Afroze, Nazma

Hasan, Sheema H.

Kayani, Naila

Pervez, Shahid

Soomro, Irshad N.

eCommons@AKU

eCommons@AKUDepartment of Pathology and Laboratory Medicine Medical College, PakistanJuly 1998Well differentiated hepatocellular carcinomametastasizing to jaw and oral cavity within sixmonths of primary diagnosis.Nazma AfrozeAga Khan UniversityIrshad N. SoomroAga Khan UniversityShahid PervezAga Khan University, shahid.pervez@aku.eduNaila KayaniAga Khan UniversitySheema H. HasanAga Khan UniversityFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_pathol_microbiolPart of the Oncology Commons, Oral Biology and Oral Pathology Commons, OrthopedicsCommons, and the Pathology CommonsRecommended CitationAfroze, N., Soomro, I. N., Pervez, S., Kayani, N., Hasan, S. H. (1998). Well differentiated hepatocellular carcinoma metastasizing to jawand oral cavity within six months of primary diagnosis.. Journal of Pakistan Medical Association, 48(7), 219-220.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_pathol_microbiol/302Well Differentiated Hepatocellular Carcinoma Metastasizing toJaw and Oral Cavity within Six Months of Primary DiagnosisPages with reference to book, From 219 To 220 Nazma Afroze,Irshad N. Soomro,Shahid Pervez,Naila Kayani,Sheema H. Hasan ( Department of Pathology, The Aga KhanUniversity Hospital, Karachi. ) Introduction Metastasis of hepatocellular carcinoma to the soft tissue and bone of the jaw and to oral cavity is a racephenomenon. One such case is described in this report. Fine needle aspiration cytology is a usefulprocedure for detection of hepatocellular carcinoma at this site. However, at times cytologicinterpretation of swelling in this region may give rise to diagnostic dilemma and clinical history may beessential in establishing the diagnosis.Case Report A sixty-seven year old male, was referred by an E.N.T. surgeon in May, 1997 for FNA of left pamtidregion swelling. Clinical history obtained revealed that the lump appeared three months back and washard and non tender on palpation.The clinical impression was parotid adenoma with a suspicion of malignancy. The smear showedclusters of large cells with abundant eosinophuilic granular cytoplasm and central round vesicularnuclei. Considering the swelling arising from parotid gland itself, a possibility of oncocytoma wasraised. Surgical removal and histological evaluation was recommended.The patient underwent surgical removal of the jaw swelling in June, 1997. Frozen section showed alarge cell carcinoma with features suggesting metastatic hepatocellular carcinoma. The clinicians wereinformed and past mdical history revealed that in October, 1996 the patient presented with liver massand got anFNAB done on that mass by another surgeon. The clinical impression at that time wascavernous haeinangioma. Cytology slides and aspirated tissue fragments were sent to our department. Adifferential diagnosis of well differentiated hepatocellular carcinoma and hepatic adenoma was givenfavouring the former. After that, the patient was lost to follow- up. Four months. later he developed aparotid swelling and reported to E.N.T. Department in May, 1997. After frozen section diagnosis of theparotid mass, a radical parotidectomy was performed with removal of left superficial and deep parotidgland and ramus of left mandible. The permanent sections revealed the typical histology of a welldifferentiated hepatocellular carcinoma which had metastasized into the soft tissue around the parotidgland. The adjacent bony tissue of minus of mandible and surrounding skeletal muscle was invaded bythe tumour. In December, 1997 the patient again developed a mass in oral cavity with a single cervicallymph node enlargement. The oral mass proved tobe a metastatic hepatocellualr carcinoma onhistology while the lymph node was benign.Discussion Metastatic tumours involving head and neck region are unusual. Hepatocellular carcinoma metastasistojaw and soft tissue of the oral cavity is a rare occurrence1. A review of literature revealed occasionalcase reports. Hepatocellular carcinoma metastasizes by direct extension, lymphatic routeorhematogenously. Distant metastasis occur in 50% of cases. Bony metastasis are relatively infrequentand are involved in 11% of cases with the spine being the most important site of localization2. Onestudy3 reported seven cases of metastatic tumours in head and neck region over a period of eighteenyears. Out of these three had arisen from prirnaiy hepatocellular carcinoma with metastasis to paranasalsinuses. In another study4 fine needle aspiration findings of fifteen hepatocellular carcinomas weredescribed, four in musculoskeletal, four in adrenal, four in regional lymph node, two in pancreas andone in pelvic region. Eleven of these cases had a biopsy proven hepatocellular carcinoma. In theremaining patients, the FNA diagnosis of hepatocellular carcinoma in metastatic sites was the initialdiagnosis. In our case the nietastatic tumour had involved the left jaw including the mandibular ramus,skeletal muscle and soft tissue around parotid gland. Involvement of the major salivary gland bymalignant neoplasm whose origin is outside the salivary gland occurs by direct extension,hematogenous mute or lymphatic route. The intimate relationship of the paraparotid and intraparotidlymphnodes with the parotid parenchyma frequently results in lymphatic migration of extrasalivaryneoplasm to parotid region. Direct extension of non salivary gland tumours into the parotid regionsoccurs primarily from squamous cell carcinoma and basal cell carcinoma of overlying skin. Eightypercent of metastasis to this site have been from primary tumour elsewhere in the head-neck region and20% have been from the infraclavicular site5. Hematogenous pathway is the route of metastasis frominfraclavicular areas. In descending order of frequency the most common infraclavicular sites ofpnmaiy tumour that metastasized to major salivary glands are lung, kidney and breast. Other infrequentsites include colon, rectum, prostate. ovary, pancreas, stomach, uterus and unnary bladder5. For mostpatients the primary tumour is known at the time of diagnosis of their salivaiy gland metastasis. In thiscase the FNA diagnosis of parotid swelling was suggestive of oncocytoma. Oncocytoma is a neoplasmmade up of large polygonal cells with granular eosinophilic cytoplasm and comparatively small roundnuclei. These cells can have cytologic resemblance to well differentiated hepatocytes. The FNAcytology slides were reviewed. On re- examination thecell clusters showed striking similarity to well differentiated hepatocytes but the characteristic FNAfeatures of hepatocellular carcinoma like presence of naked nuclei, endothelial cells derived fromcapillary vessels surrounding clusters of hepatocytes and intracytoplasmic bile pigment were not seenin this case. Initial diagnostic dilemma was due to lack of communication to the cytopathologist aboutthe previous diagnosis of malignancy. The most important and helpful factor in resolving this dilemmawas previous history. The importance of clinical history and radiographic and biochemical findings inthe diagnosis of metastatic hepatocellular carcinoma cannot be overstated4. Patient may occasionallydevelop more than one primary malignant neoplasm, however in this case histologic similarity betweenthe parotid tumour and a previously diagnosed neoplasm was a strong evidence in favour of metastasis.Farnilarity with the FNA cytology of hepatocellular carcinoma and proper medical history should allowits diagnosis in rare metastatic sites. Degree of differentiation in a hepatocellular carcinoma varies andmay predict more or less aggressive behaviour. However, metastasis to head and neck area of this verywell differentiated hepatocellular carcinoma within six months of initial diagnosis is another questionmark about the reliability of tumour grading in predicting its histological behaviour.References 1. Marker P. Clausen PP Metastasis to the mouth and jaws from hepatocellular carcinoma AcascrepoflInt. J. Oral.Maxillofae, Surg, 1991;20.371-42. Welhk K, Uayduk K, Ptitzer P Fine needle puncture cytology in metastatic hepatocellular carcinoma.Z. Gastroenterol., 1989;27:225-7.3. Mochimatsu J, Tsukuda M. Furukawa Set al. Tumours metastatsizing to the head and neck: A reportofsevcn cases J.Laryngoi Otol., 1993;107:1171-3.4. Dusenbery D. Carr Bl Fine needle aspiration diagnosis of hepatocellular carcinoma in metastaticsites. Ada. Cytol., 1996;40:443-95. Gary L, Ellis DDS, Paul L. Auselair. Turnouts of salivary gland. 1996. Third series, Fascicle-17Washington DC. Armed Forces Institute of Pathology. 1996;pp:403-410.

Well differentiated hepatocellular carcinoma metastasizing to jaw and oral cavity within six months of primary diagnosis.

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Well differentiated hepatocellular carcinoma metastasizing to jaw and oral cavity within six months of primary diagnosis.

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