A maxillary mass in a HBV-cirrhotic patient

Liver International Image DOI:10.1111/j.1478-3231.2012.02780.x A maxillary mass in a HBV-cirrhotic patient Case A 66-year-old Chinese male with cirrhosis secondary to chronic hepatitis B presented with a rapidly growing mass on his oral mucosa. The patient had undergone a right hemi-hepatectomy followed by 131 I-lipiodol fol- lowing detection of hepatocellular carcinoma (HCC) 7 years earlier. Sorafenib was commenced for hepatic tumour recurrence with pulmonary metastases 9 months later. He achieved 5 years of successful tumour suppression until the development of a non-healing leg ulcer necessitated skin grafting and drug discontinua- tion. At the time of presentation he had been off sorafenib for 6 months. Physical examination revealed a large fungating mass extending from the maxillary gingival mucosa (Fig. 1a). Computed tomography revealed extension into the oral cavity with signiﬁcant bony destruction (Fig. 1b). Biopsy of the lesion conﬁrmed well-differen- tiated metastatic HCC; immunohistochemical staining with Hep-Par 1 strongly positive (Fig. 1c). The patient underwent tumour debulking and a partial anterior maxillectomy [surgical specimen shown (Fig. 1d)]. Three months after resection, the surgical margins remained clear of macroscopic recurrence. Sorafenib was not recommenced. The multi-kinase inhibitor sorafenib induces disease stabilisation and improves overall survival, however, its use can cause delayed wound healing and tumour resistance (1). Only 25% of patients with HCC will develop extrahepatic metastases. Common sites include the lungs (18–55%), regional lymph nodes (26–53%), bones (5–38%) and adrenal glands (8–15%) (2). Max- illofacial metastases are often seen in association with pulmonary disease, with tumour spread thought to arise through the hepatic and/or portal vasculature (3). Although mandibular disease has been widely described, isolated maxillary metastases are extremely rare (3). Acknowledgements Dr Jasveen Renthawa and Dr Katrina Tang for histo- pathology and gross pathology images respectively. Vi Nguyen 1 , Jacob George 1,2 , David van der Poorten 1,2 1 Storr Liver Unit, Westmead Hospital, Sydney, Australia 2 Westmead, Millenium Institute, University of Sydney at Westmead Hospital, Sydney, Australia References 1. Llovet JM, Ricci S, Mazzaferro V, et al. Sorafenib in advanced hepatocellular carcinoma. N Engl J Med 2008; 359: 378–90. 2. Natsuizaka M, Omura T, Akaike T, et al. Clinical features of hepatocellular carcinoma with extrahepatic metastases. J Gastroenterol Hepatol 2005; 20: 1781–7. 3. Okada H, Kamino Y, Shimo M, et al. Metastatic hepatocellular carcinoma of the maxillary sinus: a rare autopsy case without lung metastasis and review. Int J Oral Max- illofac Surg 2003; 32: 97–100. (a) (b) (c) (d) Liver International (2012) © 2012 John Wiley & Sons A/S 988 Liver International ISSN 1478-3223

Upload
vi-nguyen
Category

Documents
view
215
download
0

Embed Size (px):

Transcript of A maxillary mass in a HBV-cirrhotic patient

Page 1: A maxillary mass in a HBV-cirrhotic patient

Liver International Image

DOI:10.1111/j.1478-3231.2012.02780.x

A maxillary mass in a HBV-cirrhotic patient

Case

A 66-year-old Chinese male with cirrhosis secondary tochronic hepatitis B presented with a rapidly growingmass on his oral mucosa. The patient had undergone aright hemi-hepatectomy followed by 131I-lipiodol fol-lowing detection of hepatocellular carcinoma (HCC) 7years earlier. Sorafenib was commenced for hepatictumour recurrence with pulmonary metastases 9months later. He achieved 5 years of successful tumoursuppression until the development of a non-healing legulcer necessitated skin grafting and drug discontinua-tion. At the time of presentation he had been off sorafe-nib for 6 months.

Physical examination revealed a large fungatingmass extending from the maxillary gingival mucosa(Fig. 1a). Computed tomography revealed extensioninto the oral cavity with significant bony destruction(Fig. 1b). Biopsy of the lesion confirmed well-differen-tiated metastatic HCC; immunohistochemical stainingwith Hep-Par 1 strongly positive (Fig. 1c).

The patient underwent tumour debulking and apartial anterior maxillectomy [surgical specimenshown (Fig. 1d)]. Three months after resection, thesurgical margins remained clear of macroscopic recur-rence. Sorafenib was not recommenced.

The multi-kinase inhibitor sorafenib induces diseasestabilisation and improves overall survival, however,its use can cause delayed wound healing and tumourresistance (1). Only 25% of patients with HCC willdevelop extrahepatic metastases. Common sites includethe lungs (18–55%), regional lymph nodes (26–53%),bones (5–38%) and adrenal glands (8–15%) (2). Max-illofacial metastases are often seen in association withpulmonary disease, with tumour spread thought toarise through the hepatic and/or portal vasculature(3). Although mandibular disease has been widelydescribed, isolated maxillary metastases are extremelyrare (3).

Acknowledgements

Dr Jasveen Renthawa and Dr Katrina Tang for histo-pathology and gross pathology images respectively.

Vi Nguyen1, Jacob George1,2, David van der Poorten1,2

1 Storr Liver Unit, Westmead Hospital, Sydney, Australia2Westmead, Millenium Institute, University of Sydney at

Westmead Hospital, Sydney, Australia

References

1. Llovet JM, Ricci S, Mazzaferro V, et al. Sorafenib inadvanced hepatocellular carcinoma. N Engl J Med 2008;359: 378–90.

2. Natsuizaka M, Omura T, Akaike T, et al. Clinical featuresof hepatocellular carcinoma with extrahepatic metastases.J Gastroenterol Hepatol 2005; 20: 1781–7.

3. Okada H, Kamino Y, Shimo M, et al. Metastatic hepato-cellular carcinoma of the maxillary sinus: a rare autopsycase without lung metastasis and review. Int J Oral Max-illofac Surg 2003; 32: 97–100.

(a)

(b)

(c)

(d)

Liver International ISSN 1478-3223