Cases and Research Letters
Multiple Cutaneous Metastases From Hepatocellular Carcinoma as the First Sign of Tumor Recurrence in a Transplant Patient
Metástasis cutáneas múltiples de carcinoma hepatocelular como primer signo de recidiva tumoral en paciente trasplantado
J. Alonso-González
, D. Sánchez-Aguilar, J. Toribio
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Departamento de Dermatología, Complejo Hospitalario Universitario, Facultad de Medicina, Santiago de Compostela, Spain
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Alonso-González, D. Sánchez-Aguilar, J. Toribio" "autores" => array:3 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Alonso-González" "email" => array:1 [ 0 => "julio.alonso.gonzalez@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "D." "apellidos" => "Sánchez-Aguilar" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Toribio" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Departamento de Dermatología, Complejo Hospitalario Universitario, Facultad de Medicina, Santiago de Compostela, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Metástasis cutáneas múltiples de carcinoma hepatocelular como primer signo de recidiva tumoral en paciente trasplantado" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 631 "Ancho" => 952 "Tamanyo" => 296385 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Proliferation of neoplastic cells in the dermis arranged in trabeculae, alveoli, and, in some places, pseudoglandular patterns (hematoxylin-eosin, original magnification ×100).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cutaneous metastasis, a condition with variable clinical presentation, can be the first manifestation of internal malignancy, although it is rarely seen in hepatocellular carcinoma (HCC).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In patients with HCC, the presence of cutaneous metastases is associated with a dismal prognosis, an increased likelihood of metastases at other sites, and a median survival of less than 5 months.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> This letter describes the case of a liver transplant recipient in whom multiple cutaneous metastases were the first sign of HCC recurrence.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 57-year-old man with a personal history of type 2 diabetes mellitus and liver transplant for treatment of alcoholic liver cirrhosis complicated by HCC. At the patient's regular post-transplant follow-up visits at the hepatology unit, good graft function was seen and there was no evidence of tumor recurrence. Seven months after transplant, the patient presented with rapidly growing asymptomatic lesions on the scalp and in the left supraclavicular region that had appeared several weeks earlier. Physical examination revealed 3 firm, erythematous-violaceous tumors with well-defined borders, measuring between 1 and 2<span class="elsevierStyleHsp" style=""></span>cm in diameter, in the right temporal-parietal region of the scalp (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A) and in the left supraclavicular region (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). Some of the tumors had a small central erosion and a pronounced vascular component (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Histopathologic examination of the lesions revealed a proliferation of neoplastic cells in the dermis arranged in trabeculae, alveoli, and, in some places, pseudoglandular patterns (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The cells were cuboidal, with granular cytoplasm, hyperchromatic nuclei, and marked cellular pleomorphism. Several mitotic figures were also visible. The tumor cells were positively labeled with antibodies against cytokeratin AE1/AE3 and alpha-fetoprotein, and with the hepatocyte antibody. The morphologic and immunohistochemical findings were consistent with a diagnosis of cutaneous metastases of HCC.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Two weeks after histologic confirmation of the metastases, the patient presented to the emergency department with productive cough with whitish sputum and lower chest pain on both sides. The symptoms had appeared 3 days earlier. A chest radiograph showed a poorly defined radiopaque area in the basal region of the right lung field (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A). In view of the patient's medical history, a computed tomography scan was performed, confirming the presence of a large mass measuring 4.3<span class="elsevierStyleHsp" style=""></span>cm in the right lower lobe, and showing multiple pulmonary nodules and mediastinal lymph node involvement (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>B). Metastases were also observed in the liver, around the kidneys, and in a suprarenal gland (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>C), as well as in subcutaneous tissue and muscle tissue. One month later, the patient once again presented to the emergency department with disorientation and generalized tonic-clonic seizures. Brain magnetic resonance imaging revealed a prominent left choroid plexus and an irregularly shaped, high-uptake image consistent with a metastatic lesion (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>D). Following gradual deterioration in general health, the patient died just 6 weeks after the diagnosis of cutaneous metastases.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">HCC is the most common primary malignant tumor of the liver, and its incidence has increased in recent years. However, cutaneous metastases of HCC are very rare, accounting for 0.2% to 2.7% of all cutaneous metastases.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> These metastases are of interest in part because they can be the first manifestation of the primary tumor<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> or, as in our case, the first sign of disease recurrence.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Cutaneous metastasis of HCC occurs most frequently in men over 50 years of age, usually in the sixth decade of life,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and usually manifests as a single painless, fast-growing lesion. The most common location is the head (usually the face), followed by the chest, the abdomen, and the limbs. The lesions can take a variety of clinical forms but are usually firm, bluish-red or purple, 1 to 5<span class="elsevierStyleHsp" style=""></span>cm in diameter, and nonulcerated.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4–6</span></a> They may also be necrotic or purulent or resemble pyogenic granulomas.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Three different mechanisms<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> by which a liver tumor can produce cutaneous metastases have been described: continuous growth from the liver parenchyma, systemic spread of disease, and tumor implantation or seeding following manipulation of the lesion using various diagnostic or therapeutic methods.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Histopathologic diagnosis is possible when a hepatocellular component—bile production in part of the tumor, intercellular bile canaliculi, or a trabecular growth pattern—is present.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> From an immunohistochemical perspective, the hepatocyte antibody has proved to be very helpful in the diagnosis of poorly differentiated tumors.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">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 of less than 5 months.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> This case highlights the fact that a dermatologist may be the first specialist to detect the recurrence of an internal malignancy when metastases have not reached sites other than the skin or have not manifested clinically.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Alonso-González J, et al. Metástasis cutáneas múltiples de carcinoma hepatocelular como primer signo de recidiva tumoral en paciente transplantado. Actas Dermosifiliogr. 2012;103:339-41.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 597 "Ancho" => 1601 "Tamanyo" => 176367 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Erythematous-violaceous tumors with well-defined borders in the right temporal-parietal region of the scalp. B, Similar lesion in the left supraclavicular region. C, Detail of previous figure showing the small central erosion and pronounced vascular component.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 631 "Ancho" => 952 "Tamanyo" => 296385 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Proliferation of neoplastic cells in the dermis arranged in trabeculae, alveoli, and, in some places, pseudoglandular patterns (hematoxylin-eosin, original magnification ×100).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1649 "Ancho" => 1601 "Tamanyo" => 283272 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A, Anteroposterior chest radiograph showing a poorly defined radiopaque area in the basal region of the right lung field. B, Thoracic computed tomography scan showing a large mass measuring 4.3<span class="elsevierStyleHsp" style=""></span>cm in the right lower lobe and multiple smaller pulmonary nodules. C, Abdominal computed tomography scan showing intrahepatic, perirenal, and right suprarenal metastases. D, Brain magnetic resonance imaging showing a prominent left choroid plexus and an irregularly shaped, high-uptake image consistent with a metastatic lesion.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Skin metastasis from hepatocarcinoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Magaña" 1 => "L.M. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 7 | 14 | 21 |
| 2024 Octubre | 71 | 30 | 101 |
| 2024 Septiembre | 79 | 28 | 107 |
| 2024 Agosto | 91 | 45 | 136 |
| 2024 Julio | 72 | 29 | 101 |
| 2024 Junio | 98 | 51 | 149 |
| 2024 Mayo | 75 | 34 | 109 |
| 2024 Abril | 75 | 32 | 107 |
| 2024 Marzo | 68 | 28 | 96 |
| 2024 Febrero | 77 | 35 | 112 |
| 2024 Enero | 60 | 39 | 99 |
| 2023 Diciembre | 55 | 17 | 72 |
| 2023 Noviembre | 68 | 30 | 98 |
| 2023 Octubre | 89 | 18 | 107 |
| 2023 Septiembre | 97 | 37 | 134 |
| 2023 Agosto | 49 | 17 | 66 |
| 2023 Julio | 62 | 36 | 98 |
| 2023 Junio | 73 | 21 | 94 |
| 2023 Mayo | 79 | 23 | 102 |
| 2023 Abril | 80 | 22 | 102 |
| 2023 Marzo | 60 | 21 | 81 |
| 2023 Febrero | 54 | 18 | 72 |
| 2023 Enero | 65 | 29 | 94 |
| 2022 Diciembre | 51 | 46 | 97 |
| 2022 Noviembre | 35 | 30 | 65 |
| 2022 Octubre | 44 | 24 | 68 |
| 2022 Septiembre | 47 | 37 | 84 |
| 2022 Agosto | 42 | 31 | 73 |
| 2022 Julio | 42 | 34 | 76 |
| 2022 Junio | 59 | 27 | 86 |
| 2022 Mayo | 64 | 34 | 98 |
| 2022 Abril | 64 | 44 | 108 |
| 2022 Marzo | 47 | 56 | 103 |
| 2022 Febrero | 44 | 33 | 77 |
| 2022 Enero | 70 | 54 | 124 |
| 2021 Diciembre | 34 | 36 | 70 |
| 2021 Noviembre | 49 | 54 | 103 |
| 2021 Octubre | 46 | 63 | 109 |
| 2021 Septiembre | 36 | 37 | 73 |
| 2021 Agosto | 31 | 35 | 66 |
| 2021 Julio | 35 | 28 | 63 |
| 2021 Junio | 23 | 28 | 51 |
| 2021 Mayo | 33 | 34 | 67 |
| 2021 Abril | 114 | 72 | 186 |
| 2021 Marzo | 59 | 39 | 98 |
| 2021 Febrero | 48 | 33 | 81 |
| 2021 Enero | 28 | 32 | 60 |
| 2020 Diciembre | 37 | 16 | 53 |
| 2020 Noviembre | 24 | 14 | 38 |
| 2020 Octubre | 27 | 5 | 32 |
| 2020 Septiembre | 23 | 10 | 33 |
| 2020 Agosto | 32 | 24 | 56 |
| 2020 Julio | 25 | 16 | 41 |
| 2020 Junio | 42 | 24 | 66 |
| 2020 Mayo | 29 | 10 | 39 |
| 2020 Abril | 32 | 21 | 53 |
| 2020 Marzo | 29 | 14 | 43 |
| 2020 Febrero | 5 | 0 | 5 |
| 2020 Enero | 4 | 0 | 4 |
| 2019 Diciembre | 8 | 3 | 11 |
| 2019 Noviembre | 4 | 0 | 4 |
| 2019 Septiembre | 8 | 0 | 8 |
| 2019 Agosto | 4 | 0 | 4 |
| 2019 Julio | 4 | 0 | 4 |
| 2019 Junio | 6 | 10 | 16 |
| 2019 Mayo | 5 | 16 | 21 |
| 2019 Abril | 2 | 1 | 3 |
| 2019 Marzo | 2 | 7 | 9 |
| 2019 Febrero | 2 | 0 | 2 |
| 2019 Enero | 1 | 0 | 1 |
| 2018 Diciembre | 2 | 0 | 2 |
| 2018 Noviembre | 1 | 0 | 1 |
| 2018 Octubre | 2 | 0 | 2 |
| 2018 Septiembre | 1 | 0 | 1 |
| 2018 Mayo | 0 | 1 | 1 |
| 2018 Abril | 0 | 2 | 2 |
| 2018 Febrero | 58 | 5 | 63 |
| 2018 Enero | 67 | 14 | 81 |
| 2017 Diciembre | 63 | 11 | 74 |
| 2017 Noviembre | 54 | 13 | 67 |
| 2017 Octubre | 46 | 11 | 57 |
| 2017 Septiembre | 70 | 17 | 87 |
| 2017 Agosto | 85 | 17 | 102 |
| 2017 Julio | 59 | 4 | 63 |
| 2017 Junio | 80 | 14 | 94 |
| 2017 Mayo | 65 | 20 | 85 |
| 2017 Abril | 74 | 10 | 84 |
| 2017 Marzo | 63 | 30 | 93 |
| 2017 Febrero | 41 | 10 | 51 |
| 2017 Enero | 42 | 16 | 58 |
| 2016 Diciembre | 84 | 18 | 102 |
| 2016 Noviembre | 101 | 20 | 121 |
| 2016 Octubre | 126 | 13 | 139 |
| 2016 Septiembre | 169 | 13 | 182 |
| 2016 Agosto | 73 | 8 | 81 |
| 2016 Julio | 44 | 4 | 48 |
| 2016 Junio | 12 | 8 | 20 |
| 2016 Mayo | 6 | 6 | 12 |
| 2016 Abril | 5 | 3 | 8 |
| 2016 Marzo | 12 | 0 | 12 |
| 2016 Febrero | 5 | 2 | 7 |
| 2016 Enero | 9 | 5 | 14 |
| 2015 Diciembre | 16 | 3 | 19 |
| 2015 Noviembre | 43 | 8 | 51 |
| 2015 Octubre | 45 | 2 | 47 |
| 2015 Septiembre | 35 | 4 | 39 |
| 2015 Agosto | 24 | 9 | 33 |
| 2015 Julio | 140 | 7 | 147 |
| 2015 Junio | 75 | 7 | 82 |
| 2015 Mayo | 93 | 12 | 105 |
| 2015 Abril | 103 | 8 | 111 |
| 2015 Marzo | 121 | 12 | 133 |
| 2015 Febrero | 112 | 11 | 123 |
| 2015 Enero | 88 | 21 | 109 |
| 2014 Diciembre | 105 | 9 | 114 |
| 2014 Noviembre | 76 | 11 | 87 |
| 2014 Octubre | 91 | 22 | 113 |
| 2014 Septiembre | 109 | 15 | 124 |
| 2014 Agosto | 91 | 16 | 107 |
| 2014 Julio | 88 | 26 | 114 |
| 2014 Junio | 125 | 12 | 137 |
| 2014 Mayo | 93 | 14 | 107 |
| 2014 Abril | 37 | 4 | 41 |
| 2014 Marzo | 58 | 12 | 70 |
| 2014 Febrero | 43 | 10 | 53 |
| 2014 Enero | 46 | 9 | 55 |
| 2013 Diciembre | 71 | 12 | 83 |
| 2013 Noviembre | 42 | 4 | 46 |
| 2013 Octubre | 28 | 4 | 32 |
| 2013 Septiembre | 23 | 8 | 31 |
| 2013 Agosto | 27 | 23 | 50 |
| 2013 Julio | 17 | 13 | 30 |
| 2013 Junio | 14 | 19 | 33 |
| 2013 Mayo | 15 | 13 | 28 |
| 2013 Abril | 8 | 16 | 24 |
| 2013 Marzo | 14 | 13 | 27 |
| 2013 Febrero | 31 | 5 | 36 |
| 2013 Enero | 60 | 6 | 66 |
| 2012 Diciembre | 36 | 7 | 43 |
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