Metastatic hepatocellular carcinoma presenting as facial nerve palsy and facial pain

Article (PDF Available) · December 2011with25 Reads
DOI: 10.3350/kjhep.2011.17.4.319 · Source: PubMed
Abstract
Facial nerve palsy due to temporal bone metastasis of hepatocellular carcinoma (HCC) has rarely been reported. We experienced a rare case of temporal bone metastasis of HCC that initially presented as facial nerve palsy and was diagnosed by surgical biopsy. This patient also discovered for the first time that he had chronic hepatitis B and C infections due to this facial nerve palsy. Radiation therapy greatly relieved the facial pain and facial nerve palsy. This report suggests that hepatologists should consider metastatic HCC as a rare but possible cause of new-onset cranial neuropathy in patients with chronic viral hepatitis.
The Korean Journal of Hepatology 2011;17:319-322
http://dx.doi.org/10.3350/kjhep.2011.17.4.319
Case Report
Metastatic hepatocellular carcinoma presenting as facial
nerve palsy and facial pain
Jong In Yang
1
, Jung Mook Kang
1
, Hee Jin Byun
2
, Go Eun Chung
1
, Jeong Yoon Yim
1
, Min Jung Park
1
,
Jeong-Hoon Lee
3
, Jung Hwan Yoon
3
, and Hyo Suk Lee
3
1
Departement of Internal Medicine, Seoul National University Hospital Gangnam Healthcare Center,
Seoul National University College of Medicine;
2
Department of Dermatology and
3
Departement of Internal
Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
Facial nerve palsy due to temporal bone metastasis of hepatocellular carcinoma (HCC) has rarely been reported. We
experienced a rare case of temporal bone metastasis of HCC that initially presented as facial nerve palsy and was
diagnosed by surgical biopsy. This patient also discovered for the first time that he had chronic hepatitis B and C infections
due to this facial nerve palsy. Radiation therapy greatly relieved the facial pain and facial nerve palsy. This report suggests
that hepatologists should consider metastatic HCC as a rare but possible cause of new-onset cranial neuropathy in
patients with chronic viral hepatitis. (Korean J Hepatol 2011;17:319-322)
Keywords: Metastasis; Hepatocellular carcinoma; Temporal bone; Cranial nerve palsy
Received January 7, 2011; Revised July 6, 2011; Accepted July 20, 2011
Abbreviations: HCC, hepatocellular carcinoma; MRI, magnetic resonance image; PET, positron emission tomography; HBsAg, hepatitis B surface
antigen; HBeAg, hepatitis B envelop antigen; anti-HCV, antibody to hepatitis C virus; TACE, transarterial chemoembolization
Corresponding author: Jong In Yang
Department of Internal Medicine, Seoul National University Hospital Gangnam Healthcare Center, 737 Yeoksam-dong, Gangnam-gu,
Seoul 135-984, Korea
Tel. +82-2-2112-5646, Fax. +82-2-2112-5635, E-mail; dr1004@snu.ac.kr
Copyright 2011 by The Korean Association for the Study of the Liver
The Korean Journal of HepatologypISSN: 1738-222X eISSN: 2093-8047
INTRODUCTION
Temporal bone metastasis of hepatocellular carcinoma
(HCC) has rarely been reported.
1
Only one case of facial
nerve palsy due to temporal bone metastasis of HCC has
been reported and it was detected by autopsy.
2
We
encountered a case of metastatic HCC to the temporal region
of the skull that initially presented as facial nerve palsy and
was incidentally found during the diagnostic work up.
CASE REPORT
A 61-year-old man visited our hospital because of
progressively worsening right facial pain and numbness
over a 6-month period. The pain had developed insidiously
and had been occurring intermittently. He could not make
abrupt facial expressions on the right side of his face for
seven days before he came to our hospital. He had a squeezing
headache on the right side of his head. He had no history of
previous illness.
On physical examination, he had paresthesia and
hypesthesia over all territories of 3 branches of the trigeminal
nerve, facial palsy in the right side of his face, and hearing
loss without tinnitus in his right ear. Other cranial nerve
examinations were normal. In nasopharyngeal magnetic
resonance image (MRI), a 5-cm, heterogeneously enhancing
tumor was found in T1 weighted image (Fig. 1). The tumor
was located in the masticator space and right middle cranial
fossa, abutting the right cavernous sinus and extending
intracranially to the right ipsilateral infratemporal fossa. The
tumor was hypermetabolic in positron emission tomography
(PET) study using C-11-methionine, which suggested that
the tumor might be a malignant lesion (Fig. 2). Bony
destruction of the anterior wall, which was adjacent to the
320 The Korean Journal of Hepatology Vol. 17. No. 4, December 2011
Figure 1. T1-weighted MRI of the nasopharyngeal region revealed
a 5-cm heterogeneously enhanced mass (arrow) located mainly
in the right masticator space and middle cranial fossa, abutting
the right cavernous sinus and with an intracranial extension to
the right ipsilateral infratemporal fossa.
Figure 2. C-11-methionine PET revealed a hypermetabolic lesion
(arrow) at the right temporal lobe of the brain, suggesting a
malignant tumor.
Figure 3. Photomicrograph of the biopsy specimen showing
cords of large neoplastic cells with oval nuclei resembling
hepatocytes (arrow), which suggests metastasis of hepatocellular
carcinoma (H&E stain, ×200).
Figure 4. Immunohistochemistry of the biopsy specimen with
anti-alpha-fetoprotein antibody revealed a diffusely stained pattern
over cords of large neoplastic cells with oval nuclei resembling
hepatocytes (arrow), which is consistent with a metastasis of
hepatocellular carcinoma (alpha-fetoprotein, ×200).
anterior genu portion of the facial nerve, was suspected to be
the cause of facial nerve palsy.
The patient was admitted for surgical biopsy of the tumor.
His laboratory findings were as follows: white blood cell
count was 6,900 per mm
3
, hemoglobin was 15.3 g/dL,
platelet was 152,000 per mm
3
, serum albumin was 3.4 g/dL,
total bilirubin was 1.1 mg/dL, alkaline phosphatase was
134 IU/L, aspartate aminotransferase was 97 IU/L, alanine
aminotransferase was 192 IU/L, gamma glutamyltransferase
was 131 IU/L, and prothrombin time evealed 1.1 international
normalized ratio. The serologic finding revealed positive for
hepatitis B surface antigen (HBsAg), antibody to hepatitis B
envelop antigen (HBeAg) and antibody to hepatitis C virus
(anti-HCV). His serum hepatitis B virus DNA level was
97,200 IU/mL. Serum alpha-fetoprotein was 5,200 ng/mL
and des-gamma- carboxy prothrombin was 17,268 nAU/mL.
Endoscopic surgical biopsy with sphenoidotomy via the
right nasal cavity was performed by an otolaryngologist.
During surgical biopsy, a bulging tumor was found adjacent
Jong In Yang, et al. Hepatocellular carcinoma presented as facial nerve palsy 321
Figure 5. Abdominal CT revealed a 5-cm fat-containing, ill-defined, and subtly enhanced mass lesion in segment 8 (arrow) in the
cirrhotic liver. (A) precontrast, (B) arterial phase, (C) portal phase.
to the inferolateral wall through the destroyed bone. The
pathological finding was consistent with metastatic HCC
(Fig. 3). Immunohistochemical findings of the biopsy
specimen revealed positive staining for alpha-fetoprotein,
which was also consistent with metastatic HCC (Fig. 4).
Other metastases were found in lumbar spines (L1, L2) and
right femur in bone scan. Radiation therapy was performed
for the tumor in the masticator space and right middle cranial
fossa and for the metastatic lesions in lumbar spines and
right femur. After radiation therapy was finished, his facial
pain subsided significantly and his facial nerve palsy was
partially relieved. Facial pain did not occur again and facial
nerve palsy did not progress until 7 months later.
To evaluate the primary HCC in liver, abdominal computed
tomography (CT) was performed. A 5-cm-sized, fat-containing,
ill-defined and subtly enhanced mass lesion was found in
segment 8 in the cirrhotic liver (Fig. 5). Although repeated
transarterial chemoembolization (TACE) was tried 3 times
over 7 months to treat this tumor, only marginal lipiodol
uptake was observed with each TACE.
Seven months after initial diagnosis of metastatic HCC,
back pain occurred over 2 weeks. Bone scan and spinal MRI
showed progressed spinal metastasis. As no therapy remained
for the multiple spinal metastases, the patient was transferred
to a hospital near his home for supportive care.
DISCUSSION
Temporal bone metastasis of HCC has rarely been
reported.
2
Though HCC commonly metastasizes to bone,
metastasis of HCC to skull is uncommon.
3
Facial palsy due
to HCC was reported once in an advanced cirrhotic patient
after autopsy.
2
Therefore, our report might be the first case
report of metastatic HCC to the temporal region of skull
involving the facial and trigeminal nerve, as confirmed
by surgical biopsy.
2
Metastatic HCC was diagnosed by
surgical biopsy in this case. Even if HCC had been found in
liver prior to performing the biopsy of temporal metastatic
lesion, tissue confirmation of the lesion in temporal area
would have been done for proper management because exact
diagnosis was needed for proper management and because
the lesion could have been an isolated double primary tumor
such as schwannoma.
As far as temporal bone metastasis of malignant tumors,
bilateral temporal bone involvements are more common
than unilateral involvement, but in this patient and the
previous autopsy-proven case of temporal bone metastasis
of HCC, the lesions were only on the right side.
2
Hearing
loss without vestibular manifestation was reported as the
most common symptom of temporal bone metastases in a
retrospective study of 47 autopsy cases, which was
consistent with this case.
4
In the case of facial palsy
secondary to metastasis, involvement of other cranial nerves
was more common than involvement of the facial nerve
alone, which was also consistent with this case.
4
Radiological
investigation is strongly recommended if the facial nerve
palsy is clinically associated with other neurological signs.
5,6
Bone and brain metastases of HCC have been treated with
palliative radiation therapy and pain relief has been observed
in about 78% of patients, suggesting good responsiveness to
radiation.
7
Therefore, we performed radiation therapy for
the metastatic lesion in the temporal area and the pain
completely subsided. Our case may suggest that temporal
bone metastasis of HCC is also a very good indication for
radiation therapy.
Hepatic dysfunction is known to be the main prognostic
ABC
322 The Korean Journal of Hepatology Vol. 17. No. 4, December 2011
factor in patients with HCC, even in patients with extrahepatic
metastasis. The major survival factor for our patient might
also be the progression of hepatic dysfunction.
8,9
Sorafenib
treatment might have been considered in this patient because
the intrahepatic HCC progressed despite repeated TACE;
however, sorafenib was not available during our caring for
him.
10,11
In summary, we encountered a very rare case of histo-
logically proven temporal bone metastasis of HCC that was
found during the evaluation of a patient who presented with
trigeminal, facial and auditory nerve dysfunction and who
was positive for both HBsAg and anti-HCV but without
previous history of illness. Our case suggests that hepatolo-
gists may consider metastatic HCC as a rare cause of new
onset cranial nerve palsy in patients with chronic viral
hepatitis, and radiation therapy may be considered for the
treatment of temporal bone metastasis of HCC with cranial
nerve involvement.
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1. Gloria-Cruz TI, Schachern PA, Paparella MM, Adams GL, Fulton SE.
Metastases to temporal bones from primary nonsystemic malignant
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Facial nerve palsy due to temporal bone metastasis from hepatocellular
carcinoma. J Gastroenterol Hepatol 2005;20:1131-1132.
3. Goto T, Dohmen T, Miura K, Ohshima S, Yoneyama K, Shibuya T, et al.
Skull metastasis from hepatocellular carcinoma with chronic hepatitis
B. World J Gastrointest Oncol 2010;2:165-168.
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6. Alaani A, Hogg R, Saravanappa N, Irving RM. An analysis of
diagnostic delay in unilateral facial paralysis. J Laryngol Otol 2005;
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7. Hawkins MA, Dawson LA. Radiation therapy for hepatocellular
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8. Kim SU, Kim DY, Park JY, Ahn SH, Nah HJ, Chon CY, et al.
Hepatocellular carcinoma presenting with bone metastasis: clinical
characteristics and prognostic factors. J Cancer Res Clin Oncol
2008;134:1377-1384.
9. Stuart KE, Anand AJ, Jenkins RL. Hepatocellular carcinoma in the
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Cancer 1996;77:2217-2222.
10. Llovet JM, Ricci S, Mazzaferro V, Hilgard P, Gane E, Blanc JF, et al.
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  • [Show abstract] [Hide abstract] ABSTRACT: Hepatocellular carcinoma (HCC) is the most common malignant cancer of the liver and the third ranking cause of cancer-related mortality worldwide. Following the diagnosis of HCC, intrahepatic and extrahepatic metastasis patients account for ~50-75% of all HCC cases, lung and regional lymph nodes metastasis are the most common; metastasis to bone, skin and adrenal glands are rare, orbit metastasis and intracranial invasion are extremely rare. The present study reports the rare case of a patient with HCC that metastasized to the head. The patient presented with retrobulbar and intracranial invasion, and sub-scalp extension. Based on imaging findings, the lesion was initially misdiagnosed as meningioma, however, postoperative pathological examinations resulted in a definitive diagnosis of HCC metastasis. Based on the present case and a review of the relevant literature published since 2009, the current study recommends that metastasis must be considered when diagnosing retrobulbar head lesions in patients with HCC, regardless of contradictory imaging findings and other clinical indicators, which may closely mimic the original head lesion.
    Full-text · Article · Feb 2015

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