Abstract | November 16, 2023
Solitary Scalp Metastasis – A rare presentation of Hepatocellular Carcinoma
Learning Objectives
- When observing skin lesions, it is important to keep metastatic disease on the differential, emphasizing the need for a thorough history and physical examination.
- HCC is the only solid tumor cancer which does not require biopsy if liver imaging criteria are diagnostic. Rare presentation requires multidisciplinary approach and tissue diagnosis.
Introduction:
About 30,000 people in the US are diagnosed with hepatocellular carcinoma (HCC) every year (1). The most common sites of metastasis for hepatocellular carcinoma are the lungs, lymph nodes and bones. However, because of the rarity of the presentation, the differential for firm scalp lesions often does not include metastatic disease from solid tumors (2). We are reporting on a 76-year-old male who presented with a painless scalp solitary lump, which was found to be a metastatic deposit of HCC.
Case Presentation:
A 56-year-old male presented with a lump on the vertex of his skull which had grown quickly to the size of a quarter in the last month. He had no history of trauma or injury and came to the emergency department because of mild intermittent tenderness and mild blurred vision in the mornings. He denied headaches, nausea or vomiting and denied any local itching, drainage, or bleeding. Examination revealed, a well localized, oval-shaped, non-tender, approximately 5 cm swelling, eccentrically posterior, and to the left from midline, that appeared dark in color with rough surface and firm consistency. No bleeding or drainage was noted. His examination was otherwise unremarkable with no stigmata of chronic liver disease and no focal neurological signs. Laboratory testing was not remarkable.
Computed Tomography (CT) of the head revealed a lytic, calvarial mass at the vertex with intracranial and extracranial extension concerning for malignancy with no meningeal penetration.
The patient tested positive for hepatitis C. However, alpha-fetoprotein was not elevated and there was no laboratory evidence of hepatitis B infection.
Final diagnosis:
Core biopsy of the lesion was consistent with metastatic HCC, which was confirmed by immunohistochemical analysis. Further imaging revealed nodular liver with mass in the posterior segment of right hepatic lobe measuring 3.8 x 3.7 cm. MRI was not available for the patient because of retained foreign bodies.
Management/Follow-up:
Management with Cyber-Knife SBRT to the calvarial lesion with radioembolization of the right hepatic artery was applied. The patient also underwent systemic therapy bevacizumab and atezolizumab followed by Lenvatinib. He subsequently had progression and was transitioned to hospice.
References and Resources
- Cancer Facts and Figures page 18, American Cancer Society, 2023
- Raposo, A., Correia, A., Vaz, J., Alves, L., Morais, P. Firm nodule in the scalp. Australian Journal for General Practitioners; The Royal Australian College of General Practitioners (RACGP). 294-297:48
