Nasal alar metastasis of advanced hepatocellular carcinoma misdiagnosed as reactive cutaneous capillary endothelial proliferation in a patient treated with camrelizumab and apatinib: a case report

Abstract

Background Reactive cutaneous capillary endothelial proliferation (RCCEP) is a common adverse event of camrelizumab in the treatment of advanced hepatocellular carcinoma. Facial skin metastasis is an exceptionally uncommon occurrence in hepatocellular carcinoma (HCC). It can be easily mistaken for a prevalent complication known as RCCEP, particularly when it manifests as a persistently enlarging tumor-like mass. This case report highlights a prototypical instance where a metastasis in the nasal alar region of HCC was mistakenly diagnosed as RCCEP during immunotherapy. The findings of this report hold significant clinical value in guiding the management of larger RCCEP lesions encountered during immunotherapy. Case Description In this case, the patient is a male with a history of hepatitis B. In October 2015, he was diagnosed with HCC. In April 2020, he commenced treatment with ramucirumab (200 mg every 3 weeks) as tumor progression. However, during the third treatment cycle, the patient experienced RCCEP, predominantly affecting the head, neck, trunk, and limbs. To address this, sequential administration of apatinib was initiated, resulting in the gradual regression of RCCEP in these areas. Unfortunately, the metastatic lesion in the nasal alar region continued to grow, exhibiting a tumor-like appearance. On January 25, 2021, surgical resection was performed to remove the nasal alar lesion, and subsequent pathological examination confirmed it as a liver metastasis. Post-surgery, radiation therapy was administered to effectively manage the remaining lesion in the nasal alar region. Importantly, the treatment of the nasal alar metastasis did not hinder the comprehensive management of HCC. The patient obtained excellent curative effect. Conclusions During the course of immunotherapy for HCC, the emergence of a larger RCCEP lesion that does not show signs of regression even with vigorous treatment raises the suspicion of skin metastasis. It is difficult to distinguish metastatic tumor on the skin from morule- and tumor-like RCCEP that does not easily resolve. To obtain a definitive diagnosis, an early pathological biopsy is crucial. If confirmed as a metastatic tumor, prompt consideration should be given to implementing curative surgical resection.

Reactive cutaneous capillary endothelial proliferations of the eyelids induced by camrelizumab: A case report

“…Under most circumstances, RCCEPs will regress spontaneously after SHR-1210 treatment, with a median time of 211 days ( 24 ). However, prompt treatment of RCCEPs is sitll required in some cases, including those with a high risk of haemorrhage (plump or vulnerable lesions) ( 24 ), when there is difficulty in distinguishing a metastatic tumour from an RCCEP ( 36 ) or in cases with obvious clinical manifestations, such as the eye irritation in this patient. The treatments for RCCEPs are predominantly focused on two aspects: Medication and surgery.…”

“…In clinical studies of SHR-1210 plus apatinib in solid tumours, the incidence of RCCEP ranged from 11.9-29.5% ( 14 , 15 , 26 ), which was significantly lower than the occurrence rate of 67-97% for SHR-1210 monotherapy ( 24-26 ). Significant regression of RCCEPs was reported in several cases after the initiation of apatinib ( 36 , 39 ). Furthermore, unlike other antiangiogenesis agents such as bevacizumab, which can increase anastomotic leakage and wound healing complications, apatinib is free of this problem ( 38 ).…”

“…Curative surgical resection is another optional therapy. In some conditions, it is difficult to differentiate the tomour-like RCCEPs from suspect metastatic lesions, which increases the demands of lesion excision to obtain definitive pathological findings to avoid delaying antitumour treatment ( 36 ). Other surgical indications include lesions with an unusual distribution, such as in the present case where the appearance and normal blinking were affected, as well as in lesions with a high risk of bleeding.…”