18 year old healthy male developed acute onset of anterior left knee pain after jogging. Due to ongoing pain for several weeks he was evaluated at his local ER and diagnosed with a sprain after a negative X-Ray. As pain persisted, he was then seen by an orthopedic surgeon. And presumptively diagnosed with a torn meniscus. A few weeks later, he was reevaluated at another ER where repeat X-ray revealed a pathologic fracture of the left femur.
He was transferred to our facility. CT imaging showed multiple hepatic masses with the largest measuring 9.5×7.4×8.6 cm, a destructive lesion in the left sacral ala, and an enhancing mass surrounding the proximal left femur. He underwent biopsy and intramedullary nailing of his left femur. Pathology revealed metastatic hepatocellular carcinoma (HCC). Hepatitis B and C serologies were negative, AFP of 121,000 ng/ml. He was recommended to undergo radiation to his bone metastases followed by chemotherapy.
However, he was readmitted 3 weeks later with intractable nausea, vomiting due to gastric outlet obstruction from compression by his hepatic tumor. He underwent hepatic artery chemoembolization followed by continued chemotherapy with cisplatin, doxorubicin, fluorouracil, interferon alfa-2b, and leucovorin. Follow up CT scans 2 months later showed improvement. He continued on chemotherapy for 4 months. Unfortunately, follow up CT scans showed disease progression. He was then initiated on treatment with sorafenib.
In the U.S, cancer is the leading cause of nonaccidental death among adolescents and young adults. The most common types of cancers are lymphoma, sarcoma, leukemia, and testis cancer. GI tract malignancies are rare representing only 4% of all cancers. The annual incidence of HCC in age group 15 to 19 is 1.5 per million. 5 year survival rate in this age group is only 42% as cure requires gross resection. Only 30% of tumors are found to be resectable.
Mortality and survival trends in the U.S. in adolescents with cancer have lagged behind annual improvement in the 5-year survival rate compared with other age groups. Reasons for this include delays in diagnosis due to both patient and physician factors. For physicians, adolescents are not “expected” to have cancer. As a result, clinical suspicion is low and symptoms are often attributed to physical exertion, trauma, or stress. In our patient, diagnosis, despite seeing multiple medical providers, was delayed by 5 months. Adolescents also may delay being seen by a physician or may not give an accurate account of their symptoms.
Physicians must consider cancer as a potential etiology for persistent pain even in adolescents and thus pursue a thorough diagnostic workup. We must be aware that these patients may not only present with symptoms related to their primary site of disease but like our patient have pain related to bone metastases or pathologic fracture.