October 2015 a new liver magnetic resonance imaging was performed, which showed the area of the liver tumor treated with radiofrequency without contrast uptake and without other data to guide tumor recurrence.
However, three months later it was decided to perform a new magnetic resonance imaging, in which multiple hypointense lesions appeared in T1 and slightly hyperintense lesions in T2 of small size throughout the liver parenchyma, suggesting some peripheral metastases.
The zone of segment VI where radiofrequency had been applied in the past remained without signs of tumor recurrence.
At that time, the hypothesis of a possible tumor recurrence with aggressive behavior of the previous hepatocellular carcinoma was one of the most probable diagnoses, although the radiological behavior also led to suspicion that it was metastasis from an unknown primary tumor.
Therefore, it was decided to perform a needle aspiration biopsy of the liver lesions for cytological analysis, which showed metastatic cells from a small cell neuroendocrine carcinoma (CD56+).
Subsequently, a computerized axial tomography of the cervix-thoraco-abdominal was performed to complete the study, where lesions were visualized at the level of dorsal vertebral bodies and lumbosacral metastasic, suggesting disease.
Bone scintigraphy and magnetic resonance imaging of the spine performed later confirmed the CT findings.
To date, primary tumor location has not been found, although the hypothesis of a microcytic lung carcinoma with metastatic involvement is the most probable diagnosis.
At present, the patient is receiving chemotherapy based on a consistent regimen consisting of bone and bone metastases and has received radiotherapy for pain control secondary to spinal metastases, with good clinical response.
In the toraco-abdominal axial tomography performed six months after the beginning of the chemotherapy treatment, most of the metastatic hepatic and bone lesions persist, only a few millimetric hepatic nodules persist.
Given the good response, a new cycle of cancer treatment has been restarted, whose results will be evaluated in the near future.
