A Rare Case of Isolated Hepatocellular Carcinoma Metastasis in Left Mandibular Region in a Patient with Hepatitis C Virus Liver Cirrhosis Diagnosed after the Onset of COVID-19 Infection

Abstract

Background and Objectives: Hepatocellular carcinoma (HCC) most frequently metastasizes in the lungs, abdominal lymph nodes and adrenal glands. Metastatic spread to the head and neck area is extremely rare. In the presented case, an uncommon site of solitary metastatic spread of HCC to the mandible confirmed after the core biopsy of the lesion is reported. There have been only about 80 cases of mandibular HCC metastases described in the literature to date. We contribute our experience to the pool of data. Case presentation: A 65-year-old female with HCV-related liver cirrhosis was diagnosed with an HCC that was successfully treated with liver resection. Subsequently, the patient had developed COVID-19 disease, which was associated with a painless swelling in the left jaw. A neck MDCT scan demonstrated an osteolytic soft-tissue mass in the left mandible, with the characteristics consistent for the metastasis of HCC. In order to confirm the diagnosis, a core biopsy of the mandibular mass was performed. The pathohistological evaluation confirmed the presence of a metastatic HCC in the mandible. No other sites of disease dissemination were identified in extensive MDCT scans. Despite considering various treatments, including symptomatic and palliative, the patient's overall prognosis remained poor. Conclusions: Isolated metastases of HCC to the orofacial region are extremely rare; however, it should be considered in patients with known risk factors for HCC development. Early diagnosis is critical, and clinicians should consider this possibility of HCC spread when assessing patients with orofacial swelling, among those patients with risk factors for HCC. The overall prognosis for such patients remains poor, emphasizing the challenges in managing these cases.

Keywords: biopsy; diagnosis; hepatocellular carcinoma; mandible; metastasis.

Figure 1

Axial (A) and sagittal (B) images of a contrast-enhanced CT scan obtained in the arterial phase reveal the presence of a solitary, hypervascular liver tumor in segment VIII of the liver (arrows), with washout in portal venous phase (not shown in these images), consistent with the radiological features of an HCC in the setting of a cirrhotic liver.

Figure 2

Axial (A) and sagittal (B) images of contrast-enhanced neck CT scan show a large, lobulated and intensively opacified osteolytic soft-tissue mass in the left mandible angle and ramus (arrows), extending from the base of the skull to the mandibular angle. Infiltration of masticatory muscles is observed as well. The volume-rendered images show destructed left mandibular ramus and mandible angle (arrowheads) due to tumor invasion (C), as well as an image of vascular 3D reconstruction, which shows highly vascularized tumor (arrowhead) (D).

Figure 3

The ultrasound image of the left mandibular region mass obtained during the percutaneous ultrasound-guided core needle biopsy (arrow) shows the core biopsy needle inside the left mandibular region mass.

Figure 4

Percutaneous core needle biopsy sample of the tumorous infiltration in mandibular region reveals histological findings completely consistent with previously diagnosed trabecular type of HCC.