Cutaneous metastases from hepatocellular carcinoma.

A 52-year-old South-east Asian came in with complaints of an ulcerated, profusely bleeding, painful, 7-cm cutaneous mass over his left scapula. This actively bleeding mass had a dusky vascular appearance and a boggy central core (Fig. 1). The patient first noticed the mass 6 months before seeking medical attention. At that time it was a centimeter in diameter. Figure 1. Appearance of the 7-cm scapular mass showing signs of bleeding and ulceration Download figure to PowerPoint Other complaints consisted of melena for a few days prior to admission, failure to thrive, and left upper quadrant pain relieved by bowel movements. He reported no significant past medical history. On examination, he was noted to have a 2/6 functional murmur heard over the entire precordium and a palpable abdominal mass in the left upper quadrant. His liver was not palpable below the costal margin, and a testicular mass could not be felt. In addition to the mass in his shoulder, skin examination showed spider angiomata over his face, chest, and the dorsum of his hands. Laboratory studies showed him positive for hepatitis C and B. Other laboratory findings included albumin 1.1 g/dL (normal 4–6), AST 69 IU/L(normal < 35), ALT 29 IU/L(normal < 35), alkaline phosphatase 60 U/L (normal 30–120), PT 17 s (normal 10–12), hemoglobin and hematocrit 5 g/dL and 15.1%, respectively. Serum α-fetoprotein (AFP) was elevated to 10 000 ng/mL. Serum β-HCG was undetectable at < 1mIU/mL. Computerized tomography (CT) of the chest showed a mass in the skin over the left scapula infiltrating into the dermis but not penetrating the muscle wall. An abdominal computerized tomographic scan (CT) also showed a nodular liver and an 8.5-cm bilobed mass adjacent to the liver. A 3.5-cm retroperitoneal, retrocaval nodal mass was also seen. A liver-spleen scan using technetium 99 m sulfur colloid with delayed images revealed an area of mild photopenia in the inferior aspect of the right lobe. A gallium study with gallium citrate 67 with planar images of the head, thorax and abdomen, and SPECT imaging in transverse, coronal, and sagittal projections were also obtained. Intense foci of uptake were seen projecting off the inferior surface of the left lobe of the liver and in the region of the shoulder mass. The focus projecting off the liver was believed to represent hepatoma. Some uptake was also seen in the anterior portion of the spleen and in a right paravertebral node in the upper abdomen. Over his hospital course, he required esophageal banding to limit bleeding from esophageal varicies. Liver biopsy was not done at this time because of the patient's risk for uncontrollable bleeding. The other area of intense gallium uptake, the mass lesion on the left shoulder, continued to bleed during the patient's hospital course and was biopsied to confirm skin metastases from HCC. Microscopic examination of the biopsy material showed features of a poorly differentiated metastatic carcinoma. The epidermis showed mild irregular acanthosis with extensive dermal fibroplasia and angiomatosis. Tumor cells found within the dermis were highly atypical and were lying within dilated vascular spaces. They formed cohesive aggregates and appeared to form gland-like spaces. Tumor cells showed high nuclear-to-cytoplasmic ratios with prominent nuclear pleomorphism, vesicular chromatin, prominent nucleoli, necrotic cells, and numerous mitoses, some of which were atypical (Fig. 2a,b). The tumor cells were negative for S-100, β-HCG, and mucicarmine but were strongly positive for α-fetoprotein (Fig. 3). Figure 2. (a) Mid-power view of a representative field. The lesion consists of pleomorphic, predominantly round or polyhedral cells with scattered lymphocytes. Hematoxylin-Eosin × 100. (b) High power of (a). Note large bizarre cells some of which contain eosinophilic droplets. The nuclei contain prominent nucleoli with scattered mitotic figures. The cytoplasm is moderately abundant and is eosinophilic to amphophilic. Hematoxylin-Eosin × 400 Figure 3. Many of the cells stain with antibodies to α-fetoprotein (brown stain). Some staining corresponds to intracytoplasmic droplets. Immunoperoxidase-DAB stain with hematoxylin counterstain × 400 Download figure to PowerPoint