Track

Case Reports

Abstract

Hepatocellular carcinoma (HCC) rarely metastasizes to the skin and its presence signals a worse prognosis. Metastatic cutaneous HCC is often poorly differentiated making the diagnosis challenging. There exists a male predominance, with nodules or papules resembling pyogenic granulomas or dermal deposits. Histopathology shows atypical dermal cells. Hepatoid features including nests or cords of cells arranged in a trabecular or pseudo-glandular pattern, capillary and sinusoidal involvement, or the presence of bile exist in under 50% of cases.  Limitations exist with immunostaining, especially in poorly differentiated neoplasms. Albumin in situ hybridization (ISH) is more sensitive for detecting poorly differentiated HCC. Immunostaining in conjugation with albumin ISH can maximize the detection of metastatic HCC. We report the case of a 74-year-old male with a history of HCC and a stable lung metastasis who presented with painful, growing bumps on his nose for two months.  Exam revealed multiple, pink to white, shiny dermal based papules with telangiectasias involving the right nasal tip and naris.  Alpha-fetoprotein level was markedly elevated. Computed tomography showed expanding right lower lobe lung nodules.  Histopathology of the cutaneous biopsy revealed features of a poorly differentiated basaloid carcinoma.  Immunohistochemical staining was diffusely positive for glypican-3, focally positive for arginase-1, and negative for HepPar-1.  Albumin ISH was diffusely positive, clinching the diagnosis of HCC. Metastatic HCC is a rare encounter for dermatopathologists. We aim to increase awareness of its occurrence in patients with advanced HCC and to highlight the importance of clinical correlation when faced with poorly differentiated or unusual-looking basaloid neoplasms.