Cutaneous metastasis of hepatocellular carcinoma following liver transplantation

Liver Transplant Beyond the Milan Criteria: Distant Metastases of Hepatocellular Carcinoma (Part II)

Liver transplant is one of the most effective ways to treat hepatocellular carcinoma (HCC). Thanks to the implementation of the Milan criteria, developed almost 30 years ago, 5-year survival rates for patients who underwent a transplant for HCC increased and reached the rates for patients with nontumor indications. Despite the emergence of alternative stratification systems, extrahepatic metastases remain a key contraindication to a liver transplant. Nevertheless, there have been reported cases of liver transplants in spite of the contraindication not only in times of diagnostic limitations but also in the 21st century.

We have previously reported our own case of a patient who underwent a liver transplant in spite of pulmonary lesions, which postoperatively were found to be HCC metastases. In this part of the review, we discuss similar cases from the literature.

If metastatic lesions are successfully treated, a related donor is available, and other modalities are seen as less preferable in terms of the disease prognosis, a liver transplant may be considered an appropriate way to prolong the patient’s life, although such approach should not be recommended for widespread use.

Nasal Tip Cutaneous Metastasis of Hepatocellular Carcinoma: A Case Report

Background

Cutaneous metastasis is rare in clinical practice, especially that from primary hepatocellular carcinoma (HCC), which is even rarer.

Case Presentation

This report describes a male patient with HCC with cutaneous metastases to the nasal tip. The patient developed a raised nodule at the nasal tip 5 years after surgery for HCC, with surface ulceration and crusting and no obvious symptoms. Abdominal computed tomography (CT) showed an obvious mass in the liver. The skin lesions on the nasal tip were confirmed to be cutaneous metastasis of HCC by histopathological and immunohistochemical examinations.

Conclusion

The incidence of cutaneous metastasis of HCC is extremely low, and nasal tip cutaneous metastasis of HCC has no specific clinical manifestations; therefore, it needs to be distinguished from rosacea rhinophyma, fungal and atypical mycobacterial infections, tumours of vascular origin, and tumours of skin appendages that occur in the nasal tip and is prone to misdiagnosis and missed diagnosis, thus requiring clinical dermatologists and otolaryngologists to be aware of such metastasis.

Une lésion labiale inhabituelle

A 75 years old patient presented with a papular easily bleeding lesion of the lower lip that had been growing for two months. He was known for alcoholic cirrhosis complicated with hepatocellular carcinoma treated since one year. A working diagnostic hypothesis of benign vascular lesion was proposed. Microscopic examination showed a neoplastic dermal proliferation that had been fully excised, made of lobules segregated by thin fibrous septae. The neoplastic architecture was trabecular and delineating spaces forming pseudo-rosettes. Tumour cells were monomorphic, cuboidal or cylindric with abundant eosinophilic and granulous cytoplasm and centered by a lone nucleus that often contained a prominent nucleolus. Some spaces were filled with a brownish-greenish pigmented material. Immunohistochemical study showed that tumour cells were positive with the hepatocyte paraffin 1 antibody as well as cytokeratin 8 antibody. Chromogranin A and synaptophysin stainings were negative. Thus we concluded to a lip metastasis from the previously known hepatocellular carcinoma. Skin metastasis arise in around 3% of cases of hepatocellular carcinoma. They account for less than 1% of all cutaneous metastasis. Overall appearance of cutaneous metastasis of hepatocellular carcinoma is associated with a poor prognosis and an aggravated risk of metastasis to other locations and organs and a median overall survival of less than 5 months. Since incidence of hepatocellular carcinoma is rising pathologists might face more frequently in years to come to cutaneous metastasis whose varied clinical presentations make a diagnostic challenge.

Non-iatrogenic implantation of cutaneous metastasis from hepatocellular carcinoma

PURPOSE

Cutaneous metastases as an extrahepatic metastasis from hepatomas (HCC) is extremely rare and always carry a poor prognosis and less survival time. Previously, there has been a limited number of literature that reported skin metastasis in a large number of cases, which has rarely been discussed in the empirical treatment and therapy of cutaneous metastasis, especially for non-iatrogenic implantation. It is necessary to discuss this kind of metastasis.

PATIENTS AND METHODS

We summarize cases from our medical center from 2013 to 2021, there are 12 patients diagnosed with non-iatrogenic implantation of cutaneous metastasis after HCC. We conducted the investigation of the clinical prognosis, pathological characteristics, and treatment of those patients.

RESULTS

All patients were male, the age ranged from 21 to 71 years old, the average size of primary HCC was over 5 cm, there was four patient's cutaneous metastasis from the skin of head (including scalp and occipital region), followed by right abdominal (2 patients), right chest wall (2 patients), back (2 patients), umbilical (1 patient), gluteal region (1 patient). The cutaneous metastases presented as solitary or multiple nodules, papules, and erythema without ulcers with sizes between 0.5 cm and 5 cm. 7 patients died after being diagnosed with cutaneous metastasis within 2-19 months.

CONCLUSIONS

The rate of non-iatrogenic implantation cutaneous metastasis is low, but the prognosis is poor, combining with histopathological analysis and history of diseases can be helpful in diagnosis. For large HCC (> 5 cm), systematic treatment is recommended to prevent the occurrence of cutaneous metastasis and improve the prognosis after hepatectomy.

Cutaneous Metastases from Primary Liver Cancers: The Need for Knowledge and Differential Diagnosis

Primary skin tumors are certainly more frequent than metastatic tumors, but the latter can sometimes be the first sign of otherwise unrecognized neoplastic pathology and always correspond to an advanced stage of the disease. Among the various neoplasms that can metastasize in cutaneous districts, skin metastases from primary malignant neoplasms from the liver and biliary tract are infrequent, and when they do occur they can pose differential diagnosis problems to the pathologist. Here we present two cases of metastatic skin lesions, respectively originating from the liver and the intrahepatic biliary tract, and we conduct a brief review of the current literature.