Solitary skull metastasis as the first symptom of hepatocellular carcinoma: case report and literature review

Figures & data

Figure 1 CT of cranial bones.

Notes: (A) Bony window of cranial CT scan showed a 5 × 5 cm² soft tissue mass within the irregularly destructive area of the right parietal-occipital region of the skull. (B) Contrast-enhanced CT scan showed a hypervascular enhancement with osteolytic pathological change in the parietal-occipital region of the skull.
Abbreviation: CT, computed tomography.

Figure 2 MRI of cranial bones.

Notes: (A) T2-weighted MRI and (B) T1-weighted MRI demonstrated a homogeneous, well-defined, and isosignal intensity carcinoma in the right parietal-occipital region. (C) Gadolinium enhanced T1-weighted MRI images showed a strong enhancement of the carcinoma.
Abbreviation: MRI, magnetic resonance imaging.

Figure 3 Abdominal B ultrasound showed a large mass in the right lobe of the liver.

Figure 4 Contrast-enhanced computed tomography of abdomen showed a huge enhanced carcinoma in the liver.

Notes: (A) Plain. (B) Arterial phase. (C) Portal phase.

Figure 5 Computed tomography (CT) of breast showed no lung metastases.

Figure 6 Single-photon emission computed tomography of total skeletal bones showed no other metastases.

Table 1 Laboratory data on admission

Hematology	Blood chemistry	Serological tests	Coagulation tests
WBC 6.46 × 10^9/L	T-BiL 15.30 μmol/L	AFP 12511.0 ng/mL	PT 10.30 s
RBC 4.00 × 10^9/L	D-BiL 4.83 μmol/L	CEA 1.7 ng/mL	APTT 24.40 s
Hb 118.00 g/L	TP 59.60 g/L	CA 19-9 15.6 μ/mL	TT 15.70 s
Ht 29.5%	Alb 37.00 g/L	CYFRA 21-1 5.21 ng/mL	PT% 154.80%
Plate 110 × 10^9/L	Glb 22.60 g/L	HBsAg (+)	D-dimer 435.00 μg/L
	AST 37 μg/L	HCVAb (−)
	ALT 33 μg/L
	GGT 138 μg/L
	ALP 153 μg/L
	CHE 32 μg/L
	LDH 166 μg/L
	T-chol 3.56 mmol/L

Abbreviations: Hb, hemoglobin; Ht, hematocrit; Plate, platelets; RBC, red blood cells; WBC, white blood cells; T-Bil, total bilirubin; D-Bil, direct bilirubin; TP, total protein; Alb, albumin; Glb, globulin; AST, aspartate transaminase; ALT, alanine transaminase; GGT, gamma glutamyl transpeptidase; ALP, alkaline phosphatase; CHE, cholinesterase; LDH, lactate dehydrogenase; T-chol, total cholesterol; AFP, alpha fetal protein; CEA, carcinoembryonic antigen; CA 19-9, carbohydrate antigen 19-9; CYFRA 21-1, Cytokerantin-19-fragment CYFRA 21-1; HBsAg, hepatitis B surface antigen; HCVAb, hepatitis C virus antibody; PT, prothrombin time; APPT, activated partial thromboplastin time; TT, thrombin time; s, seconds.

Figure 7 The histopathological characteristics of carcinoma and the immunohistochemical finding.

Notes: (A) Histopathological characteristics of carcinoma. The carcinoma showed thick trabecular growth pattern with intercellular canaliculi resembling liver cell plates and sinusoids. The carcinoma cells maintain a polygonal shape and have abundant granular eosinophilic cytoplasm, round vesicular nuclei, and prominent nucleoli (HE ×200). (B) The immunohistochemical finding. The carcinoma cells show glypican-3 (+), AFP (−), villin (++), CK7 (−), CK20 (−), vimentin (−), CD10 (−), and Ki67 (+) of about 30%.
Abbreviations: HE, hematoxylin-eosin staining; AFP, alpha fetal protein; CK, creatine kinase; CD, cluster of differentiation or leukocyte differentiation antigen; Ki67, nuclear-associated antigen Ki67.

Table 2 Summary of reported cases in the literature with skull metastases from HCC (n=59)*

Period	Calvarial metastases	Skull base metastases	Facial skeleton metastases	Total
1966–1989	6	4	4	14
1990–2011	25	12	8	45
Total	31	16	12	59

Note:

* Fourteen cases in the literature with solitary skull metastases from HCC were reported.

Abbreviation: HCC, hepatocellular carcinoma.

Table 3 Summary of reported cases in the literature with skull metastases as the first symptom from HCC (n=33)

Period	Misdiagnosis*			Total
	Calvarial metastases	Skull base metastases	Facial skeleton metastases
1966–1989	4 (4)	0 (0)	1 (1)	5 (5)
1990–2011	10 (8)	7 (4)	2 (0)	19 (12)
Total	12	7 (4)	3 (1)	24 (17)

Note:

* The data in parentheses is the number of patients who were misdiagnosed.

Abbreviation: HCC, hepatocellular carcinoma.