REl'ORT
HEPATOCELLULAR CARCINOMA INVASIVE TO CHEST WALL TIMOTHY E. KNIGHT, M . D . / A. STEPHEN WOO JK, M.D.,* AND JODI MATSUURA BLAISDELL, M.D.*
Abstract An 88-year-old white man developed hepatocellular carcinoma forming a large subcutaneous mass by direct invasion of the posterior chest wall. Forty-seven cases of cutaneous metastases from primary liver cancer have been reported. These cutaneous metastases showed protean morphologic features with the face and scalp being the most common sites of involvement. The metastatic lesions may be the presenting sign of the cancer. Average survival, after development of a skin metastasis, was 5 months. Skin metastases from primary liver cancer are being reported more frequently. This is due, in part, to more prolonged survival of liver cancer patients, which allows development of skin metastases, and also due to increased awareness by the clinician. Primary liver cancer can metastasize via the blood vessels or the lymphatics and may invade adjacent tissues directly. We are reporting a case of invasive hepatocellular carcinoma that fortned a subcutaneous mass by direct extension within the posterior chest wall. We have reviewed the data of 47cases from tbe world literature of cutaneous metastatic liver cancer (Table 1).
Figure 1. Infrascapular subcutaneous chest wall mass.
Case Report An 88-year-old white man complained of right upper quadrant pain for 6 months, a mass on the right side of the back for 3 months, and recent onset of anorexia, weight loss, and epigastric pain. Physical examination revealed a 6 x 10 cm fixed, rubbery, subcutaneous mass inferior to the right scapula (Fig. 1), spider telangiectasia on the upper chest, and bilateral palmar erythema. Hepatomegaly was present to 6 cm below the right costal margin in the midclavicular line without masses or nodules. The spleen was not palpable. Rectal examination and stool guaiac were negative. Chest roentgenogram showed a 6 X 10 X 12 cm mass in the right posterior field with erosion of the adjacent 8th rib. Abdominal computed tomographic scan revealed a large homogeneous mass posterior to the right lobe of the liver without definite contiguity with the liver (Fig. 2). The CEA, alphafetoprotein.
Figure 2. Abdominal computed tomographic scan showing chest wall mass in close association with liver parenchyma.
and bilirubin were normal, and SGOT, LDH, and alkaline phosphatase were mildly elevated. Fine needle aspiration biopsy of the posterior chest wall mass revealed well-differentiated hepatocellular carcinoma (Fig. 3). Despite radiotherapy the patient died 2 weeks later. Permission for a postmortem examination was denied. . .
DlSCUSStON
From the •Division of Dermatology, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, the *Hilo Hospital, Hilo, Hawaii, and the *Tufts University School of Medicine, Boston, Massachusetts.
..:. .
:
.
:
. :
:,
'
Tbe infrascapular chest wall mass was invasive bepatocellular carcinoma to the rib and chest wall by direct extension. Two otber cases of liver cancer bave been reported tbat presented as masses involving tbe bone (rib) or muscle of the right anterior chest wall and, as
Address for correspondence: Timothy E. Knight, M.D., 75184 Hualalai Rd, Kailua-Kona, HI 96740. 273;
Internation.Tl Journal of Dermatology Vol. 31. No. 4. April 1992
Table 1. Cutaneous Metastases of Primary Liver Cancer
No. of
Duration of Skin Mets Reference Prior to Death (weeks)
Sex
Histologic Type
Site
NS Hepatocellular NS Hepatocellular
T r u n k (3), s c a l p ( 1 ) , e x t r e m i t i e s (1)
Patients 5
44
1
67
1 1
• NS
2M-3F M NS
64 NS 63 12 NS
M M M F NS
3>
1 3 . S.
• .
1 1 1 1
43 44 72 62
' M M M M
8 1 1 1 1 1 1 1
NS NS 83 66 66 48 56 56 61
NS NS M
-l:
78
F M M F M
1
52- •
M
1
67
M
1 1
62 46 44
M M M
\
52
M
1
45
M
1
81
M
NS
M M
•
"
Hepatocellular Hepatocellular Hepatocellular Adenocarcinoma Adenocarcinoma Hepatocellular Hepatocellular with sarcomatous proliferation Hepatocellular Adenocarcinoma Hepatocellular Hepatocellular Hepatocellular Hepatocellular Hepatocellular Hepatocellular Hepatocellular •: Hepatocellular Hepatocellular Epithelioid hemangio-endothelioma Hepatocellular Hepatocellular Cholangiocarcinoma (adenocarcinoma) Cholangiocarcinoma (adenocarcinoma) Cholangiocarcinoma (adenocarcinoma) Hepatocellular
NS Scalp . . Chin & rt. cheek NS ' Upper lip, forehead Ant. abd &c ant. thorax NS Lt. scalp Posterior rt. shoulder, ant. chest (3) Rt. scalp Lt. scalp NS , .' ' NS Chin, nose, rt. 1. eyelid, scalp Lt. inguinal - It. scalp Ant. torso & extremities Anterior abdomen* Lower lip, chin, occip. scalp. It. clavicle Lt. buttock Rt. upper abdomen, scalp Nose Anterior abdomen* Diffuse mets (-20)
15
3 7 16
NS NS . NS NS NS 8.5 NS 3 25 NS 4 NS NS 34.5 NS NS NS 4
NS NS 86
20 31 25 28 13 14 14 14
32 15 15 26
33 '
33 30 21
18 19
NS
22 2f 17
• 17
Z4.
17 1
23 34
Nose, neck, scalp, lt. forearm. It & rt. thighs Scalp
30
34
13
34
Palm, sole, ant. shoulder
30
27
Rt. cheek, lt. chest (2) Face, nose, ear, rt. upper arm Forehead (2), back
34.5
"•Iatrogenic metastasis. Ant. = anterior; It. = left; rt. = right; NS = not stated; mets = metastases.
Figure 3. Fine needle biopsy of chest wall mass. Hepatocellular carcinoma in trabecular pattern with bile plug (Hematoxylin-eosin stain, original magnification x 100).
in this case, resembled subcutaneous tumors.'-- As these cases illustrate, a differential diagnosis of a subcutaneous mass of the right hemithorax should include invasive or metastatic liver carcinoma. Although we were unable, in this case, to confirm involvement of the overlying skin or subcutaneous tissue, metastatic liver cancer may uncommonly involve the skin. Cutaneous metastasis from any malignancy is not a common finding. In several autopsy studies of patients who died of various malignancies, 1.4% to 4.4% of patients had cutaneous metastases.'-''-'' Liver cancer metastasizes in 55 to 70% of cases'"^'" most frequently to the lungs, lymph nodes, adrenal glands, portal or hepatic veins, bone, spleen, kidneys, and other organs.*-^ Cutaneous metastases have a reported incidence from none'''**'''"-'^ to 3.4% of cases of primary liver cancer.''''^"^^
Metastatic Liver Cancer Knighr. Woo, and Blaisdell
In our review of 47 cases of cutaneous metastatic liver cancer, 31 patients had hepatocellular carcinomas, six had cholangiocarcinomas (adenocarcinomas), and one had an epithelioid hemangioendothelioma.'^ In nine of the cases the term "primary liver cancer" or "carcinoma" was not further classified. The patients were from 12 to 83 years old with an average age of 55 years. Women presented at an earlier age (42) than men (59). The man to woman ratio was more than 4 to 1. The skin metastases of liver cancer can present as papules, nodules, indurated plaques"* or as inflammatory nodules.'' The lesions may be skin colored, violaceous,''••^"-^^ pyogenic granuloma-like,-^--'* or show a hemangiomatous morphology,"'" which may bleed profusely when injured or surgically incised.'-'^' One unusual case showed black nodules of the palm and sole that clinically resembled malignant melanoma.^^ The nodules may be singular or multiple and are most often painless, but may be pruritic.^** The face and scalp were the most common sites of involvement, followed by the torso, and then the extremities (Fig. 4). In case studies with autopsy findings, skin metastases invariably indicated metastatic involvement elsewhere. In only one case, an iatrogenically-induced metastasis, was the skin the only focus of metastasis.-' In six cases the metastatic skin lesions were the presenting sign of liver cancer,'•'''*-20.22,26 ^^j ^^^.^ ^(^^^ ^^^^ ^ l^j.^ manifestation and indicated a dismal prognosis. The average survival of patients after development of skin metastases was 5 months. An exceptional patient was a 78-yearold man who lived 20 months after developing a violaceous metastatic nodule on the tip of the nose.'Two cases of iatrogenically-induced skin metastases were reviewed. In the first case the needle track became seeded with the primary hepatocellular carcinoma after a diagnostic fine needle aspiration biopsy of the liver. Three months later the patient developed a metastatic skin nodule overlying the biopsy site.^" In the second case, 5 months after repeated percutaneous needle ethanol infusion treatments of hepatocellular carcinoma, the patient developed a large, friable, metastatic abdominal wall mass overlying the site of the needle punctures.'' The skin offers the clinician ready access for biopsy of nodules which sometimes may be the presenting sign of the hepatic cancer. In addition, confirming a cutaneous metastasis of liver cancer does have prognostic value.
Figure 4. Composite distribution of cutaneous metastatic liver cancer. Hemangioendothelioma not included. "Multiple" lesions are represented by three dots. Placement within a region, e.g., "scalp", unless location was specifically stated, is arbitrary.
3.
Cates O. Cutaneous metastases of malignant disease. Am J Cancer 1937; 30:718-730.
4.
Reingold IM. Cutaneous metastases from internal carcinoma. Cancer 1966; 19:162-168. Abrams HL, Spiro R, Coldstein N. Metastases in carcinoma: analysis of 1000 autopsied cases. Cancer 1950; 3:74-85.
7.
9.
10.
11.
12.
13. 14.
REFERENCES
15. 1.
2.
Chakravorty RC, Makoui C. Symptomatic bony metastases from occult primary liver cancer. Dig Dis 197722:471-473.
16.
Bennett AJ, Kaira JK, Cortes EP. Hepatocellular carcinoma: manifestation as a chest wail metastasis. Arch Dermatol 1982; 118:69-70.
17.
275
Kay CJ. Primary hepatic cancer: review of ninety-six cases. Arch Intern Med 1964; 113:46-53. Eppstein S. Primary carcinoma of the liver. Am J Med Sci 1964; 247:137-144. Nakashima T, Okuda K, Kojiro M, et al. Pathology of hepatocellular carcinoma in Japan. Cancer 1983; 51: 863-877. Blanes Berenguel A, Ispizua y Uribarri I, Ramon y Cajal, et al. Estudio necropsico de 30 casos de tumor hepatico primitivo. Rev Clin Esp 1975; 139:453-460. Linder GT, Crook JN, Cohn I Jr. Primary liver carcinoma. Cancer 1974; 33:1624-1629. Revestido R, Larrauri J. Hepatocarcinoma: revision del material de autopsia. Castroenterol Hepatol 1984; 7: 486-492. Pedreira J, Vilaseca J, Villalonga C, et al. Localizaciones metastasicas en el hepatoma. Rev Clin Esp 1976; 141: 457-460. Okuda K, Peters RL. Hepatocellular carcinoma. New York: John Wiley & Sons, 1976:158. Reingold IM, Smith BR. Cutaneous metastases from hepatomas. Arch Dermatol 1978; 114:1045-1056. The Liver Cancer Study Group of Japan. Primary liver cancer in Japan. Cancer 1984; 54:1747-1755. Viranuvatti V, Satapanakul C. Primary carcinoma of the liver. Primary carcinoma (World Congress of GastroEnterology). Baltimore:Williams & Wilkins, 1969:516. Vignon-Pennamen MD, Varroud-Vial C, Janssen F, et al. Metastases cutanees d'un hemangio-endotheliome
tnternational Journal of Dermatotogy Vol. 31,No. 4, April 1992
epithelioide hepatique. Ann Dermatol Venereol 1989; 116:864-866. 18.
19.
20.
Martinez H, Antonio J, Miguelez Morales M, et al. Metastasis cutaneas como manifestacion inicial de un hepatocarcinoma. Rev Esp Enferm Apar Dig 1988; 73(5I):527-531.
22.
Galvan Casas C, Marti'n Moreno L, de Castro Torres A. Metastasis cutanea unica como primer sintoma de un hepatocarcinoma. Rev Clfn Esp 1989; 184:74-76.
25.
28. 29.
Kahn JA, Sinhamohapatra SB, Schneider AF. Hepatoma presenting as a skin metastasis. Arch Dermatol 1971; 104:299-300. Perez MM, Puig L, Orobitg J, et al. Metastasis cutaneas de hepatocarcinoma. Rev Clfn Esp 1988; 183:80-81.
24.
27.
Simon Marco MA, Olart Ciria C, Moreno Mateo R, Blanco Ramos JR. Metastasis cutaneas como primera manifestacion del hepatocarcinoma. Rev Cli'n Esp 1989; 184:86.
21.
23.
26.
30.
31. 32.
Yoshinaga H, Yamada M. Skin metastasis of hepatic cancer. Jpn J Clin Dermatol 1975; 29:139-145. Yamanishi K, Kishimoto S, Hosokawa Y, et al. Cutaneous metastasis from hepatocellular carcinoma resembling granuloma teleangiectaticum. J Dermatol 1989; 16:500-504.
33.
Beurey J, Weber M, Mazx-t J, Puchelle JC. Metastases cutanees d'un hepatome malin. Bull Soc Fr Dermatol Syphiligr 1972; 79:332-333.
34.
Berbis PH, Auffranc JC, Andrac L, et al. Metastases cutanees d'aspect angiomateux revelatrices d'un hepatocarcinome. Ann Dermatol Venereol 1986; 113:563-567. Kato T, Kawashima T, Koitabashi T, et al. Skin metastasis of liver cancer showing an appearance of malignant melanoma. Rinsho Dermatol 1984; 26:923-925. Helson L, Carcia EJ. Skin metastases and hepatic cancer in childhood. NY State J Med 1975; Sep: 1728-1 730. Saito I, Yamamoto S, Ideguchi S, et al. Case report of hepatic cancer which caused direct infiltrative tuberous metastasis to skin. Can No Rinsho (Cancer Clinic) 1989; 35:1681-1685. Onodera H, Oikawa M, Abe M, et al. Cutaneous seeding of hepatocellular carcinoma after fine-needle aspiration biopsy. J Ultrasound Med 1987; 6:273-275. Brownstein MH, Helwig EB. Metastatic tumors of the skin. Cancer 1972; 29:1298-1307. Tsujimoto M, Aozasa K, Nakajima Y, Kariya M. Hepatocellular carcinoma with sarcomatous proliferation showing an unusual and wide-spread metastasis. Acta Pathol Jpn 1984; 34:839-845. Nogueira Sorian JM, Reina Campos F, Caballero Gomez J, et al. Metastasis cutanea como primera manifestacion del hepatocarcinoma. Rev Esp Enferm Apar Dig 1987; 72:633-636. Kashiwa N, Takaiwa T. Three cases of skin metastasis of hepatic cancer. Nishinihon J Dermatol 1980; 42: 415-418.
Demonstration of Samoan tattoo method on Lyic Tuttlc, noted San Francisco tattoo artist. From the World of Tattoos collection, Honolulu, HI. Submitted by Norman Goldstein, M.D., Honolulu, HI. 27S
HEPATOCELLULAR CARCINOMA INVASIVE TO CHEST WALL TIMOTHY E. KNIGHT, M . D . / A. STEPHEN WOO JK, M.D.,* AND JODI MATSUURA BLAISDELL, M.D.*
Abstract An 88-year-old white man developed hepatocellular carcinoma forming a large subcutaneous mass by direct invasion of the posterior chest wall. Forty-seven cases of cutaneous metastases from primary liver cancer have been reported. These cutaneous metastases showed protean morphologic features with the face and scalp being the most common sites of involvement. The metastatic lesions may be the presenting sign of the cancer. Average survival, after development of a skin metastasis, was 5 months. Skin metastases from primary liver cancer are being reported more frequently. This is due, in part, to more prolonged survival of liver cancer patients, which allows development of skin metastases, and also due to increased awareness by the clinician. Primary liver cancer can metastasize via the blood vessels or the lymphatics and may invade adjacent tissues directly. We are reporting a case of invasive hepatocellular carcinoma that fortned a subcutaneous mass by direct extension within the posterior chest wall. We have reviewed the data of 47cases from tbe world literature of cutaneous metastatic liver cancer (Table 1).
Figure 1. Infrascapular subcutaneous chest wall mass.
Case Report An 88-year-old white man complained of right upper quadrant pain for 6 months, a mass on the right side of the back for 3 months, and recent onset of anorexia, weight loss, and epigastric pain. Physical examination revealed a 6 x 10 cm fixed, rubbery, subcutaneous mass inferior to the right scapula (Fig. 1), spider telangiectasia on the upper chest, and bilateral palmar erythema. Hepatomegaly was present to 6 cm below the right costal margin in the midclavicular line without masses or nodules. The spleen was not palpable. Rectal examination and stool guaiac were negative. Chest roentgenogram showed a 6 X 10 X 12 cm mass in the right posterior field with erosion of the adjacent 8th rib. Abdominal computed tomographic scan revealed a large homogeneous mass posterior to the right lobe of the liver without definite contiguity with the liver (Fig. 2). The CEA, alphafetoprotein.
Figure 2. Abdominal computed tomographic scan showing chest wall mass in close association with liver parenchyma.
and bilirubin were normal, and SGOT, LDH, and alkaline phosphatase were mildly elevated. Fine needle aspiration biopsy of the posterior chest wall mass revealed well-differentiated hepatocellular carcinoma (Fig. 3). Despite radiotherapy the patient died 2 weeks later. Permission for a postmortem examination was denied. . .
DlSCUSStON
From the •Division of Dermatology, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, the *Hilo Hospital, Hilo, Hawaii, and the *Tufts University School of Medicine, Boston, Massachusetts.
..:. .
:
.
:
. :
:,
'
Tbe infrascapular chest wall mass was invasive bepatocellular carcinoma to the rib and chest wall by direct extension. Two otber cases of liver cancer bave been reported tbat presented as masses involving tbe bone (rib) or muscle of the right anterior chest wall and, as
Address for correspondence: Timothy E. Knight, M.D., 75184 Hualalai Rd, Kailua-Kona, HI 96740. 273;
Internation.Tl Journal of Dermatology Vol. 31. No. 4. April 1992
Table 1. Cutaneous Metastases of Primary Liver Cancer
No. of
Duration of Skin Mets Reference Prior to Death (weeks)
Sex
Histologic Type
Site
NS Hepatocellular NS Hepatocellular
T r u n k (3), s c a l p ( 1 ) , e x t r e m i t i e s (1)
Patients 5
44
1
67
1 1
• NS
2M-3F M NS
64 NS 63 12 NS
M M M F NS
3>
1 3 . S.
• .
1 1 1 1
43 44 72 62
' M M M M
8 1 1 1 1 1 1 1
NS NS 83 66 66 48 56 56 61
NS NS M
-l:
78
F M M F M
1
52- •
M
1
67
M
1 1
62 46 44
M M M
\
52
M
1
45
M
1
81
M
NS
M M
•
"
Hepatocellular Hepatocellular Hepatocellular Adenocarcinoma Adenocarcinoma Hepatocellular Hepatocellular with sarcomatous proliferation Hepatocellular Adenocarcinoma Hepatocellular Hepatocellular Hepatocellular Hepatocellular Hepatocellular Hepatocellular Hepatocellular •: Hepatocellular Hepatocellular Epithelioid hemangio-endothelioma Hepatocellular Hepatocellular Cholangiocarcinoma (adenocarcinoma) Cholangiocarcinoma (adenocarcinoma) Cholangiocarcinoma (adenocarcinoma) Hepatocellular
NS Scalp . . Chin & rt. cheek NS ' Upper lip, forehead Ant. abd &c ant. thorax NS Lt. scalp Posterior rt. shoulder, ant. chest (3) Rt. scalp Lt. scalp NS , .' ' NS Chin, nose, rt. 1. eyelid, scalp Lt. inguinal - It. scalp Ant. torso & extremities Anterior abdomen* Lower lip, chin, occip. scalp. It. clavicle Lt. buttock Rt. upper abdomen, scalp Nose Anterior abdomen* Diffuse mets (-20)
15
3 7 16
NS NS . NS NS NS 8.5 NS 3 25 NS 4 NS NS 34.5 NS NS NS 4
NS NS 86
20 31 25 28 13 14 14 14
32 15 15 26
33 '
33 30 21
18 19
NS
22 2f 17
• 17
Z4.
17 1
23 34
Nose, neck, scalp, lt. forearm. It & rt. thighs Scalp
30
34
13
34
Palm, sole, ant. shoulder
30
27
Rt. cheek, lt. chest (2) Face, nose, ear, rt. upper arm Forehead (2), back
34.5
"•Iatrogenic metastasis. Ant. = anterior; It. = left; rt. = right; NS = not stated; mets = metastases.
Figure 3. Fine needle biopsy of chest wall mass. Hepatocellular carcinoma in trabecular pattern with bile plug (Hematoxylin-eosin stain, original magnification x 100).
in this case, resembled subcutaneous tumors.'-- As these cases illustrate, a differential diagnosis of a subcutaneous mass of the right hemithorax should include invasive or metastatic liver carcinoma. Although we were unable, in this case, to confirm involvement of the overlying skin or subcutaneous tissue, metastatic liver cancer may uncommonly involve the skin. Cutaneous metastasis from any malignancy is not a common finding. In several autopsy studies of patients who died of various malignancies, 1.4% to 4.4% of patients had cutaneous metastases.'-''-'' Liver cancer metastasizes in 55 to 70% of cases'"^'" most frequently to the lungs, lymph nodes, adrenal glands, portal or hepatic veins, bone, spleen, kidneys, and other organs.*-^ Cutaneous metastases have a reported incidence from none'''**'''"-'^ to 3.4% of cases of primary liver cancer.''''^"^^
Metastatic Liver Cancer Knighr. Woo, and Blaisdell
In our review of 47 cases of cutaneous metastatic liver cancer, 31 patients had hepatocellular carcinomas, six had cholangiocarcinomas (adenocarcinomas), and one had an epithelioid hemangioendothelioma.'^ In nine of the cases the term "primary liver cancer" or "carcinoma" was not further classified. The patients were from 12 to 83 years old with an average age of 55 years. Women presented at an earlier age (42) than men (59). The man to woman ratio was more than 4 to 1. The skin metastases of liver cancer can present as papules, nodules, indurated plaques"* or as inflammatory nodules.'' The lesions may be skin colored, violaceous,''••^"-^^ pyogenic granuloma-like,-^--'* or show a hemangiomatous morphology,"'" which may bleed profusely when injured or surgically incised.'-'^' One unusual case showed black nodules of the palm and sole that clinically resembled malignant melanoma.^^ The nodules may be singular or multiple and are most often painless, but may be pruritic.^** The face and scalp were the most common sites of involvement, followed by the torso, and then the extremities (Fig. 4). In case studies with autopsy findings, skin metastases invariably indicated metastatic involvement elsewhere. In only one case, an iatrogenically-induced metastasis, was the skin the only focus of metastasis.-' In six cases the metastatic skin lesions were the presenting sign of liver cancer,'•'''*-20.22,26 ^^j ^^^.^ ^(^^^ ^^^^ ^ l^j.^ manifestation and indicated a dismal prognosis. The average survival of patients after development of skin metastases was 5 months. An exceptional patient was a 78-yearold man who lived 20 months after developing a violaceous metastatic nodule on the tip of the nose.'Two cases of iatrogenically-induced skin metastases were reviewed. In the first case the needle track became seeded with the primary hepatocellular carcinoma after a diagnostic fine needle aspiration biopsy of the liver. Three months later the patient developed a metastatic skin nodule overlying the biopsy site.^" In the second case, 5 months after repeated percutaneous needle ethanol infusion treatments of hepatocellular carcinoma, the patient developed a large, friable, metastatic abdominal wall mass overlying the site of the needle punctures.'' The skin offers the clinician ready access for biopsy of nodules which sometimes may be the presenting sign of the hepatic cancer. In addition, confirming a cutaneous metastasis of liver cancer does have prognostic value.
Figure 4. Composite distribution of cutaneous metastatic liver cancer. Hemangioendothelioma not included. "Multiple" lesions are represented by three dots. Placement within a region, e.g., "scalp", unless location was specifically stated, is arbitrary.
3.
Cates O. Cutaneous metastases of malignant disease. Am J Cancer 1937; 30:718-730.
4.
Reingold IM. Cutaneous metastases from internal carcinoma. Cancer 1966; 19:162-168. Abrams HL, Spiro R, Coldstein N. Metastases in carcinoma: analysis of 1000 autopsied cases. Cancer 1950; 3:74-85.
7.
9.
10.
11.
12.
13. 14.
REFERENCES
15. 1.
2.
Chakravorty RC, Makoui C. Symptomatic bony metastases from occult primary liver cancer. Dig Dis 197722:471-473.
16.
Bennett AJ, Kaira JK, Cortes EP. Hepatocellular carcinoma: manifestation as a chest wail metastasis. Arch Dermatol 1982; 118:69-70.
17.
275
Kay CJ. Primary hepatic cancer: review of ninety-six cases. Arch Intern Med 1964; 113:46-53. Eppstein S. Primary carcinoma of the liver. Am J Med Sci 1964; 247:137-144. Nakashima T, Okuda K, Kojiro M, et al. Pathology of hepatocellular carcinoma in Japan. Cancer 1983; 51: 863-877. Blanes Berenguel A, Ispizua y Uribarri I, Ramon y Cajal, et al. Estudio necropsico de 30 casos de tumor hepatico primitivo. Rev Clin Esp 1975; 139:453-460. Linder GT, Crook JN, Cohn I Jr. Primary liver carcinoma. Cancer 1974; 33:1624-1629. Revestido R, Larrauri J. Hepatocarcinoma: revision del material de autopsia. Castroenterol Hepatol 1984; 7: 486-492. Pedreira J, Vilaseca J, Villalonga C, et al. Localizaciones metastasicas en el hepatoma. Rev Clin Esp 1976; 141: 457-460. Okuda K, Peters RL. Hepatocellular carcinoma. New York: John Wiley & Sons, 1976:158. Reingold IM, Smith BR. Cutaneous metastases from hepatomas. Arch Dermatol 1978; 114:1045-1056. The Liver Cancer Study Group of Japan. Primary liver cancer in Japan. Cancer 1984; 54:1747-1755. Viranuvatti V, Satapanakul C. Primary carcinoma of the liver. Primary carcinoma (World Congress of GastroEnterology). Baltimore:Williams & Wilkins, 1969:516. Vignon-Pennamen MD, Varroud-Vial C, Janssen F, et al. Metastases cutanees d'un hemangio-endotheliome
tnternational Journal of Dermatotogy Vol. 31,No. 4, April 1992
epithelioide hepatique. Ann Dermatol Venereol 1989; 116:864-866. 18.
19.
20.
Martinez H, Antonio J, Miguelez Morales M, et al. Metastasis cutaneas como manifestacion inicial de un hepatocarcinoma. Rev Esp Enferm Apar Dig 1988; 73(5I):527-531.
22.
Galvan Casas C, Marti'n Moreno L, de Castro Torres A. Metastasis cutanea unica como primer sintoma de un hepatocarcinoma. Rev Clfn Esp 1989; 184:74-76.
25.
28. 29.
Kahn JA, Sinhamohapatra SB, Schneider AF. Hepatoma presenting as a skin metastasis. Arch Dermatol 1971; 104:299-300. Perez MM, Puig L, Orobitg J, et al. Metastasis cutaneas de hepatocarcinoma. Rev Clfn Esp 1988; 183:80-81.
24.
27.
Simon Marco MA, Olart Ciria C, Moreno Mateo R, Blanco Ramos JR. Metastasis cutaneas como primera manifestacion del hepatocarcinoma. Rev Cli'n Esp 1989; 184:86.
21.
23.
26.
30.
31. 32.
Yoshinaga H, Yamada M. Skin metastasis of hepatic cancer. Jpn J Clin Dermatol 1975; 29:139-145. Yamanishi K, Kishimoto S, Hosokawa Y, et al. Cutaneous metastasis from hepatocellular carcinoma resembling granuloma teleangiectaticum. J Dermatol 1989; 16:500-504.
33.
Beurey J, Weber M, Mazx-t J, Puchelle JC. Metastases cutanees d'un hepatome malin. Bull Soc Fr Dermatol Syphiligr 1972; 79:332-333.
34.
Berbis PH, Auffranc JC, Andrac L, et al. Metastases cutanees d'aspect angiomateux revelatrices d'un hepatocarcinome. Ann Dermatol Venereol 1986; 113:563-567. Kato T, Kawashima T, Koitabashi T, et al. Skin metastasis of liver cancer showing an appearance of malignant melanoma. Rinsho Dermatol 1984; 26:923-925. Helson L, Carcia EJ. Skin metastases and hepatic cancer in childhood. NY State J Med 1975; Sep: 1728-1 730. Saito I, Yamamoto S, Ideguchi S, et al. Case report of hepatic cancer which caused direct infiltrative tuberous metastasis to skin. Can No Rinsho (Cancer Clinic) 1989; 35:1681-1685. Onodera H, Oikawa M, Abe M, et al. Cutaneous seeding of hepatocellular carcinoma after fine-needle aspiration biopsy. J Ultrasound Med 1987; 6:273-275. Brownstein MH, Helwig EB. Metastatic tumors of the skin. Cancer 1972; 29:1298-1307. Tsujimoto M, Aozasa K, Nakajima Y, Kariya M. Hepatocellular carcinoma with sarcomatous proliferation showing an unusual and wide-spread metastasis. Acta Pathol Jpn 1984; 34:839-845. Nogueira Sorian JM, Reina Campos F, Caballero Gomez J, et al. Metastasis cutanea como primera manifestacion del hepatocarcinoma. Rev Esp Enferm Apar Dig 1987; 72:633-636. Kashiwa N, Takaiwa T. Three cases of skin metastasis of hepatic cancer. Nishinihon J Dermatol 1980; 42: 415-418.
Demonstration of Samoan tattoo method on Lyic Tuttlc, noted San Francisco tattoo artist. From the World of Tattoos collection, Honolulu, HI. Submitted by Norman Goldstein, M.D., Honolulu, HI. 27S
