Intractable bleeding from solitary mandibular metastasis of hepatocellular carcinoma

A Rare Case of Isolated Hepatocellular Carcinoma Metastasis in Left Mandibular Region in a Patient with Hepatitis C Virus Liver Cirrhosis Diagnosed after the Onset of COVID-19 Infection

Background and Objectives: Hepatocellular carcinoma (HCC) most frequently metastasizes in the lungs, abdominal lymph nodes and adrenal glands. Metastatic spread to the head and neck area is extremely rare. In the presented case, an uncommon site of solitary metastatic spread of HCC to the mandible confirmed after the core biopsy of the lesion is reported. There have been only about 80 cases of mandibular HCC metastases described in the literature to date. We contribute our experience to the pool of data. Case presentation: A 65-year-old female with HCV-related liver cirrhosis was diagnosed with an HCC that was successfully treated with liver resection. Subsequently, the patient had developed COVID-19 disease, which was associated with a painless swelling in the left jaw. A neck MDCT scan demonstrated an osteolytic soft-tissue mass in the left mandible, with the characteristics consistent for the metastasis of HCC. In order to confirm the diagnosis, a core biopsy of the mandibular mass was performed. The pathohistological evaluation confirmed the presence of a metastatic HCC in the mandible. No other sites of disease dissemination were identified in extensive MDCT scans. Despite considering various treatments, including symptomatic and palliative, the patient's overall prognosis remained poor. Conclusions: Isolated metastases of HCC to the orofacial region are extremely rare; however, it should be considered in patients with known risk factors for HCC development. Early diagnosis is critical, and clinicians should consider this possibility of HCC spread when assessing patients with orofacial swelling, among those patients with risk factors for HCC. The overall prognosis for such patients remains poor, emphasizing the challenges in managing these cases.

Hidden colon adenocarcinoma diagnosed from mouth metastasis: case report and literature review

BACKGROUND

We report an unusual case of metastatic colon adenocarcinoma to the maxilla as an initial clinical sign of the disease, this being the second case reported in the palate. In addition, we show an extensive review of the literature, with clinical cases of adenocarcinoma with metastasis to the mouth.

CASE PRESENTATION

An 80-year-old man complained of "swelling on the palate" with a 3-week evolution time. He reported suffering from constipation and high blood pressure. The intraoral examination revealed a pedunculated, red, and painless nodule on the maxillary gingiva. Under the diagnostic hypotheses of squamous cell carcinoma and malignant neoplasm of the salivary gland, an incisional biopsy was performed. Microscopically, the columnar epithelium was observed forming papillary areas, neoplastic cells with prominent nucleoli, hyperchromatic nuclei, atypical mitotic figures, and mucous cells, being positive for CK 20, suggesting the provisional diagnosis of metastatic adenocarcinoma, probably of gastrointestinal origin. The patient was submitted to endoscopy and colonoscopy exams, and a lesion in the sigmoid region of the colon was observed. After a colon biopsy, a moderately differentiated adenocarcinoma was confirmed, establishing the final diagnosis of metastatic neoplasia of colon adenocarcinoma to the oral lesion. The literature review revealed 45 clinical cases of colon adenocarcinoma with metastasis to the oral cavity. To the best of our knowledge, it is the second case on the palate.

CONCLUSIONS

Colon adenocarcinoma with metastasis to the oral cavity is rare but should be included in the differential diagnosis of neoplasms of the oral cavity, even when there are no known primary tumors in some cases, and this may be the first indication of the presence of a tumor.

Radiotherapy for mandibular metastases from hepatocellular carcinoma: a single institutional experience

Purpose

A mandibular metastasis is uncommon in patients with hepatocellular carcinoma (HCC). We report the clinical features of this rare lesion and evaluate the effectiveness of radiotherapy in affected patients.

Materials and Methods

We retrospectively reviewed our institutional medical records for HCC patients who received radiotherapy for bone metastasis, and included cases of mandible metastasis. The clinical features of these cases, and the characteristics and outcomes of the treatments were assessed.

Results

A total of 1,498 patients with a bone metastasis from HCC were treated with radiotherapy between July 1998 and April 2012 at our institution. We identified 9 patients (0.6%) in this cohort that received radiotherapy for a mandibular metastasis. The condyle was the most common location of mandibular metastasis. The median radiation dose was 40 Gy (range, 27.5 to 60 Gy), with a daily dose of 2–3 Gy. All of these 9 patients died during a median follow-up of 9 months (range, 1 to 19 months). Symptom relief was achieved in 7 of 8 patients who completed radiotherapy. Tumor size reduction was observed in 2 of 4 patients who underwent radiologic evaluation after radiotherapy.

conclusions

Metastasis to the mandible from HCC has a poor prognosis. Radiotherapy can be an effective local treatment option for symptomatic relief in these cases.

Hepatocellular carcinoma metastasis to the mandibular ramus: a case report

Hepatocellular carcinoma (HCC) is one of the most commonly reported cancers worldwide. Although the extrahepatic metastasis of this carcinoma has been reported frequently, the mandible is a rare site for HCC metastasis. Here we have presented a rare case of mandibular metastatic HCC in a 37-year-old man presenting with painless swelling over his right parotid gland for the previous 3 months. This patient had a history of HCC caused by a hepatitis C viral infection. The tumor cells exhibited eosinophilic and rich cytoplasm, and they appeared to be trabecular (similar to hepatic cells), with sinusoids between the tumor cells. Moreover, the tumor cells were positive for Hep Par-1 and Glypican-3 in the cytoplasm. A 64-multidetector-row computed tomography scan was performed, and it showed pathological tracer uptake in the right mandible. Therefore, an excisional biopsy was performed, and with the support of an immunohistochemical analysis, an HCC mandibular metastasis diagnosis was made. The patient was treated with radiotherapy and chemotherapy. This patient was followed up in the oncology department for 1 year, and he was still alive at the time this report was written. This extremely rare case highlights the differential diagnosis difficulties that can be encountered, and the importance of diagnostic clues, such as the clinical history, histopathology, and immunohistochemistry, in the establishment of a definitive diagnosis. Clinicians should be aware of the possibility of encountering HCC metastasis in the mandible, and take this into consideration in order to prevent a misdiagnosis.

Hepatocellular carcinoma with thoracic metastases presenting as hemothorax: A case report and literature review

RATIONALE

Hemothorax caused by metastasis or direct invasion of hepatocellular carcinoma (HCC) in the chest is rare. We report a case of hemothorax caused by metastasis in the mediastinum and treated with transcatheter arterial embolization (TAE).

PATIENT CONCERNS

A 60-year-old woman with HCC was admitted to receive chemotherapy. Two days after admission, she complained of dyspnea, and a chest X-ray revealed right pleural effusion. Thoracentesis confirmed the diagnosis of hemothorax. Computed tomography (CT) angiography showed lung, pleural, and mediastinal metastases and contrast extravasation from the right lower mediastinal mass.

DIAGNOSES

Hemothorax caused by spontaneous rupture of mediastinal metastasis of hepatocellular carcinoma.

INTERVENTIONS

During emergent angiography, contrast extravasation from the right T10 intercostal artery was observed and we performed embolization with lipiodol and gelatin sponge particles. After embolization, no active bleeding was observed.

OUTCOMES

The patient died because of sepsis and multiple organ failure 22 days after admission.

LESSONS

We reviewed 21 cases of HCC with metastasis or direct invasion in the chest presenting hemothorax. The results revealed that male sex and right hemothorax were predominant in these cases. The average age of the patients was 61.24±10.82 years. The most common symptoms were dyspnea, chest wall pain, and shock. Thoracentesis can confirm the diagnosis, and CT angiography can help identify the location of contrast extravasation before TAE. The reported bleeding arteries were the intercostal, inferior phrenic, bronchial, hepatic, and superficial cervical arteries. TAE with embolic agents is a feasible treatment. The overall outcomes in these cases were poor.

Scapular metastasis of hepatocellular carcinoma presenting as acute bleeding and hematoma: A case report of safe and effective treatment

RATIONALE

The occurrence of bleeding and hematoma from bone metastasis of hepatocellular carcinoma (HCC) is extremely rare.

PATIENT CONCERNS

We present a case of scapular metastasis of HCC in a 69-year-old man who presented with acute bleeding and hematoma.

DIAGNOSES

Chest computed tomography showed a large hematoma within the right pectoral muscle of the right upper chest and an exophytic metastatic mass in the right scapula with bony destruction, which caused the intramuscular hematoma. The final diagnosis was scapular metastasis of HCC presenting as acute bleeding and hematoma.

INTERVENTIONS

Selective right subclavian angiography showed a hypervascular metastatic lesion in the right scapula. Subsequently, embolization of the tumoral feeding artery using a microcoil was performed and tumoral bleeding was stopped.

OUTCOMES

The patient was discharged on hospital day 14 without any complications.

LESSONS

Despite being extremely rare, the possibility of bleeding from bone metastasis of HCC needs to be considered. Transcatheter arterial embolization may be an effective means to treat bleeding from bone metastasis of HCC.

A Case of Hepatocellular Carcinoma Presenting as a Gingival Mass

Oral metastatic tumor, which is uncommon and represents less than 1% of malignant oral neoplasms, usually arises from a primary mucosal or cutaneous cancer located in the head and neck regions. Metastasis of hepatocellular carcinoma (HCC) to the oral cavity, especially to gingiva, is extremely rare. A 50-year-old man, who was a chronic alcoholic and hepatitis B virus carrier, presented with abdominal distension and weight loss for the past 3 months. Three-phased contrast-enhanced abdominal CT revealed numerous conglomerated masses in the liver, suggesting huge HCCs arising in the background of liver cirrhosis with a large amount of ascites. He complained of recurrent profuse bleeding from the left upper gingival mass. A facial CT revealed an oral cavity mass destructing the left maxillary alveolar process and hard palate, which was diagnosed as metastatic HCC by an incisional biopsy. Herein, we report a case of metastatic HCC to the gingiva.

Metastasis to the Jawbones: A review of 453 cases

The purpose of the present article was to review the characteristics of the jawbone metastases to analyze all variables. A relevant English Literature search in PubMed, Scopus, and Google Scholar was performed. All variables such as age, gender, primary and secondary tumor sites were analyzed. There were 453 metastatic cases. The male-to-female ratio was 1.2:1, and the mean age of the patients was 53.4 years. The lung was the most common primary site in men, and breast in women. The most common metastatic site was the mandible, and adenocarcinoma was the most frequent histological diagnosis. Metastases to the jaw bones occur in the advanced stages of a malignancy hence; a careful examination of patients with jaw bone lesions is strongly suggested. Dentists, as well as general physicians, should take into consideration the possible presence of jaw metastases in cases which present atypical symptoms, especially in patients with known malignant disease.

Metastasis to the oral soft tissues: A review of 412 cases

The present review article analyzes the characteristics of metastases to the oral soft tissues from 1937 to 2015. An extensive literature search was performed. All variables such as age, gender, and primary and secondary tumor sites were analyzed. Metastases to the major salivary glands were not included in this review. In general, there were 412 metastatic lesions developed in the oral soft tissues. The male-to-female ratio was approximately 1.8:1. The mean age of the patients at diagnosis was 58. The lung was the most common primary site and the gingiva was the most common metastatic site. The greater part of the histological examination yielded adenocarcinoma. The diagnosis of a metastatic lesion in the oral cavity is a challenge to the clinicians due to the lack of pathognomonic signs and symptoms. Oral metastases usually occur in the advanced stages of cancers, and the interval between appearance and death is usually short. The oral soft tissue metastasis can be easily recognized compared to the metastasis of jawbones. Early detection of oral lesions is important in the case of being the first sign of a malignancy in other parts of body.

Metastasis to the jaws as a first manifestation of hepatocellular carcinoma: report of a case and analysis of 41 cases

INTRODUCTION

Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide. Local metastasis is common but metastasis to the jaw is rare with 40 reported cases in the English language literature.

REPORT OF CASE

We describe a case of a 54-year-old man who, for the past two months, had noticed a rapidly growing facial mass in the posterior mandibular area. The patient was known to be a hepatitis C virus carrier and suffered from liver cirrhosis but the presence of HCC was unknown.

METHODS AND RESULTS

The English language literature was searched for documented cases of HCC metastasis to the jaw, applicable data was evaluated. The literature analysis revealed 41 reported cases (including the present case). In most cases (81%) the jaw lesion was the only known metastasis at the time of HCC diagnosis. Clinical presentation occurred up to 2 years before discovery of the jaw metastasis. Patients with HCC jaw metastasis have a poor survival rate with an average of 6.1 months between diagnosis and death.

CONCLUSIONS

This study shows that an isolated jaw mass may be the initial presentation of HCC and therefore must be considered in the differential diagnosis, especially in the presence of known liver cirrhosis or chronic viral hepatitis.

Solitary skull metastasis as the first symptom of hepatocellular carcinoma: case report and literature review

Skull metastasis from hepatocellular carcinoma (HCC) is reported rarely. In addition, solitary skull metastasis as the first symptom of HCC is reported even less. Here, we reported a case of solitary skull metastasis as the first symptom of HCC and reviewed the literature on skull metastasis. A 49-year-old male patient was admitted to Jinjiang Hospital of Quanzhou Medical College with a painless parietal-occipital scalp mass, and he denied any history of hepatic disease. A cranial computed tomography demonstrated a hypervascular enhancement with osteolytic change in the right parietal-occipital region, cranial magnetic resonance imaging indicated a highly enhanced and osteolytic skull tumor, and abdominal computed tomography showed a huge tumor in the liver. The other examinations showed no other metastases. Laboratory data showed no liver dysfunction while hepatitis B surface antigen was positive, and alpha fetal protein level was high. A craniectomy was performed and the mass was totally removed. The histological diagnosis was skull metastasis from HCC. The patient was subsequently treated by transcatheter arterial chemoembolization. In a review of published literature, the incidence of skull metastasis from HCC in the period between 1990 and 2011 has significantly increased. The misdiagnosis rate of skull metastases as the first symptom from HCC was high. Therefore, it is necessary to give each patient with a scalp mass that has invaded the skull a liver ultrasound or computed tomography scan. On the other hand, we found that metastases that occurred in the calvaria site were more frequent than those that occurred in the skull base and facial skeleton. This may be worthy of further investigation in the future.

Two rare forms of hepatocellular carcinoma metastases

An 80-year-old man with known metastatic hepatocellular carcinoma, not on current treatment, was presented with bleeding gingival and penile masses. Bleeding from both sites was able to be controlled with local treatment and subsequent discontinuation of his clopidogrel. The gingival mass was biopsied and was found consistent with metastatic hepatocellular carcinoma. Owing to the concern of recurrent bleeding, the penile mass was not biopsied. Given the significant progression of his disease, the patient was discharged to hospice care.

Hepatocellular carcinoma metastatic to the scalp

A case of scalp metastasis from hepatocellular carcinoma (HCC) is reported that was initially diagnosed as a soft-tissue tumor. Attempted excision of the lesion resulted in an open wound requiring soft-tissue reconstruction of the scalp. Results of pathologic examination showed metastatic HCC. The patient returned postoperatively with bleeding, which was unable to be controlled, resulting in his death. Scalp metastases from HCC are very rare but must be considered when treating a patient with known cirrhosis, hepatitis, or HCC.

PET/CT characteristics of isolated bone metastases in hepatocellular carcinoma

PURPOSE

To compare the prognostic implications and positron emission tomography (PET)/computed tomography (CT) characteristics of isolated bone metastasis secondary to hepatocellular carcinoma (HCC) with those of HCC metastases to bone and other sites.

MATERIALS AND METHODS

This study was approved by the institutional ethics committee, and informed consent was obtained from all patients. Extrahepatic metastases were diagnosed in 257 patients with HCC by using dual-tracer (carbon 11 [(11)C] acetate and fluorine 18 fluorodeoxyglucose [FDG]) PET/CT. Metastatic bone lesions were identified with visual inspection and semiquantitative assessment and confirmed with histopathologic examination and/or supported by findings at other radiologic examinations or serial PET/CT.

RESULTS

The frequency of bone metastasis from HCC was 19% (49 of 257 patients; eight patients had histopathologic proof and 41 had imaging proof). Metastasis isolated to bone (group 1, 30 of 257 patients [12%]) was more common than metastasis to bone and other sites (group 2, 19 of 257 patients [7%]). At lesion-based analysis of group 1 (71 index lesions; mean lesion size ± standard deviation, 3.25 cm ± 1.88), (11)C acetate PET was more sensitive than FDG PET (93% [66 of 71 lesions] vs 62% [44 of 71 lesions], respectively; P < .05). The combined sensitivity was 97% (69 of 71 lesions) with dual-tracer PET and 72% (51 of 71 lesions) with CT. At patient-based analysis, (11)C acetate PET had an incremental value of 23% (seven of 30 patients) over FDG PET. At lesion-based analysis of group 2, FDG PET was more sensitive than (11)C acetate PET (87% [33 of 38 lesions] vs 50% [19 of 38 lesions], respectively; P < .05). Tracer avidities of metastatic bone lesions were closely correlated with that of their corresponding primary HCC tumors. The median survival time was longer in group 1 than in group 2 (18 months vs 11 months, respectively; P < .05).

CONCLUSION

Isolated bone metastasis from HCC may not be as uncommon as previously believed. The detection of these metastases can be significantly enhanced with (11)C acetate PET compared with FDG PET alone. Identification of this group of patients also seems to have prognostic importance.

Metastasis of hepatocellular carcinoma into the mandible with radiographic findings mimicking a radicular cyst: a case report

INTRODUCTION

Hepatocellular carcinoma (HCC) is a common neoplasm worldwide, with more than half of the tumors associated with regional metastasis. Extrahepatic metastasis is also common, and the most frequently affected sites are the lungs, abdominal lymph nodes, diaphragm, and bone. However, HCC metastasis to the mandible is rare, with approximately 50 cases reported in the literature.

METHODS

In this report, we describe a case of HCC metastasis to the mandible at the apex of #18 root in a 62-year-old man. This patient had already been diagnosed with metastasis to pancreatic caput lymph node. The radiographic features of the mandible resembled radicular cyst and did not show typical findings of malignancy.

RESULTS

Under the first diagnosis of radicular cyst, root canal treatment was initially performed, and then surgical treatment of the removal of the cystic lesion and #18 extraction were performed. Finally, the lesion was diagnosed as HCC metastasis from pathological examination. Consequently, he received constitutional chemotherapy in the hepatitis unit and is now in remission.

CONCLUSION

This case shows the importance of considering the differential diagnosis of malignancy.