A Rare Case of Cutaneous Metastasis of Hepatocellular Carcinoma to the Chin: Case Report and Review of Surgical Management

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Hepatocellular carcinoma (HCC) has an annual incidence of 1% to 6% worldwide, with untreated cases demonstrating life expectancy reductions to 9 months, dependent upon staging.^1,2 The etiology may be multifactorial, with hepatitis B, hepatitis C, cirrhosis, hemochromatosis, and nonalcoholic fatty liver disease as contributing factors, either singularly or in combination. HCC demonstrates metastasis in approximately one-third of cases, with typical propensity for lung, peritoneum, or bone.^3,4 Cutaneous HCC metastases are infrequent, comprising less than 1% of cases.³ The majority of reports detailing cutaneous metastases are attributed to iatrogenic seeding during biopsy or primary tumor extirpation,⁴ highlighting the rarity of true cutaneous metastasis.  Non-iatrogenic metastatic cutaneous spread is mainly to the head, neck, and upper chest regions.^5-7 Classically, lesions may appear nodular, papular, or ulcerated. While cutaneous metastases typically do not cause pain, they do significantly impact quality of life.^8-10 A high level of suspicion and confirmatory biopsy of potential metastatic lesions is indicated. The use of imaging studies such as computed tomography, magnetic resonance imaging, and positron emission tomography may be indicated, and use should be individualized and dependent on the clinical scenario.  

A 66-year-old man with a past medical history of hepatitis B, hyperlipidemia, and hypothyroidism was diagnosed with HCC confined to the liver in 2019. His initial management included partial hepatectomy with clear margins and no noted metastatic disease. A recurrent hepatic tumor and lung metastases were diagnosed 2 years later. Subsequent chemoembolization failed to control the disease. Concurrently, the patient noted a growing skin lesion on his chin that frequently hemorrhaged. A biopsy indicated metastatic HCC. The patient was referred to the plastic surgery clinic for evaluation and treatment.  

Physical exam

The patient was noted to have Fitzpatrick skin type V and facial hair routinely styled in a short beard. Physical examination revealed a 3.5 x 3.5-cm cutaneous exophytic mass located in the midline of the chin (Figure 1). The lesion was mobile, and preserved bilateral mental nerve sensation was noted. The motor function of the regional musculature remained intact, and the patient demonstrated oral competence. There was moderate skin laxity of the submentum and anterior neck with deep static transverse rhytids and minimal subcutaneous fat.

Figure 1: Preoperative photograph demonstrating a 3.5 x 3.5-cm exophytic cutaneous mass located in the midline of the chin consistent with biopsy-proven metastatic hepatocellular carcinoma.

Diagnostic studies

Initial biopsy results of the chin lesion were reported as “carcinoma consistent with metastatic hepatocellular carcinoma, lesion transected at the deep and peripheral inked margins.” Surveillance PET scan demonstrated several new subcentimeter lung nodules consistent with progressive distant metastasis.

Treatment

After collaborative discussion of the risks and benefits of palliative resection and reconstruction of the cutaneous lesion in the setting of metastatic HCC, excision was recommended. First-stage wide excision to the underlying musculature with wide margins was performed. A resultant 7 x 5-cm defect consisting of the chin subunit was temporized with placement of an Integra Bilayer Wound Matrix (Integra LifeSciences) and secured with a tie-over bolster (Figure 2). The specimen was sent for permanent pathologic evaluation of margins, which revealed adequate excision of the tumor with free margins.

Figure 2: Preoperative photograph at second-stage operation demonstrating a 7 x 5-cm open wound defect.

Reconstruction was performed 10 days after the index operation. The silicone layer of the wound matrix was removed, revealing a well-vascularized matrix. A 15 x 15-cm random pattern local skin advancement flap was designed caudal to the defect, incorporating the laxity of the submental and anterior neck skin. The flap was elevated in the pre-platysmal plane, extending to the level of the thyroid cartilage inferiorly and laterally to the anterior border of the masseter and sternocleidomastoid muscle bilaterally. The flap was advanced cephalad to resurface the entirety of the chin defect. Bilateral standing cutaneous deformities were addressed with M-plasties (Figure 3). A 10F Jackson-Pratt drain was placed subcutaneously in the neck. The patient was observed overnight and discharged on postoperative day 1 without issues.

Figure 3: Immediate postoperative photograph after inset of a 15 x 15-cm random pattern local advancement flap.

Follow-up

The flap healed well postoperatively, and the patient displayed preserved oral competence, full active neck range of motion, and intact mental nerve sensation (Figure 4). The patient proceeded with initiation of palliative immunochemotherapy with bevacizumab and atezolizumab for treatment of his other primary and metastatic sites.

Figure 4: One month postoperative, the incision was completely healed. The patient had intact oral competence and full neck range of motion.

HCC most frequently results from cirrhotic liver disease; up to 80% of cirrhotic cases develop into HCC.¹⁰ Prognosis for HCC is poor, with a survival rate averaging 9 months in the absence of medical or surgical treatment.² Further management is dependent on the surgical candidacy of the patient, as partial hepatectomy or liver transplantation are the only potentially curative measures.¹¹ A tumor size of less than 5 cm, fewer than 3 separate tumors, the absence of metastasis, and the absence of major vessel involvement are considerations for surgical extirpation.¹¹ For successful surgical cases, liver resection increases the 5-year survival rate to nearly 70%.¹² Recurrence rates of up to 80% have been reported following resection, necessitating close follow-up.¹² Surveillance after surgical management typically occurs every 6 months for up to 5 years after the procedure, with liver ultrasound in combination with alpha-fetoprotein screening being the most widely used modality.^13,14

Metastasis primarily to lung, peritoneum, or bone is indicative of a poorer prognosis.¹⁰ The median survival time is reduced to less than 5 months in cases of cutaneous metastasis.^10,15,16 The frequency of direct metastasis to the skin occurs in less than 1% of cases, highlighting its rarity.¹⁰ It is likely that the metastatic spread of HCC occurs in either a hematogenous or lymphatic fashion.¹⁰ The majority of cutaneous metastases of HCC are of iatrogenic origin, occurring during  liver biopsy or surgical excision of a primary HCC lesion at or near the incision site.^5,7 Palliative treatment options for those with recurrence or metastases after surgical intervention include transarterial chemoembolization, percutaneous ethanol injection, radiation, and immunochemotherapy with sorafenib or doxorubicin for more advanced stages.¹¹

The clinical appearance of cutaneous metastatic HCC skin lesions varies significantly. Some case reports describe small, nodular-appearing lesions,^5,15-17 while others describe prominent swollen masses.^5,7,10 Most of these lesions are painless and present above the level of the shoulders, with propensity for the face.^5-7 Confirmatory diagnosis of a cutaneous lesion is made by tissue biopsy. Advanced imaging may be indicated, dependent on cutaneous tumor character and size, location, or other concerns for deeper structure involvement.

The importance of recognizing and treating HCC is highlighted by the fact that the appearance of skin lesions indicates likely metastasis to other organ systems such as the lungs.¹⁰ Reports have indicated that cutaneous metastatic HCC may be the first sign of metastatic disease, alerting the need for additional investigation.^5,6

Because of the limited life expectancy of our patient, we recommended palliative operative intervention to maintain his quality of life. Our patient did not demonstrate coagulopathy or delayed healing that would preclude surgical management of his cutaneous metastasis. Proceeding with operative palliation of the lesion would likely reduce the need for ongoing wound care, limit visits to health care clinics, decrease the financial burden, prevent frequent hemorrhage, and improve his limited quality of life. The patient stressed the importance of maintaining his usual appearance to continue to engage socially for the remainder of his life without stigma. We prioritized options with a quick recovery to maximize his time spent outside of the hospital.

A number of options exist for submental reconstruction. A pedicled submental flap can affect defect closure and be completed with a single operation, providing limited morbidity of the donor site.¹⁸ Aesthetic debulking may be required. Contraindications include prior facial artery ligation or other previous extensive surgical procedures of the neck. Pectoralis major muscle or myocutaneous flaps are effective at providing reliable and rapid defect closure in this region.¹⁹ Free tissue transfer of various size, tissue components, and thickness can be considered dependent on the resulting defect; however, the added complexity and extended operative time should be weighed against the patient’s overall health, life expectancy, and possible delay in other ongoing treatments. Intraoperative flap vascularity, if in question, can be assessed by indocyanine green angiography or fluorescein dye/Wood lamp assessment/evaluation. Skin grafting may also be an option, but only in cases where a sufficient underlying tissue/wound bed is present.²⁰

In our management, a local advancement flap utilizing the redundancy of the submental and anterior neck skin and subcutaneous tissue was an ideal solution for this patient. It allowed reconstruction of the defect with like tissues, maintaining the patient’s normally styled facial hair. The operation was performed expeditiously, with minimal operative time. This rare case of metastatic HCC to the chin with palliative surgical management via local tissue advancement flap is an example of a treatment option that maintains patient dignity and quality of life in the context of a significantly shortened lifespan. Achieving satisfactory aesthetics, preserving functionality, and allowing for minimal social disruption in the patient’s life is a hallmark of reconstructive efforts, especially in the context of palliation for this patient.