Title: Synchronous Mandibular and Giant Parieto-occipital Skull Metastasis From Hepatocellular Carcinoma
Abstract: A 79-year-old man affected by multiple, well-differentiated hepatocellular carcinomas (HCCs) presented to our institute 4 months after transarterial chemoembolization with a rapidly growing scalp mass of approximately 5 × 6 cm, associated with a smaller nodular lesion of the right parotid space (Figure A). His serum α-fetoprotein level was 11.4 ng/mL. Magnetic resonance imaging of the head revealed a nonhomogenous, well-defined mass in the midline parietal bone extending subcutaneously, associated with an osteolytic lesion of the head (plane sagittal T1-weighted and axial T2-weighted images), and right ramus of mandible (Figure B). An abdominal computed tomography scan revealed 2 separate hepatic masses in segments 8 and 4 of the liver, according to recurrence of HCC. A percutaneous fine-needle biopsy of the skull and mandible tumefactions showed cytologic characteristics, compatible with well-differentiated HCC as positive for anti-human hepatocyte antigen and negative for cytokeratin 7 (Figure C). The incidence of skeletal metastasis from HCC is estimated to be 2% to 16%.1Yen F.S. Wu J.C. Lai C.R. et al.Clinical and radiological pictures of hepatocellular carcinoma with intracranial metastasis.J Gastroenterol Hepatol. 1995; 10: 413-418Crossref PubMed Scopus (38) Google Scholar The most frequent sites of osseous metastasis from HCC are vertebrae, sternum, ribs, and long bones, although the incidence in the skull is low at 0.5% to 1.6%.2Hsieh C.T. Sun J.M. Tsai W.C. et al.Skull metastasis from hepatocellular carcinoma.Acta Neurochir (Wien). 2007; 149: 185-190Crossref PubMed Scopus (41) Google Scholar Moreover, with improvements in the treatment of primary HCC, the incidence of metastases from this cancer to the bone and skull may increase.1Yen F.S. Wu J.C. Lai C.R. et al.Clinical and radiological pictures of hepatocellular carcinoma with intracranial metastasis.J Gastroenterol Hepatol. 1995; 10: 413-418Crossref PubMed Scopus (38) Google Scholar Finally, skull metastases from HCC should be included in the differential diagnosis of metastatic tumors, such as breast cancer, lung cancer, prostate cancer, and malignant lymphoma.