Intractable bleeding from solitary mandibular metastasis of hepatocellular carcinoma

Abstract

Hepatocellular carcinoma (HCC) metastasizes to the mandible is infrequently seen. Solitary bony metastasis to the mandible is rarer. The intractable bleeding caused by rupture of the metastatic HCC is challenging to clinicians. We present a case of a 74-year-old woman with HCC under control without progression for 3 years. Left facial swelling and episodes of bleeding developed recently and biopsy revealed a metastatic HCC. Computer tomography showed a large tumor in parapharyngeal space with evident mandibular ramus destruction. Bleeding occurred from the metastatic tumor but could not be controlled by electrocauterization, Surgical, tissue glue, and bone wax and angiographic embolization. Palliative radiotherapy (2400 cGy in 6 fractions) was tried and the intractable bleeding was successfully stopped after the radiotherapy. Because of the hypervascular and osteolytic nature of the solitary mandibular metastatic lesion, the bleeding was troublesome. Radiotherapy provided successful control of intractable bleeding from the metastatic tumor.

Figure 1

Axial and coronal CT scan of the neck with intravenous contrast showing a 6.2 cm х 5.0 cm, heterogeneously enhancing mass, which appears to be a left parapharyngeal mass involving the pterygoid muscle and temporal muscle (A and B); axial and coronal CT scan of the head and neck showing a 4.0 cm х 2.5 cm mass which shrunk after completion of radiotherapy (C and D).

Figure 2

Histopathology of the metastatic lesion. A: The tumor is composed of polygonal cells featuring abundant clear to eosinophilic cytoplasm and microvesicular fatty change, and the tumor cells are arranged in broad trabeculae surrounded by sinusoid spaces which are characteristic of hepatocellular carcinoma (HE, х 100); B: Histology of the metastatic tumor (HE, x 200); C: The tumor cells showing immunoreactivity to Hep Par-1 with a cytoplasmic granular staining pattern (х 200); D: The tumor cells showing focal immunoreactivity to AFP (х 200).