Hepatocellular carcinoma in variegate porphyria: a case report and literature review.

Variegate porphyria is an autosomal dominant acute hepatic porphyria characterized by photosensitivity and acute neurovisceral attacks. Hepatocellular carcinoma has been described as a potential complication of variegate porphyria in case reports. We report a case of a 48-year-old woman who was diagnosed with hepatocellular carcinoma following a brief history of right upper quadrant pain which was preceded by a few months of blistering lesions in sun-exposed areas. She was biochemically diagnosed with variegate porphyria, and mutational analysis confirmed the presence of a heterozygous mutation in the protoporphyrinogen oxidase gene. Despite two hepatic resections, she developed pulmonary metastases. She responded remarkably well to Sorafenib and remains in remission 16 months after treatment. A review of the literature revealed that hepatocellular carcinoma in variegate porphyria has been described in at least eight cases. Retrospective and prospective cohort studies have suggested a plausible association between hepatocellular carcinoma and acute hepatic porphyrias. Hepatic porphyrias should be considered in the differential diagnoses of hepatocellular carcinoma of uncertain aetiology. Patients with known hepatic porphyrias may benefit from periodic monitoring for this complication.

Cascade testing of primary care blood samples with hyperferritinaemia identifies subjects with iron overload and porphyria cutanea tarda.

INTRODUCTION: Serum ferritin is routinely used as a first line test for iron status. Testing subjects with low pre-test probability often results in unexpected abnormal results. Raised ferritin is typically found in subjects with iron overload, liver disease, malignancy or inflammation. We sought to determine whether primary care patients with high ferritin had either porphyria cutanea tarda (PCT) or hereditary haemochromatosis (HH). METHODS: Redundant serum samples were collected from consecutive specimens with high ferritin (>500 µg/L) which had been received from primary care sources. Samples were analysed for serum iron and iron-binding capacity and for porphyrins by fluorescence scanning and HPLC. RESULTS: There were 240 samples (91 females, 149 males) which represented 2.7% of total over the collection period. Serum iron was 17.3 (18.9) µmol/L (median (IQR)), TIBC 47.3 (14.2) µmol/L and transferrin saturation 35.7 (41.1) %. There were 87/240 (36%) with transferrin saturation >45% (57 males, 30 females). Of the samples 19/236 (8%) were positive for porphyrins by spectrofluorimetry and 14/15 (4 insufficient sample) had total porphyrins >11.2 nmol/L (40(63) median (IQR)) with 3/15 (1.25%) having a typical pattern for PCT. DISCUSSION: This study demonstrates the feasibility of cascading tests using laboratory protocols and confirms the ability to identify potential cases. However, further studies for HH genotype and urine and stool porphyrin analysis will be necessary to confirm the diagnoses.

Measurement of plasma 5-hydroxyindole acetic acid by liquid chromatography tandem mass spectrometry--comparison with HPLC methodology.

In patients with carcinoid disease, urinary concentration of the serotonin metabolite 5-hydroxyindole acetic acid (5-HIAA) is currently used to monitor disease progression or response to treatment as it is the metabolic end-product resulting from free and stored serotonin turnover. However, due to the undignified, cumbersome and error-prone nature of 24-h urine collections, there is constant pressure to replace them. It has been demonstrated using high performance liquid chromatography (HPLC) with fluorescence detection technology that plasma can achieve this, with the added advantage that it can be used for diagnostic purposes also. Here we describe a much simpler method using liquid chromatography-tandem mass spectrometry (LC-MS/MS) that is twice as fast as a HPLC method currently in routine use. The sample preparation protocol requires 50 micorL of plasma and a simple protein precipitation step facilitated by acetonitrile. Chromatography was performed on a Phenomenex C18 Security Guard column coupled to a SIELC Primesep B reversed-phase, anion-exchange dual chemistry column and methanolic mobile phase gradient elution. Eluant was directly connected to a Waters Quattro Premier XE tandem mass spectrometer operating in positive ion mode. We detected multiple reaction monitoring transitions m/z 191.9>145.6 and 193.9>147.6 for 5-HIAA and d2-5-HIAA respectively, which co-eluted at 2.1 min. Ion suppression was negligible, recovery from spiked plasma was 103% (range 97-113%) and the method showed good linearity to 10,000 nmol/L (r(2)=0.999). Within-batch and between-batch imprecision was <10% and bias <15% at 3 concentrations, the limit of detection was 5 nmol/L and lower limit of quantitation 15 nmol/L. No interference was observed with l-tryptophan or 5-hydroxytryptamine. Comparison of LC-MS/MS and HPLC showed good agreement between the two methods but this LC-MS/MS assay displays several advantages; it requires 10-fold less sample, has a simpler extraction procedure and extended linearity, thus increasing laboratory throughput, lowering reagent costs and removing the need to dilute samples in patients with established carcinoid disease being monitored for therapeutic efficacy.