Mr. W is a 66 y.o white man who presented with a 6 month history of a rapidly growing abdominal wound and abdominal pain. He has a history of myeloproliferative disease (MPD) and had a prior ventral hernia repair in 2001, complicated by an infected mesh removed in 2004, with the abdominal wound allowed to heal by secondary intention. His wound persisted but was only ∼4cm x 4cm in size. Over the past 6 months, the wound progressively enlarged, associated with new purulent drainage and worsening RUQ abdominal pain. Exam showed an obese, soft abdomen, with tenderness at the RUQ. A 14x14cm supraumbilical wound was present, with mild bleeding and purulent discharge. Laboratory data showed leukocytosis (30,000/cmm) and thrombocytosis (993,000 /cmm) which were greatly above Mr. W’s chronically elevated baseline levels due to his underlying MPD. Alkaline phosphatase was also elevated at 270 IU/L. CT abdomen showed multiple hypodense, poorly defined liver lesions, concerning for hepatic abscesses versus metastatic squamous cell skin cancer (SCC), seeding from the wound. Broad spectrum antibiotics were begun. The FNA from the liver masses were consistent with hepatocellular carcinoma (HCC), an unexpected finding in this patient who does not have a history of cirrhosis, viral hepatitis, or past alcohol abuse. Liver cultures remained negative. The abdominal wound pathology showed metastatic poorly differentiated carcinoma, with similar morphology to the liver findings. CEA was 1.55, and AFP was 1.4. The wound culture grew pseudomonas aeruginosa, treated with 14 days of meropenem. Mr. W’s final diagnosis was metastatic HCC, with future treatment to include sorafinib.
HCC most often metastasizes to the lungs, abdominal lymph nodes, or bone (1). Cutaneous metastases from HCC are very rare but can be the first clinical sign of HCC (6,8). Prior reports have described these skin lesions to be rapidly growing, firm, painless, nonulcerative, 1‐2.5 cm nodules, found mostly on the face, scalp, chest, and shoulders (1,2). Some lesions have a pyogenic granuloma‐like or a hemangiomatous character (1,3). In one study (4), skin metastases were shown to account for only 2.7% of cirrhotic HCC’s with no cases found in noncirrhotic HCC (like our case). There have been reports of cutaneous metastases due to direct implantation from a procedure, such as a biopsy or ablation of HCC.
Here, we report HCC metastasizing to a chronically unhealed abdominal wound. Usually, a non‐healing wound transforms into SCC. The possibility of skin metastasis should be considered in HCC patients who present with new skin nodules or non‐healing wounds, with diagnosis confirmed by biopsy. In our review of the literature, this is the first reported case of metastatic HCC to a non‐healing wound.
To cite this abstract:Caga‐anan G, Abdelrahim M. A Nonhealing Wound That Is Not Skin Cancer!. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 295. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/a-nonhealing-wound-that-is-not-skin-cancer/. Accessed March 31, 2020.