Dermoscopy of Cutaneous Metastases from Primary Hepatocellular Carcinoma
Cutaneous metastases from primary hepatocellular carcinoma (HCC) are a rare but significant clinical entity. This case report highlights the clinical, dermoscopic, and pathological features of cutaneous metastases in a patient with HCC, providing valuable insights into the diagnosis and management of this condition.
Clinical Presentation
The patient, a 62-year-old man, presented with multiple progressively enlarging and bleeding reddish nodules on his face over a period of 20 days. He had a history of untreated hepatitis B for 20 years and was diagnosed with HCC and multiple metastases (including lung and inferior vena cava) three months prior to the dermatological presentation. His treatment regimen included transcatheter arterial chemoembolization and antiviral drugs.
On physical examination, six reddish, firm nodules ranging from 1 to 10 mm in diameter were observed on his face. Some of these lesions exhibited capillary dilatation, rupture, and bleeding. The rapid growth and clinical appearance of these nodules raised suspicion of cutaneous metastases from HCC.
Dermoscopic Examination
Dermoscopy, a non-invasive diagnostic tool, revealed several characteristic features in the cutaneous nodules. The most prominent findings included a homogenous, blurry milky-red area, multiple serpentine and arborizing vessels, and irregular red lacunas over the milky-red areas. These vascular patterns are indicative of cutaneous metastases and are consistent with previous reports. The presence of serpentine and arborizing vessels, in particular, is a common dermoscopic feature in non-pigmented metastatic lesions.
Histopathological and Immunohistochemical Findings
A skin biopsy was performed on one of the bleeding nodules. Histopathological examination revealed a large number of mass tumor cells in the dermis, composed of pleomorphic cells with increased mitotic activity and intercellular bleeding. These findings confirmed the diagnosis of cutaneous metastasis from HCC.
Immunohistochemical staining further supported the diagnosis. The tumor cells were positive for hepatocyte, arginase-1, and cytokeratin, with a Ki-67 proliferation index of 30%. Negative staining for cytokeratin 19, alpha-fetoprotein, carcinoembryonic antigen, and epithelial membrane antigen helped to rule out other potential primary tumors and confirmed the hepatic origin of the metastatic cells.
Discussion
Cutaneous metastases from HCC are relatively rare, accounting for only 0.2% to 2.7% of all cutaneous metastases. Most cases arise from needle tracks or surgical wound contamination, with non-iatrogenic metastasis being uncommon. This rarity is partly due to the fact that HCC more frequently invades the portal veins rather than the systemic circulation.
Clinically, cutaneous metastases from HCC can present as asymptomatic or painful reddish-blue nodules of varying sizes, which are firm on palpation and may or may not ulcerate. These lesions often exhibit rapid growth, as observed in the present case. The diverse clinical manifestations underscore the importance of a thorough diagnostic workup, including histopathology and immunohistochemical staining.
Dermoscopy has emerged as a valuable tool in the early diagnosis of cutaneous metastases. The most common dermoscopic findings in non-pigmented metastatic lesions are vascular patterns, including serpentine, arborizing, dotted, and comma-shaped vessels. In this case, the presence of serpentine and arborizing vessels, along with irregular red lacunas, was consistent with the dermoscopic features of cutaneous metastases.
The prognosis for patients with cutaneous metastases from HCC is generally poor, with overall survival rates ranging from a few weeks to six months. Treatment options include surgery, radiotherapy, radiofrequency ablation, and targeted drug therapy. While these interventions can improve survival rates in advanced HCC, the management of cutaneous metastases remains challenging.
Conclusion
This case report underscores the importance of considering cutaneous metastases in patients with HCC, particularly those with a history of untreated hepatitis B and advanced disease. The combination of clinical examination, dermoscopy, histopathology, and immunohistochemical staining is essential for accurate diagnosis. Early recognition and appropriate management of cutaneous metastases can improve patient outcomes, although the overall prognosis remains poor.
doi.org/10.1097/CM9.0000000000000413
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