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Year : 2020  |  Volume : 63  |  Issue : 1  |  Page : 145-147
Metastatic hepatocellular carcinoma in brain masquerading as rhabdoid CNS tumor – A case report


1 Departmentof Pathology, AFMC, Pune, Maharashtra, India
2 Department of (Path) and GI Pathologist, AFMC, Pune, Maharashtra, India

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Date of Web Publication31-Jan-2020
 

How to cite this article:
Kumar H, Kinra P, Malik A. Metastatic hepatocellular carcinoma in brain masquerading as rhabdoid CNS tumor – A case report. Indian J Pathol Microbiol 2020;63:145-7

How to cite this URL:
Kumar H, Kinra P, Malik A. Metastatic hepatocellular carcinoma in brain masquerading as rhabdoid CNS tumor – A case report. Indian J Pathol Microbiol [serial online] 2020 [cited 2020 Feb 23];63:145-7. Available from: http://www.ijpmonline.org/text.asp?2020/63/1/145/277431




Editor,

Meningiomas are notorious for the variety of their cytological and histological presentations. These tumors are further segregated into three grades based on mitosis, cellularity, brain invasion, and presence of necrosis. The variants of high-grade meningiomas include the following: anaplastic, chordoid, and rhabdoid types. Rhabdoid meningioma has got a very aggressive course and poor prognosis for the patient. However, it is essential to differentiate this variant morphologically from other rhabdoid morphology tumors of central nervous system (CNS) as they have an entirely different management. The incidence of hepatocellular carcinoma (HCC) metastasizing to brain is extremely rare, occurring in ~1% of HCC patients.[1]

We report a case of 60-year-old male presenting with an occipital swelling with an initial diagnosis of sebaceous cyst scalp in a primary health center. During operation of the swelling, he started bleeding profusely and was rushed to our tertiary care center for emergency surgery. The dural mass measuring 7 × 4-cm bled easily on touch. Since the patient was wheeled in as an emergency, no preoperative MRI/CT-scan was available. Microscopy revealed an uncapsulated tumor infiltrating into the overlying bony tissue. Tumor displayed sheets of loosely cohesive atypical cells in vague trabecular and nodular pattern. Tumor cells had rhabdoid morphology, having a large size, abundant dense eosinophilic cytoplasm, round, eccentric pleomorphic nuclei with vesicular chromatin and prominent nucleoli. Tumor cells also showed prominent hyaline, paranuclear, intracytoplasmic inclusions, and brisk mitotic activity [Figure 1]a. No necrosis, glomeruloid proliferation, or psammoma bodies were seen. The tumor was seen invading the overlying bony trabeculae and the underlying brain tissue. A differential diagnosis of rhabdoid meningioma, atypical teratoid/rhabdoid teratoma (ATRT), malignant melanoma, and metastases was entertained. Immunohistochemistry (IHC) of tissue revealed tumor cells to be positive for Pan CK [Figure 1]b, CK20, and focal positivity for EMA was noticed. Tumor cells were negative for vimentin (ruling out meningioma) [Figure 1]c and HMB45 (ruling out melanoma). S100, LCA, GFAP, and CD34 IHC were also reported negative. There was no loss of INI-1 protein expression (ruling out ATRT) [Figure 1]d, and MiB labeling index was 10%. At this stage a metastatic tumor with unknown primary was entertained. To narrow down the primary site following IHC were performed – CDX2, TTF1, calretenin, and NSE. However all of them were reported negative thereby ruling out metastasis from gastrointestinal tract, lung, thyroid, adrenal, and kidney. The full body PET scan and CT scan showed small space occupying lesion in liver with multiple mediastinal and retroperitoneal enlarged lymph nodes [Figure 1]e and [Figure 1]f. Serum AFP was not raised. Subsequently, Hep Par-1 IHC of brain metastasis was carried out in a different referral center that revealed tumor cells to be positive [Figure 1]g. At our center, a liver biopsy was carried out, which showed a well-differentiated HCC [Figure 1]h.
Figure 1: (a) Tumor showing a vague trabecular pattern with cells having rhabdoid morphology. The tumor cells are large with abundant eosinophilic cytoplasm (H and E, ×400); (b) immunohistochemistry – tumor cells are positive for PanCK ×400; (c) negative for Vimentin ×400; (d) no INI loss ×400; (e) SOL liver in PET scan; (f) CT scan arterial phase- showing a 2 cm nodule in right lobe of liver; (g) immunohistochemistry – tumor cells are positive for HepPar-1 ×100; (h) liver biopsy – two- to three-cell thick hepatocellular plates/cords, nuclear atypia, and absence of portal tracts (H and E, ×400)

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Dural CNS metastases are often from breast and prostate, but also unusual primaries such as HCC have been described in intradural sites.[2] Approximately 25% (range: 14%–37%) of patients with HCC develop extrahepatic metastasis. The most common sites of this type of metastasis are in lymph nodes and the lungs. Occasionally, bones, adrenal glands, and brain may also be seeded.[3] Brain involvement by HCC is extremely rare. Only close to 60 cases have been reported in literature till date. The overall survival and 5-year survival rates of HCC patients with brain metastases are 2.7% and 5%, respectively.[4] Rhabdoid meningioma has been found to be histologically indistinguishable from other CNS tumors having rhabdoid morphology.[5] Rhabdoid meningiomas are rare, aggressive variant of meningiomas, which may be evident on initial presentation or appear only in recurrent tumors.

Statement of informed consent

Patient information has not been disclosed at any stage during the publishing of this article.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Cossu A, Massarelli G, Manetto V, Viale G, Tanda F, Bosincu L, et al. Rhabdoid tumours of the central nervous system. Virchows Arch A Pathol Anat Histopathol 1993;422:81-5.  Back to cited text no. 1
    
2.
Tunc B, Filik L, Tezer-Filik I, Sahin B. Brain metastasis of hepatocellular carcinoma: A case report and review of the literature. World J Gastroenterol 2004;10:1688-9.  Back to cited text no. 2
    
3.
Daga D, Dana R, Kothari N. Hepatocellular carcinoma - An unusual metastatic presentation on the chest wall. Clin Exp Hepatol 2016;1:133-5.  Back to cited text no. 3
    
4.
Chang L, Chen YL, Kao MC. Intracranial metastasis of hepatocellular carcinoma: Review of 45 cases. Surg Neurol 2004;62:172-7.  Back to cited text no. 4
    
5.
Perry A, Scheithauer BW, Stafford SL, Abell-Aleff PC, Meyer FB. “Rhabdoid” meningioma: An aggressive variant. Am J Surg Pathol 1998;22:1482-90.  Back to cited text no. 5
    

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Correspondence Address:
Prateek Kinra
Department of Pathology and GI Pathology, Armed Forces Medical College, Wanowrie, Pune - 411 040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_86_19

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