carcinoma

Mass on Left Temple as Initial Presentation of Metastatic Hepatocellular Carcinoma

NYNKE C. DEN HOLLANDER, MD
Katy, Texas

ELIZABETH HSU, MD
LINDSAY K. SONSTEIN, MD
University of Texas Medical Branch, Galveston

Dr den Hollander is a hospitalist with Total Inpatient Services in Katy, Texas. Dr Hsu is an internal medicine resident and Dr Sonstein is assistant professor at the University of Texas Medical Branch, Galveston

The authors report no external sources of funding for this report and no conflicts of interest.

 

A 46-year-old man presented with a 6-month history of a progressively enlarging mass on his left temple that was associated with proptosis of the left eye and blurry vision. He also reported left hip pain and weakness of similar duration. One week earlier, he had noticed increasing abdominal girth. His previous medical history was significant for hepatitis C virus (HCV) infection without cirrhosis.

carcinoma

Figure 1 – A large mass appears on the left temple along with proptosis of the left eye.

PHYSICAL EXAMINATION

The patient’s initial vital signs showed tachycardia and hypertension, and he appeared ill and wasted. Proptosis of the left eye was evident along with normal extraocular movements. A firm, nontender mass (4 cm × 6 cm) was located at the left temple. The abdomen was nontender but significantly distended, and a fluid wave test was positive for ascites. The patient’s left lower limb strength was decreased secondary to hip pain.

LABORATORY AND IMAGING STUDIES

Laboratory results showed an alpha-fetoprotein (AFP) level that was higher than 200,000 ng/mL. CT scans of the head, abdomen, and pelvis revealed a large calvarial/dural mass in the left frontal bone (Figure 1 and Figure 2), several hypodense lesions in the liver, portal vein thrombosis, massive ascites, and a destructive lesion at the acetabulum. Fine-needle aspiration of the mass on the left temple established the diagnosis of hepatocellular carcinoma (HCC) (Figure 3). Paracentesis was performed, and 7 L of fluid were drained; the cytologic results were negative for malignancy.

ct scan

Figure 2 – a ct scan of the head reveals a calvarial/dural mass destroying portions of the lateral orbit, sphenoid bone, and temporal bone.

OUTCOME OF THIS CASE

During the patient’s hospital stay, altered mental status and acute renal failure developed. He died 3 days after he was admitted.

DISCUSSION

Throughout the world, HCC is one of the most common cancers and the second leading cause of cancer-related death.1 Its occurrence is primarily associated with cirrhosis secondary to hepatitis B and hepatitis C.

Hepatocellular carcinoma metastasizes to the lungs, regional lymph nodes, peritoneum, and adrenal glands. Bony metastasis does occur, usually to the vertebrae, pelvis, or ribs. Skull metastasis and dural metastasis, especially, are extremely rare.2,3 In this patient, skull metastasis was evident before any symptoms or signs of liver cirrhosis or HCC.

FNA brain

Figure 3 – a Romanowsky stain of the fine-needle aspirate of the mass on the left temple shows neoplastic cells with cytologic features consistent with metastatic hepatocellular carcinoma

In the United States, patients with cirrhosis are regularly screened for the development of HCC. However, this patient did not have known cirrhosis at the time of diagnosis and had not undergone screening or consistent follow-up. His death reflects the steadily increasing number of HCV-related deaths in the United States.4 Because of the high number of silent HCV infections occurring among the “baby boomer” population, the incidence of HCC will increase. Therefore, recognition of the different presentations of HCC will be vital.

Noteworthy in this case is not only the rare location of metastatic disease but also the exceptionally elevated AFP level, which is highly specific when greater than 200 ng/mL.5

REFERENCES:

1.Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA Cancer J Clin. 2011;61:69.

2.Hsieh CT, Sun JM, Tsai WC, Tsai TH, Chiang YH, Liu MY. Skull metastasis from hepatocellular carcinoma. Acta Neurochir. 2007;149:185-190.

3.Torres M, Alvarez R, López D, Titó L. Hepatocellular carcinoma skull metastasis with both extradural and subcutaneous extension. J Hepatol. 2002;36:569.

4.Ly KN, Xing J, Klevens M, Jiles R, Ward J, Holmberg S. The increasing burden of mortality from viral hepatitis in the United States between 1999 and 2007. Ann Intern Med. 2012;156:271-278.

5.Gupta S, Bent S, Kohlwes J. Test characteristics of alpha-fetoprotein for detecting hepatocellular carcinoma in patients with hepatitis C. Ann Intern Med. 2003;139:46-50.