P4728 - Cutaneous Metastasis in a Patient With Combined Hepatocellular Cholangiocarcinoma

Sirisha Gaddipati, MD¹, Carla Molliner, PA-C², Melissa Duarte, MD², Francesco Alessandrino, MD², Clara Milikowski, MD², Lynn Feun, MD², Benjamin Spieler, MD², Patricia Jones, MD, MSCR^2
1University of Miami Miller School of Medicine at Jackson Memorial Hospital, Miami, FL; ²University of Miami Miller School of Medicine, Miami, FL

Introduction: Combined hepatocellular cholangiocarcinoma (cHCC-CC), a rare aggressive malignancy with characteristics of both hepatocellular carcinoma (HCC) and cholangiocarcinoma (CC), typically metastasizes to lymph nodes and bone. It is rare for either HCC or CCA to metastasize to the skin. We present a case of cHCC-CC presenting as a cutaneous abdominal lesion.

Case Description/Methods: A 73-year-old woman with biopsy-proven HCC (diagnosed October 2022) underwent radioembolization in March 2023. Pre-treatment alpha-fetoprotein (AFP) level was 4,471 ng/mL. Durvalumab and Tremelimumab were started three months later due to rising AFP and viable disease on imaging. After two cycles, treatment was suspended due to immunotherapy-related colitis and pneumonia. Surveillance computerized tomography (CT) scans done 4 months later showed continued viability of liver lesions but did not demonstrate metastatic disease. Proton therapy was delivered to the liver over 15 sessions from October to November 2023. Shortly thereafter, the patient developed a pruritic rash with rapid growth of one cutaneous lesion (1.5 cm) below the right breast and smaller (7-8 mm) solid papules scattered on the abdomen and right flank.

In January 2024, Dermatology performed punch biopsy of left abdominal mass with pathology revealing metastatic HCC (supported by positive staining for HepPAr-1 and E-Cadherin). Surgical Oncology also performed core biopsies of the right upper quadrant abdominal mass, which revealed poorly differentiated adenocarcinoma with extensive necrosis with immunohistochemistry positive for CK-7, Albumin ISH, and SATB2, suggestive of intrahepatic cholangiocarcinoma. Serum Ca19-9 was also elevated at 254.8 U/mL. Of note, CA 19-9 was also elevated at diagnosis at 152.6 U/mL. CT scan demonstrated new abdominal wall masses, a 2.4 cm chest wall mass, a periumbilical mass, and bulky pulmonary lymph nodes, all suggestive of metastatic implants. Due to rapid progression and associated pain, palliative radiation to cutaneous nodules was recommended. The patient and family preferred focusing on comfort care and opted for home hospice.

Discussion: To our knowledge, this is the first reported case of cutaneous metastasis from cHCC-CC. Initial liver biopsy suggested only HCC, which impacted choice of systemic therapy. Differentiating this entity from radiation-related skin changes and primary squamous neoplasm is important for early identification and treatment for this aggressive cancer.



Disclosures:


Sirisha Gaddipati, MD¹, Carla Molliner, PA-C², Melissa Duarte, MD², Francesco Alessandrino, MD², Clara Milikowski, MD², Lynn Feun, MD², Benjamin Spieler, MD², Patricia Jones, MD, MSCR². P4728 - Cutaneous Metastasis in a Patient With Combined Hepatocellular Cholangiocarcinoma, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.