A case of hepatocellular carcinoma diagnosed as facial cutaneous metastasis survives for 18 months

To the Editor: Cutaneous metastasis of an internal malignancy is uncommon. Its clinical presentation is variable, although it is rarely seen in hepatocellular carcinoma (HCC).^[1] For patients with HCC, the presence of cutaneous metastases is associated with a dismal prognosis. Here, we described a patient, with elderly-onset HCC for more than ten years, who has survived for 18 months after being diagnosed as facial cutaneous metastasis.

A 66-year-old male patient was referred to our department with cutaneous nodular lesions in nasolabial fold, which was developed over the past 6 months. The patient was treated twice with CO₂ laser ablation but soon relapsed after pathologic biopsy. The surface of the lesion was uneven with several rice-sized papule. The red-purple lesions were painless and fragile, measuring 1.5 cm × 1.5 cm, arising from the subcutaneous tissue, and with a tendency to bleed [Figure 1A]. Diagnosed with liver cancer 17 years ago, the patient had been treated with chemotherapy for more than 10 times according to his medical history. In 2010, computed tomography (CT) showed the lung metastases. In January 2017, CT showed a nodule in the adrenal junction, and metastatic tumor was considered. In March 2017, a punch biopsy from the skin lesion was performed in our institute. The lesions were exogenous, with focal epidermal atrophy and the clear tumor cells masses in the dermis. Vasodilation and proliferation in stroma, atypical lymphocytes can be seen in lymph vessels [Figure 1B]. At high magnification, the cells were cuboidal, mitoses and heterogeneous cell was obvious. In previous immunohistochemistry staining showed the tissue was negative for epithelial membrane antigen (EMA), cytokeratin 20 (CK20), carcino embryonic antigen (CEA), cytokeratin 7 (CK7), but almost 40% of tissue was positive for antigen KI 67 (Ki-67). This patient was initially diagnosed as skin metastatic carcinoma, subsequently receiving a second immunehistochemistry. Heptocyte (+) was expressed in cytoplasm [Figure 1C], Arginase-1(+) in nucleus and cytoplasm [Figure 1D]. The cell membrane and cytoplasm showed cytokeratin 8/18 (CK8/18) (+), eccrine gland and hair follicle also feature such expression. Staining suggested that the tissue was negative for alpha-fetoprotein (AFP), glypican-3 and cytokeratin (CK) with weak expression in cytoplasm. The final diagnosis was the cutaneous metastases from HCC. In October 2017, CT showed a large number of tumor active lesions in the liver [Figure 1E], multiple stones in gallbladder, and multiple lung metastases [Figure 1F]. CA125 was 252.2 IU/mL and CA19-9 was 66.1 IU/mL.

Figure 1.

(A) Clinical picture at the first visit to our hospital with several rice-sized papules on his face. (B) Vascular dilatation and proliferation in stroma, and visible of atypical lymphocytes in abnormal lymphatic vessels (hematoxylin-eosin [HE] staining, original magnification ×200). (C) Hepatocyte (+) (immunohistochemistry, original magnification ×200). (D) Arginase-1 (+) (immunohistochemistry, original magnification ×200). (E) Multiple round-like low-density lesions in liver S3 segment, considering metastatic cancer. (F) Multiple lung metastases and lipiodol deposition.

Cutaneous metastasis refers to the growth of cancer cells in the skin originating from an internal cancer. The lesions take on a variety of clinical forms but are usually develop in the structure of a firm, round or oval, mobile, painless nodule, and the skin metastases may break down and ulcerate through the skin.

With respect to skin metastasis of internal organs, approximately 68% of patients die within 1 year after the appearance of skin lesions.^[2] Cutaneous metastasis from HCC is a rare event, accounting for 0.2% to 2.7% of all cutaneous metastases.^[3] The presence of cutaneous metastases of HCC is associated with a very poor prognosis, an increased likelihood of metastases at other sites, and a median survival less than 5 months.^[4] The case in this study survived over 18 months, and he almost abandoned treatment in the past 6 months. Histopathology of cutaneous HCC demonstrated a bottom heavy architecture, with the main infiltrating substances located in the deep dermis, and the presence of trabecular and pseudoglandular patterns composed of acidophilic cells.^[5]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initial will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Funding

This study was supported by grants from Guangzhou Science and Technology Plan General Project (No. 201607010340), and Guangdong Enterprise Technology Research and Development Fund Project (No. 2013B021800044).

Conflicts of interest

None.