Distant metastasis of hepatocellular carcinoma to Meckel's cave and cranial nerves: A case report and review of literature

Abstract

Background: Metastasis occurs as a late event in the natural history of hepatocellular carcinoma (HCC), and most patients die of liver failure attributed to the tumor supplanting the liver. Conversely, the brain is a less common metastatic site.

Case summary: We describe a rare case of hepatitis C virus-related multiple HCC metastasizing to the cavernous sinus, Meckel's cave, and the petrous bone involving multiple cranial nerves in an 82-year-old woman. At admission imaging studies including Gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (MRI) revealed multiple HCC nodules in both right and left lobes. Ultrasound guided biopsy of the left lobe revealed moderately differentiated HCC. Molecular targeted therapy with Lenvatinib (8 mg/d for 94 d, per os) and Ramucirumab (340 mg/d and 320 mg/d, two times by intravenous injection) were administered for 4 mo, resulting in progression of the disease. Three months after the start of molecular target therapy, the patient presented with symptoms of hyperalgesia of the right face and limited abduction of the right eye, indicating disturbances in the right trigeminal and abducens nerves. Brain MRI disclosed a mass involving the cavernous sinus, Meckel's cave and the petrous bone. Contrast-enhanced MRI with gadolinium-chelated contrast medium revealed a well-defined mass with abnormal enhancement around the right cavernous sinus and the right Meckel's cave.

Conclusion: The diagnosis of metastatic HCC to the cavernous sinus, Meckel's cave, and the petrous bone was made based on neurological findings and imaging studies including MRI, but not on histological examinations. Further studies may provide insights into various methods for diagnosing HCC metastasizing to the craniospinal area.

Keywords: Abducens nerve; Case report; Hepatocellular carcinoma; Magnetic resonance imaging; Meckel’s cave; Trigeminal nerve.

Figure 1

Imaging findings and histopathological findings. A: Ethoxybenzyl magnetic resonance imaging (MRI), hypervascular hepatocellular carcinoma (HCC) in the right and left lobes; B: Brain MRI [T2-weighted image (T2WI)], no findings in the cavernous sinus or Meckel’s cave; C: Brain MRI [T1-weighted image (T1WI)], intact findings of bone marrow in the petrous bone; D: Brain MRI (T2WI), low intensity mass in the right Meckel’s cave (arrow); E: Brain MRI (T1WI), loss of normal fatty bone marrow signal intensity in the right petrous bone (or apex); F: Brain MRI (T2WI), low intensity mass around the right cavernous node, the right Meckel's cave, and the right petrous bone on T2WI; G: Histopathological finding (hematoxylin and eosin staining), moderately differentiated HCC; H: Contrast enhanced MRI, well-defined mass with abnormal enhancement in the right cavernous sinus, and the right Meckel’s cave (arrow). L: left; R: Right.