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Hepatocellular cancer metastatic to the zygoma: Primary resection and immediate reconstruction. (Original Article).


Hepatocellular carcinoma is common worldwide but relatively rare in the United States, where only 13,000 new cases are diagnosed each year. Metastasis to osseous structures in the head and neck are extremely rare; when they do occur, most appear as oral cavity masses secondary to mandibular and maxillary involvement. We report the case of an isolated zygomatic metastasis in a patient who had been previously treated for hepatocellular carcinoma with orthotopic liver transplantation. The patient underwent a complete excision of the mass followed by immediate reconstruction of the zygomnaxillary buttress and the orbital rim and floor. To our knowledge, only one other case similar to ours has been previously reported; in that instance, the metastatic tumor was not resectable.


Hepatocellular carcinoma is common worldwide; metastasis to the head and neck is rare. Only 48 cases of metastasis to the oral cavity, mandible, or maxilla have been reported in the English-language literature since 1957. (1) In this article, we describe a case of hepatocellular carcinoma metastatic to the zygoma. The metastasis was treated by wide resection and reconstruction.

Case report

A 59-year-old man with advanced liver cirrhosis was found to have two liver nodules (<3 cm) on computed tomography (CT) and CT arteriography. He was subsequently diagnosed with multicentric hepatocellular carcinoma of the right and left lobes of the liver. At that time, a thorough evaluation--including a whole-body technetium 99-MDP bone scan and CT of the brain, chest, abdomen, and pelvis--failed to reveal any evidence of metastatic disease. The patient underwent liver transplantation 4 months after diagnosis. Six months later, he developed a tender right zygomatic mass, for which he sought medical evaluation.

Our examination revealed the presence of an isolated, firm, 4-cm mass in the right zygomatic arch that extended to the lateral aspect of the inferior orbital rim. Findings on ophthalmologic and head and neck examinations were normal. Facial CT and a repeat technetium 99-MDP bone scan detected a solid, 3.9-cm soft-tissue mass emanating from and destroying a portion of the right anterior zygomatic arch (figure 1). Analysis of a fine-needle aspiration specimen identified a moderate-to-well-differentiated hepatocellular carcinoma. Radiologic evaluation of the transplanted liver revealed no recurrent hepatoma. Again, findings on CT of the brain, chest, abdomen, and pelvis, as well as whole-body technetium bone scanning, were negative. Laboratory analysis revealed an elevated alpha-fetoprotein level (165 IU/ml).

The patient underwent definitive surgical management 3 weeks after the zygomatic metastasis was discovered. Surgery included resection of the right inferior orbital rim, the anterior orbital floor, the zygomatic arch, and the anterior face of the maxilla. This was accomplished with an extended Weber-Fergusson incision. Reconstruction of the orbital floor and zygomaxillary defect was accomplished by using an absorbable plate and sheet system made of the polymer 70:30 Poly(L-lactide-co-D,L-lactide) (MacroPore, Inc.; San Diego) (figure 2).

Postoperatively, the patient has done well and is pleased with the cosmetic result. He initially complained of mild diplopia, but it slowly diminished with the resolution of postoperative edema. He has received postoperative chemotherapy in the hope that this will eradicate any possible micrometastasis. He remains disease-free 1 year after surgical resection.


Although hepatocellular carcinoma is one of the most common malignancies worldwide, it is relatively rare in the United States, where only 13,000 new cases are diagnosed each year. (2) Most of these cases develop in the setting of cirrhosis secondary to alcohol abuse or hepatitis B or C infection. (2) In a study by Pawarode et al, extrahepatic metastases were seen in 18% of 157 patients with untreated hepatocellular carcinoma. (3) The most common site of extrahepatic involvement is the lung, followed by bone, the lymphatics, and the brain. (3,4)

In those uncommon cases when hepatocellular carcinoma does metastasize to the head and neck region, it is usually seen in the brain parenchyma; a few cases have involved the cervical lymph nodes. Metastasis to other head and neck sites is extremely rare. For example, only 48 cases of metastasis to the oral cavity, mandible, or maxilla have been reported worldwide since 1957. (1) Isolated cases of metastasis to the sphenoid, frontal, and ethmoid sinuses have been reported, as have soft-tissue metastases to the orbit, parotid, hypopharynx, and tonsil. (5-9)

In this article, we report a case of hepatocellular carcinoma that had metastasized to the zygomatic arch and that was treatable by surgical resection. To our knowledge, only one other case similar to ours has been previously reported in the literature--this by Reichbach et al in 1970. (10) They described a patient who had a zygomatic metastasis that was unresectable.

Our patient had undergone resection and transplantation as a treatment for the primary hepatocellular carcinoma, and he has not shown any evidence of local recurrence. Van Thiel et al reported that 3-year post-transplant overall and tumor-free survival rates for patients with multicentric hepatocellular carcinoma were 46 an 44%, respectively. (11) Little is known about the prognosis and survival of patients with isolated extrahepatic bony metastasis. Nevertheless, the fact that we were able to resect the zygomatic metastasis and administer postoperative chemotherapy might enhance our patient's prospects for survival at 3 years. As is true with most other rare conditions, more cases similar to this one will nee to be treated before we are able to determine effective treatment protocols.


(1.) Chin A, Liang TS, Borislow AJ. Initial presentation of hepatocellular carcinoma as a mandibular mass: Case report and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:457-60.

(2.) Wands JR, Blum HE. Primary hepatocellular carcinoma. N Engl J Med 1991;325:729-31.

(3.) Pawarode A, Voravud N, Sriuranpong V, et al. Natural history of untreated primary hepatocellular carcinoma: A retrospective study of 157 patients. Am J Clin Oncol 1998;21:386-91.

(4.) Okusaka T, Okada S, Ishii H, et al. Prognosis of hepatocellular carcinoma patients with extrahepatic metastases. Hepatogastroenterology 1997;44:251-7.

(5.) Sim RS, Tan HK. A case of metastatic hepatocellular carcinoma of the sphenoid sinus. J Laryngol Otol 1994;108:503-4.

(6.) Schwab L, Doshi H, Shields JA, et al. Hepatocellular carcinoma metastatic to the orbit in an African patient. Ophthalmic Surg 1994;25:105-6.

(7.) Dargent JL, Deplace J, Schneider E, et al. Hepatocellular carcinoma metastatic to the parotid gland: Initial diagnosis by fine needle aspiration biopsy [letter]. Acta Cytol 1998;42:824-6.

(8.) Hayase N, Fukumoto M, Yoshida D, et al. Extraosseous metastases of hepatocellular carcinoma: Detection and therapeutic assessment with Tc-99m PMT SPECT. Clin Nucl Med 1999;24:326-9.

(9.) Mochimatsu I, Tsukuda M, Furukawa S, Sawaki S. Tumours metastasizing to the head and neck--a report of seven cases. J Laryngol Otol 1993;107:1171-3.

(10.) Reichbach EJ, Levinson JD, Fagin RR. Unusual osseous metastases of hepatoma. JAMA 1970;213:2078-9.

(11.) Van Thiel DH, Colantoni A, De Maria N. Liver transplantation for hepatocellular carcinoma? Hepatogastroenterology 1998;45:1944-9.
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Comment:Hepatocellular cancer metastatic to the zygoma: Primary resection and immediate reconstruction. (Original Article).
Author:Willcox, Thomas O., Jr.
Publication:Ear, Nose and Throat Journal
Article Type:Brief Article
Geographic Code:1USA
Date:Jan 1, 2002
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