P1923 - Rare Case of Skull Metastasis From Recurrent Hepatocellular Carcinoma

Soumya Shekhar, BS¹, Sudha Kodali, MD², David Victor, MD², Akshay Shetty, MD^2
1Texas A&M Health Science Center, Houston, TX; ²Houston Methodist Hospital, Houston, TX

Introduction: Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide with rising incidence. HCC frequently spreads to the lungs, lymph nodes, bones, and adrenal glands. Common sites for bone metastases include vertebrae, pelvis, ribs, and very rarely, the skull. While intrahepatic HCC can be managed with surgical resection or liver transplant (LT), metastatic or recurrent HCC lacks curative strategies.

Case Description/Methods: A 74-year-old male with a history of hepatitis C cirrhosis was found to have a 2.2 cm hepatoma on ultrasound and was characterized as LI-RADS 5 on MRI, confirming the diagnosis of HCC. He was treated with transarterial chemoembolization, yttrium-90 radioembolization, and was subsequently transplanted. Explant pathology confirmed moderately differentiated HCC with no evidence of microvascular invasion. The patient’s Risk Estimation of Tumor Recurrence After Transplant score was 2, based on alpha-fetoprotein (AFP) level and tumor size on explant. Thus, his 3-year post transplant recurrence risk was estimated to be 5.6%. He was followed with surveillance scans as per institutional protocol and 23 months after transplant, he presented with headaches of unknown etiology. His AFP was elevated at 862 ng/mL. MRI brain (Fig 1) showed a 5.0 cm central occipital bone lesion which was biopsied, and pathology confirmed moderately differentiated HCC. The patient underwent craniectomy of the occipital skull followed by stereotactic body radiation therapy (SBRT). Four months later, the patient developed intrahepatic disease which was treated with locoregional therapy. He showed disease progression with metastatic disease to the lumbar spine and was transitioned to systemic therapy with sorafenib. He continues to follow up 15 months since recurrence.

Discussion: Only four cases have been published about skull metastases after LT. HCC can manifest post-transplant due to a combination of factors including recipient immunosuppression, inadequate treatment of initial HCC, and the presence of microvascular invasion. There is limited evidence on best management for recurrent extrahepatic HCC, but experts recommend decreasing immunosuppression and using SBRT or locoregional therapy. Targeted treatment with sorafenib and lenvatinib are also being investigated. As skull metastases from recurrent HCC are rare, identifying those patients at highest risk for HCC recurrence and surveillance protocols could allow for closer follow up and earlier detection of potential recurrences.



Disclosures:


Soumya Shekhar, BS¹, Sudha Kodali, MD², David Victor, MD², Akshay Shetty, MD². P1923 - Rare Case of Skull Metastasis From Recurrent Hepatocellular Carcinoma, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.