P6072 - A Rare Case of Hepatocellular Carcinoma Metastasized to the Mandible

Ahmed Attia, MD¹, Mason Eghbali, MD², Abdelrhman Refaey, MD³, Abdalnasir Limay, MD⁴, Abiye Kassa, MD⁵, Ameer Abutaleb, MD⁶
1Transplant Institute, Department of Surgery, George Washington University School of Medicine and Health Science, Washington, DC; 2The George Washington University Hospital, Department of Medicine, Washington, DC; 3Division of Gastroenterology and Liver Disease, Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC; 4The George Washington University Hospital, Department of Radiology, Washington, DC; 5The George Washington University Hospital, Department of Pathology, Washington, DC; 6The George Washington Transplant Institute, Department of Surgery, The George Washington University Hospital, Washington, DC

Introduction: Hepatocellular carcinoma (HCC) is the sixth most common cancer and the third leading cause of cancer-related death. It accounts for 80-90% of primary liver malignancies and carries a poor prognosis, with a five-year survival rate of 33% (localized), 11% (regional), and 2% (distant). Extrahepatic metastases most commonly involve the lungs, lymph nodes, and bones, but mandibular involvement is exceedingly rare, occurring in less than 1% of cases.

Case Description/

Methods: A 65-year-old woman with a history of HCC secondary to hepatitis C and alcohol-related cirrhosis and diabetes mellitus presented with altered mental status and was diagnosed with diabetic ketoacidosis. During hospitalization, she developed an acute, tender preauricular mass with trismus. Examination revealed a 2 cm firm, fluctuant, fixed mass on the ascending mandibular ramus. CT head showed a lytic lesion in the cortical bone of the mandibular condyle, and maxillofacial imaging confirmed a 2.3 cm by 2.2 cm heterogeneously enhancing mass with bony destruction. A bedside ultrasound confirmed a hypoechoic fluid collection anterior to the ascending ramus. Aspiration yielded 1 mL of blood. Biopsy identified metastatic HCC with tumor cells diffusely positive for glypican-3 and patchily positive for HepPar1, CD10, and AE1/AE3. MRI of the abdomen revealed a 6.0 cm right hepatic lobe mass consistent with HCC, and Alpha-fetoprotein was 1,060 ng/ml. The patient later developed additional scalp nodules concerning for further metastases. Given the disease burden, she was transitioned to comfort care and received five sessions of palliative radiation to the right mandible and the right liver mass before hospice discharge.

Discussion: HCC is an aggressive malignancy with a high propensity for extrahepatic spread. Metastasis to the oral cavity is rare (1-4% of cases), often via hematogenous spread, and typically involves the mandible due to its rich vascularization. Clinical presentations are often nonspecific and may mimic odontogenic or soft tissue infections. Radiologically, mandibular metastases appear as destructive, radiolucent lesions with ill-defined borders. Diagnosis requires histopathologic confirmation. Early recognition is critical, as treatment options for advanced HCC are limited to systemic therapy or palliative care. This case highlights the need for a high index of suspicion for metastatic disease in patients with known malignancies and unusual presentations.


Figure: Biopsy from the mandibular mass showing tumor cells diffusely positive for glypican-3 and patchily positive for HepPar1, CD10, and AE1/AE3, consistent with poorly differentiated HCC.


Figure: A. MRI showing a 6.0 cm right hepatic lobe mass with restricted diffusion, concerning for hepatocellular carcinoma.
B. CT Maxillofacial bones showing a 2.3 x 2.2 cm heterogeneously enhancing mass in the right mandibular neck with destructive changes and associated soft tissue component concerning for malignancy.

Disclosures:
Ahmed Attia indicated no relevant financial relationships.
Mason Eghbali indicated no relevant financial relationships.
Abdelrhman Refaey indicated no relevant financial relationships.
Abdalnasir Limay indicated no relevant financial relationships.
Abiye Kassa indicated no relevant financial relationships.
Ameer Abutaleb indicated no relevant financial relationships.

Ahmed Attia, MD¹, Mason Eghbali, MD², Abdelrhman Refaey, MD³, Abdalnasir Limay, MD⁴, Abiye Kassa, MD⁵, Ameer Abutaleb, MD⁶. P6072 - A Rare Case of Hepatocellular Carcinoma Metastasized to the Mandible, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.