Introduction: Hepatocellular carcinoma (HCC) is the fifth-most common cancer in the world and the third leading cause of cancer-related death. It accounts for 75% of liver cancers, with rapidly rising incidence rates in the USA. Treatment includes locoregional therapy, chemotherapy, surgery, and transplant if within Milan Criteria. Extrahepatic metastases of HCC occur in 30%-50% of patients. The most common sites include the lungs, lymph nodes, bone, and brain. Here we present a rare case of nasopharyngeal metastases of HCC after liver transplant.
Case Description/Methods: A 76-year-old female with alcoholic cirrhosis complicated by HCC with known metastases to the lungs and kidney status post (s/p) locoregional therapy and orthotopic liver transplant with an HBV core antibody positive donor liver (within Milan criteria), and non-Hodgkin’s lymphoma s/p XRT in remission presented to the ER with one month of right eye swelling and rhinorrhea without fever.
Vital signs were significant for chronic asymptomatic bradycardia and hypertension. Physical examination with right orbital swelling without pupillary or extraocular muscle abnormalities. No neurological deficits were noted.
Liver enzymes were AST 9 U/L, ALT 3 U/L, total bilirubin 0.4 mg/ dL (direct 0.1), INR 1.2. Serum AFP one month prior to presentation was 24.5 ng/mL. CBC showed WBC of 3.7 K/UL, hemoglobin 8.2 g/dL and PLT 186 K/UL. Computed tomography showed a large expansile infiltration centered at the right ethmoid and upper nasal cavity extending to the superior medial aspect of the orbit, with associated mass effect upon the frontal lobes.
Nasopharyngeal biopsies revealed poorly differentiated adenocarcinoma with immunostaining positive for heppar-1 compatible with metastatic HCC. The patient underwent bifrontal craniotomy for resection of the anterior skull base lesion, with a hospital course complicated by encephalopathy and sepsis necessitating ICU. The patient was discharged on comfort measures and hospice.
Discussion: HCC metastasizing to the nasopharynx is exceedingly rare. The first case report documenting an isolated nasopharyngeal metastasis from a liver primary was described by Kattepur et al in 2014. In our case, the patient reported swelling behind the right eye as the initial presentation of a metastatic HCC after liver transplant. In patients with history of HCC, clinicians should maintain a broad differential with clinical suspicion for uncommon presentations of extra hepatic metastases, even after liver transplant.
