A Confusing Complication of Liver Biopsy: First Case Report of Seeding/ Implantation of Hepatocellular Carcinoma 9 Years from the Original Liver Biopsy

The incidence of seeding/implantation of hepatocellular carcinoma (HCC) after liver biopsy or radio frequency ablation (RFA) is not well reported but estimated to be low. With the introduction of immunosuppression the risk has been increased and most of the seeding sites are chest wall and abdominal muscles. We report the first case report of HCC seeding after 9 years from the original liver biopsy. A 66 years old gentleman with cirrhosis secondary to hepatitis C virus infection and long history of alcohol abuse found to have a liver lesion during his screening by ultrasound and underwent percutaneous liver biopsy, which revealed hepatocellular carcinoma in 2006 and then the patient had a liver transplantation surgery in 2006 from cardiac death donor. The post transplantation course was uneventful and started on dual immunosuppression including Tacrolimus and Mycophenolate mofetil with acceptable levels through the whole treatment duration. All the follow up routine check ups including CT scan, liver biopsy, liver function tests and cancer screening were unremarkable and alphafetoprotein (AFP) was within acceptable level except slight increase in the AFP early 2015. His increase in AFP raised the concern for recurrence of HCC and his work up for possible recurrence or metastasis was negative including CT scan of the chest, abdomen and pelvis. Later in the 2015, the patient presented to his primary care physician complaining of right upper quadrant pain and swelling for which he underwent excisional biopsy of the skin. The skin nodule been fully resected and was 1.5 cm in diameter and its 10-15 cm from the original HCC. The pathology results of the specimen revealed that its metastatic hepatocellular carcinoma involving the subcutaneous tissue with negative margins, the immunostains were positive for Heppar1 immunestains and equivocal for glypican 3. This represents a local seeding of the original HCC 9 years after the liver biopsy location. This finding also was confirmed upon reviewing the images of the original HCC and the new metastatic HCC that showed it has same track of the liver biopsy in 2006. This case report is to increase the awareness of hepatologist and primary care physicians of the risk of skin HCC implantation and consider a routine check during the clinic visits in addition to the dermatologist skin screening visits. More research needed to investigate the rule of immunosuppression on seeding and implantation of HCC.