Initial Presentation Of Hepatocellular Carcinoma Research Articles

Solitary skull metastasis as initial presentation of hepatocellular carcinoma

Solitary skull metastasis as initial presentation of hepatocellular carcinoma

Cannonball Pulmonary Metastases as Initial Presentation of Hepatocellular Carcinoma: A Case Report and Literature Review

BackgroundHepatocellular carcinoma is a major public health problem, as is considered the fastest growing cause of cancer-related death. Cannonball metastases as an initial finding in hepatocellular carcinoma are considered a rare phenomenon.Case PresentationA 59-year-old man presented to the outpatient clinic for subacute cough, asthenia, and involuntary weight loss. Chest X-ray showed multiple, round, bilateral pulmonary solid lesions. Contrast-enhanced computed tomography of the chest and abdomen revealed multiple bilateral, contrast-enhanced pulmonary nodules known as "cannonball" lesions and a heterogeneous lesion located in the right lobe of the liver with retroperitoneal lymphadenopathy. A biopsy was performed, and the histopathological result was compatible with metastatic poorly differentiated hepatocellular carcinoma. Due to the advanced stage of the disease, the patient received palliative care and expired two months later.ConclusionCannonball metastases in hepatocellular carcinoma are considered a rare finding and represents a poor prognosis. It is important to awaken the interest of clinicians in a timely diagnosis, as well as a possible suspicion of hepatocellular carcinoma in patients with this radiographic pattern.

Unusual Initial Presentation of Hepatocellular Carcinoma as a Clavicular Head Mass

Unusual Initial Presentation of Hepatocellular Carcinoma as a Clavicular Head Mass

Hemorrhagic Brain Metastasis as an Initial Presentation of Hepatocellular Carcinoma in a Patient With Alcohol-Related Liver Cirrhosis: A Case Report and Review of Literature

Hepatocellular carcinoma (HCC) is the most common primary hepatic cancer. Although it usually presents as a liver mass, rarely HCC can have an initial presentation at an extrahepatic site before the diagnosis of the primary lesion in the liver. Even rarely was that brain metastasis as initial extrahepatic presentations. Furthermore, the initial presentation of HCC as brain metastases has been with most cases being secondary to hepatitis-related hepatoma. In this case report, we are presenting a rare and unusual case of hemorrhagic cerebral metastasis as an initial extrahepatic presentation of an alcohol-related hepatoma. Our case is the second case in the English literature that has been presented in such a way. Due to the uncommonness of presentation, there can be diagnostic dilemmas and delay in treatment. Therefore, a high level of suspicion is needed in the high-risk patients of HCC who present with unexplained or new neurological signs and symptoms. More exploration is warranted for clinical research and treatment guidelines for brain metastases of HCC to help improve survival and quality of life.

Unusual presentation of a common tumor

Hepatocellular carcinoma(HCC) is the most common primary malignant tumour of liver. It is 5th most common malignancy in males and 8th most common tumour in females. The patients of HCC may remain clinically asymptomatic or may present with abdominal pain, weight loss, malaise, fever, jaundice or ascitis. HCC is a highly malignant tumor with frequent extrahepatic metastasis. The most frequent site of metastasis is lungs (47%), followed by lymph nodes (45%), bones (37%), and adrenal glands (12%). We present a case of 67 year old male, who presented with progressively increasing swelling in the left occipital region for 2 months. MRI brain showed large lobulated moderately enhancing T2 isointense to hyperintense and T1 hypointense mass lesion in occipital region, causing destruction of occipital bone with large intracranial extradural soft tissue component. Possibilities suggested were Meningioma or metastatic lesion. The scalp mass was excised. The histopathological examination of the excised tissue followed by elaborate immunohistochemistry suggested metastatic hepatocellular carcinoma, which was later confirmed by S.AFP and multiphase CT thorax, abdomen, pelvis which showed multiple liver lesions. Initial presentation of HCC as a subcutaneous lesion is very rare and only very few cases of HCC presenting with primary soft tissue swelling have been reported.

Bilateral orbital metastasis as an initial presentation of hepatocellular carcinoma

Purpose: To describe a case of biopsy-confirmed bilateral orbital metastasis of previously undiagnosed hepatocellular carcinoma, presenting with bilateral proptosis.
 Case description: A 57-year-old man presented with painless bilateral proptosis over 2 months. At presentation, the best-corrected visual acuity was 20/60 in the right eye and 20/20 in the left eye. Ocular examination revealed bilateral asymmetrical non-axial proptosis with Hertel exophthalmometer reading of 24 mm in the right eye and 22 mm in the left eye. There was mild inferior displacement in both eyes. Apart from mild exposure keratopathy in the right eye, both anterior and posterior segment examinations were not remarkable. Orbital computerized tomography (CT) scan showed soft tissue masses in the superotemporal quadrants of both orbits associated with lytic bone lesions. An orbital biopsy confirmed that it was metastatic hepatocellular carcinoma (HCC). Ultrasound abdomen revealed multifocal HCC with underlying cirrhosis. We planned for further investigations such as hepatitis serology, alfa-fetoprotein, and CT abdomen, but he refused to proceed with investigations and treatment.
 Conclusion: Orbital metastasis, more so as a bilateral involvement, is a rare phenomenon. It may present as an initial manifestation of undiagnosed systemic cancer. Orbital metastasis should be considered when diagnosing patients with bilateral proptosis, and orbital biopsy is crucial for histopathological diagnosis.

S2720 Hemorrhagic Shock as Initial Presentation of Hepatocellular Carcinoma: A Case Series

INTRODUCTION: Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer-related death worldwide. In the United States (US) Texas has the highest HCC incidence rate in 2015 (13.2/100,000 individuals), 45% higher than national average. Hemorrhagic shock due to tumor rupture is a rare, life-threatening presentation that requires acute intervention. Given its rare presentation, this has been documented through small case series. As such, the true impact of HCC tumor rupture on outcomes has been difficult to ascertain in different populations. CASE DESCRIPTION/METHODS: Case 1 81-year-old Hispanic man with medical history of CAD and atrial fibrillation presents to the hospital for severe right upper quadrant (RUQ) pain for 1 day. Vitals significant for BP 60/40 mmHg. On exam he is in distress with findings of acute abdomen. Hb noted at 11.4 mg/dL. CT abdomen shows a 4.1 cm mass at the posterior segment of the right lobe of the liver with perihepatic and peri-splenic fluid. Patient was initially resuscitated with normal saline and PRBCs, however he required norepinephrine and emergent trans-arterial embolization (TAE). After the procedure patient had US-guided paracentesis with 1.8 L serosanguineous fluid removal. Case 2 55-year-old Hispanic woman with Hepatitis C comes to the hospital for sudden onset severe RUQ pain. Vitals are stable, on exam has RUQ tenderness. Laboratory showed Hb 8.8 mg/dL. CT Angiography abdomen reports 3.5 cm right lobe liver mass and peri-hepatic moderate complex fluid collection. Patient received 1 unit of PRBC and went for emergent TAE of ruptured HCC. DISCUSSION: The pathogenesis behind tumor rupture remains unclear, some studies report tumor location, growth and vessels friability with high intra-tumoral pressure as a cause of bleeding and rupture. Patients present with acute abdominal pain and hypovolemic/hemorrhagic shock in 33–99% of cases. Diagnosis can be made with abdominal CT or US showing tumor location/size and hemoperitoneum if present. Paracentesis can show sanguineous peritoneal fluid. Acute management is focused on patient’s hemodynamic stabilization and bleeding control with TAE. If bleeding persists, emergency liver resection is indicated with post-operative mortality rate of 16-100%. This case series demonstrates an uncommon and life-threatening initial presentation of HCC. The high incidence of HCC among Texas-based Hispanic population warrants early recognition of this dreadful complication.Figure 1.: Case 1.CT abdomen showing 4.1 cm mass at the posterior segment of the right lobe of the liver.Figure 2.: Case 2. CT Angiography Abdominal showing arterial enhancing of a 3.5 × 3.5 cm right lobe liver mass adjacent to the lateral capsular surface. Hemoperitoneum noted.

2323 Bone Metastasis as Index Presentation of Hepatocellular Carcinoma

INTRODUCTION: Hepatocellular carcinoma (HCC) is the most common primary tumor of the liver, and the fifth most common cancer worldwide Extrahepatic mestastasis rarely occurs in patients with early course HCC. Bone metastasis as the initial presentation of HCC is even more rare. Here we present an unusual case of Bone metastasis to the ninth rib as the index presentation of HCC. CASE DESCRIPTION/METHODS: The patient is a 60 year old male with a medical history of hypertension, hepatitis C virus, hyperlipidemia, rheumatoid arthritis and chronic obstructive pulmonary disease who presented to the emergency department complaining of right upper quadrant pain for one week. Physical exam was notable for tenderness over the patients right ninth rib. The rest of the physical exam was unremarkable. Notable laboratory workup included a complete blood count and comprehensive metabolic panel within normal limits. Notable imaging included a computed tomography of the abdomen showing a mass over the ninth rib with multiple foci in liver. The next day an alpha fetoprotein (AFP) level was ordered and returned elevated at 1139.0 ng/ml. Other tumor markers including carcinoembryonic antigen (CEA), carbohydrate antigen 19 9 (CA 19 9) and prostate specific antigen (PSA) were within normal limits. Interventional radiology was then consulted and performed a biopsy of the ninth rib mass which showed metastatic carcinoma with a primary of hepatocellular malignancy. This diagnosis was supported by positive staining with Hep-Par 1. Following this diagnosis the oncology service was consulted and recommended palliative radiotherapy to the ninth rib and starting treatment with Sorafenib. The patient was then discharged with pain medications and follow up appointments. DISCUSSION: Common risk factors for the development of HCC include Hepatitis B, Hepatitis C, Aflatoxin exposure, and cirrhosis of any cause (including alcohol). The most common sites of extra-hepatic metastasis of HCC are lung, lymph node, musculoskeletal, and adrenal gland. Isolated bone metastasis of HCC is rare occurring in only 9.5% of patients. Symptoms associated with HCC include right upper quadrant pain, jaundice and ascites in more advanced cases. Treatment of metastatic HCC to bone includes chemotherapy and targeted radiotherapy. More recently Bisphosphonates have also been shown to have success.

Hepatocellular Carcinoma Presenting as ST Elevation in V1 and V2 (Brugada Pattern)

Introduction: Hepatocellular carcinoma (HCC) is usually discovered on routine ultrasound screening in patients with chronic liver disease or when symptomatic enough to warrant investigation. However, initial presentation of HCC as ST—segment elevation in V1 and V2 (Brugada pattern) has never been previously reported. Case Presentation: We report a 63—year—old African American male with past medical history of hypertension, tobacco abuse, and schizophrenia, who presented with 3 weeks of right upper quadrant and epigastric abdominal pain, which was worse when bending over. EKG on admission showed new ST elevation in V1 and V2 with reciprocal changes in inferior leads when compared to previous EKG in June 2016, which was concerning for acute STEMI (Fig. 1). Cardiology was consulted, and the patient underwent cardiac catheterization, which was negative. Following negative cardiac catheterization, he was transferred back to the General Medicine service for workup of his abdominal pain. Abdominal ultrasound was negative for cholecystitis or stones. Due to continued symptoms he received a CT abdomen (Fig. 2), which showed a large mass in the left lobe of the liver, as well as gastric wall thickening and large left upper quadrant varices. The patient at this time acknowledged being diagnosed with hepatitis C infection more than 20 years ago. Gastroenterology was consulted, and the patient underwent EGD, MRCP, and colonoscopy. MRI (Fig. 3) showed 2 focal masses within the left lobe of the liver, findings concerning for infiltrative neoplastic process. Tumor markers, including AFP, CA19—9, and CEA, as well as hepatitis serologies were drawn. AFP was significantly elevated to approximately 10,000 ng/mL, and the diagnosis of hepatocellular carcinoma was considered highly likely. Initial read of triple—phase CT was atypical for hepatocellular carcinoma; therefore, liver biopsy was scheduled with Interventional Radiology. Final read of the CT showed left hepatic lobe mass with invasion and occlusion of the left portal vein, most consistent with hepatocellular carcinoma. Pathology from liver core biopsy was consistent with HCC.3025_A.tif Figure 1: EKG showing ST segment elevation in V1 and V2 (Brugada pattern)3025_B.tif Figure 2: CT abdomen showing a large mass in the left lobe of the liver3025_C.tif Figure 3: MRI abdomen showing 2 focal mass—like areas within medial segment of left lobe of the liverDiscussion: HCC is the ninth most commonly diagnosed cancer worldwide. HCC is usually discovered either during routine screening or when symptomatic. In our case, HCC was presented in a patient with acute epigastric pain and EKG findings of ST—segment elevation. This case shows that intra—abdominal tumors, such as HCC, may present as ST elevation.

An Unusual Cause of Obscure Gastrointestinal Bleeding

Question: A 54-year-old man was referred to our hospital with a 1-month history of intermittent tarry to bloody stool. His medical history included hepatitis B–related liver cirrhosis and hepatocellular carcinoma (HCC). His hepatoma was diagnosed 1 year earlier (American Joint Committee on Cancer Staging T3aN0M0) , and he was treated with radiofrequency ablation and tumor embolization. The tumor recently progressed with portal vein tumor thrombosis (Figure A). He underwent sorafenib therapy; however, the drug was discontinued after the bleeding episode. Examination with upper endoscopy and colonoscopy failed to identify the cause of bleeding. Despite medical therapy, including a proton pump inhibitor and octreotide, the bleeding persisted, and he was referred to our hospital for deep enteroscopy. The laboratory examination revealed anemia (hemoglobin 9.1 g/dL), thrombocytopenia (platelet count, 131 × 109/L), and a normal prothrombin time. The calculated Model for End-stage Liver Disease score was 8 and the Child-Pugh class was B. Deep enteroscopy via the anal route was performed, and a lesion at 100 cm from the ileocecal valve was found (Figure B, Video Clip A). What are the findings of enteroscopy? What is the differential diagnosis? Look on page 361 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI. Enteroscopy revealed a bleeding submucosal tumor in the ileum (Figure B). Hemostasis via enteroscopy failed, and a submucosal tattoo was placed around the lesion. Review of the computed tomography examination revealed a previously unrecognized tumor in the ileum (Figure C, arrow). To control the bleeding, the patient decided to undergo laparoscopic tumor resection (Figure D). Pathologic examination revealed a 2.5-cm ulcerative tumor involving the whole layer of the small intestine with pleomorphic nuclei, coarse chromatin, prominent nucleoli, and abundant eosinophilic cytoplasm (Figure E) with positive staining for Hep-par-1 (Figure F). Metastatic HCC was diagnosed. After surgery, the bleeding was controlled, but the patient died of progressive liver failure after 6 weeks. HCC is the most common liver malignancy. Distant metastases from HCC usually involve the lung, regional lymph nodes, bone, or adrenal glands, and only 0.2% of metastatic HCC involve the gastrointestinal tract.1Chen L.T. Chen C.Y. Jan C.M. et al.Gastrointestinal tract involvement in hepatocellular carcinoma: clinical, radiological and endoscopic studies.Endoscopy. 1990; 22: 118-123Crossref PubMed Scopus (79) Google Scholar The mechanisms of gastrointestinal tract metastasis are direct invasion (82%), hematogenous metastasis (9%), and seeding (9%), and most cases are discovered at autopsy.2Yang C.W. Soon M.S. Chen Y.Y. et al.Synchronous metastasis to the oral cavity and proximal upper small intestine as an initial presentation of hepatocellular carcinoma: report of a case.Gastroenterol J Taiwan. 2009; : 318-320Google Scholar The present case was considered to have hematogenous spread because of portal vein tumor thrombus and no peritoneal dissemination or direct invasion. Endoscopic findings of gastrointestinal metastases from HCC included raised and centrally ulcerated lesions, polypoid tumors, and submucosal tumors.1Chen L.T. Chen C.Y. Jan C.M. et al.Gastrointestinal tract involvement in hepatocellular carcinoma: clinical, radiological and endoscopic studies.Endoscopy. 1990; 22: 118-123Crossref PubMed Scopus (79) Google Scholar, 2Yang C.W. Soon M.S. Chen Y.Y. et al.Synchronous metastasis to the oral cavity and proximal upper small intestine as an initial presentation of hepatocellular carcinoma: report of a case.Gastroenterol J Taiwan. 2009; : 318-320Google Scholar The treatment of HCC with gastrointestinal tract metastases comprises palliative care, minimally invasive surgery, or rarely, endoscopic resection.3Igawa A. Oka S. Tanaka S. et al.Small bowel metastasis of hepatocellular carcinoma detected by capsule endoscopy.Case Rep Gastroenterol. 2013; 7: 492-497Crossref PubMed Scopus (7) Google Scholar The prognosis is usually ominous with a median overall survival of 5 months, because gastrointestinal involvement is often a sign of advanced disease.2Yang C.W. Soon M.S. Chen Y.Y. et al.Synchronous metastasis to the oral cavity and proximal upper small intestine as an initial presentation of hepatocellular carcinoma: report of a case.Gastroenterol J Taiwan. 2009; : 318-320Google Scholar eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJhMjYxNTVkZmZkYjU3NjRkYjlmMTAxZDc2NGRiZTZjZSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc5MDkzMTYzfQ.gdjzK2Nf51DgpOUxpyDVFJgvcc-1uFMg1xcGldDxkDRwgr2AgdFYgTWngJGS61kOUBpAhf3qRuJTNYKkDx9DkX4KQX1FYq5EUoWWRg4oFhL_VIZvDHAXfAtczZVEO_TVyrmguX12SRZFCnTd0_pMze0DJqL08Z_k3nG51b3-46KHlBbts1qKZhr-VGQc7NgQHuv82BEymLbZfKXCY2KT83UqeigxGVTnA9ZsR7pTF9-VSZXsRoEVxSEaITBsmO-1YUJK7065Zj4cFT4h5GgN9m3Zj7MSdf5DnK9DdvdxU-qhqGXXrhz11BUGr9XjiEo7YXaHKNQJ-q6s_jVcGsTqJA Download .mp4 (63.22 MB) Help with .mp4 files Video Clip

Metastasis to the jaws as a first manifestation of hepatocellular carcinoma: report of a case and analysis of 41 cases

Abstract Introduction Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide. Local metastasis is common but metastasis to the jaw is rare with 40 reported cases in the English language literature. Report of case We describe a case of a 54-year-old man who, for the past two months, had noticed a rapidly growing facial mass in the posterior mandibular area. The patient was known to be a hepatitis C virus carrier and suffered from liver cirrhosis but the presence of HCC was unknown. Methods and results The English language literature was searched for documented cases of HCC metastasis to the jaw, applicable data was evaluated. The literature analysis revealed 41 reported cases (including the present case). In most cases (81%) the jaw lesion was the only known metastasis at the time of HCC diagnosis. Clinical presentation occurred up to 2 years before discovery of the jaw metastasis. Patients with HCC jaw metastasis have a poor survival rate with an average of 6.1 months between diagnosis and death. Conclusions This study shows that an isolated jaw mass may be the initial presentation of HCC and therefore must be considered in the differential diagnosis, especially in the presence of known liver cirrhosis or chronic viral hepatitis.

An Atypical Initial Presentation of Hepatocellular Carcinoma as Spinal Cord Compression

A young male with quiescent hepatitis B presented with sub-acute onset of lower limb weakness found to have an incidental hepatoma that had metastasized to the vertebrae causing an oncologic emergency in the form of spinal cord compression, a rare initial presentation in HBV-related hepatocellular carcinoma (HCC).

Fatal Initial Presentation of Hepatocellular Carcinoma Invading IVC to Right Atrium, Missed Opportunity for Cure

Fatal Initial Presentation of Hepatocellular Carcinoma Invading IVC to Right Atrium, Missed Opportunity for Cure

Initial presentation of hepatocellular carcinoma as soft tissue swelling of the forearm: A rare cytomorphological diagnosis

Bone is quite an uncommon site of metastasis in patients with hepatocellular carcinoma (HCC). We report a rare case of HCC presenting as a rapidly progressive painful soft tissue swelling with isolated metastasis to the radius bone of right forearm. The present article emphasizes the point that HCC should be considered in the differential diagnosis of patients presenting with palpable soft tissue swelling with destruction of the underlying bone. Fine-needle aspiration cytology (FNAC) of the soft tissue mass revealed cytomorphological features of HCC. The primary tumor of the liver was diagnosed retrospectively, following FNAC of the osteolytic lesion in the right radius bone, which revealed HCC.

HCC without cirrhosis metastasizing to the clivus

The initial presentation of hepatocellular carcinoma (HCC) as a cranial nerve palsy is exceedingly rare. A lack of cirrhosis and elevated AFP in metastatic HCC is also uncommon. To our knowledge, this is the first case report of HCC presenting with ageusia without prior evidence of liver pathology. A 65-year-old man was admitted to our hospital for dysphagia. Over months, he had noticed 36 kg weight loss, dysphagia, ageusia, and horizontal diplopia. He had a low AFP, no evidence of cirrhosis, and no symptoms of liver pathology. On brain magnetic resonance imaging, he was found to have a mass in the clivus. On biopsy, metastatic HCC was diagnosed. HCC can be fatal if not recognized early. It rarely causes neurologic complications through metastasis to the skull. It is important to understand the localization of lesions to the clivus and include internal malignancy in creating a differential for cases of neurologic complaint.

Pituitary Tumor as the Initial Presentation of Hepatocellular Carcinoma

Pituitary Tumor as the Initial Presentation of Hepatocellular Carcinoma

Incidence and risk factors for surveillance failure in patients with regular hepatocellular carcinoma surveillance.

Initial presentation of hepatocellular carcinoma (HCC) at an advanced stage in patients under a regular surveillance program is a devastating problem. We assessed the prevalence and factors associated with this surveillance failure. A total of 304 HCC patients who received regular surveillance were retrospectively reviewed. Surveillance failure was defined when the tumor was diagnosed at beyond the Milan criteria. Surveillance failure rate was 5.9%. Macronodular cirrhosis (MC), ultrasonography-only surveillance (US-S) and infiltrative tumor type were independent factors associated with surveillance failure. The surveillance failure rate was higher in patients with MC (10.3 vs. 3.2%, p=0.022), US-S (14.6 vs. 4.3%, p=0.013) and when the tumor was infiltrative type (57.1 vs. 2.1%, p<0.001). Based on the two baseline factors (MC and US-S), the surveillance failure rates were 35.7, 6.8, 5.9 and 2.6% for MC(+)/US-S(+), MC(+)/US-S(-), MC(-)/US-S(+) and MC(-)/US-S(-), respectively (p<0.001). The HCC surveillance failure was not rare in clinical practice. These data suggest that special attention for surveillance failure might be needed for patients with MC who receive US-S.

A case of monocular blindness as the initial presentation of hepatocellular carcinoma with skull metastasis.

A 52-year-old man suffering from monocular blindness, with light perception only, was admitted to our hospital. The symptom had begun as low vision and developed rapidly within 3weeks into monocular blindness in the right eye, with no other systemic manifestations. Imaging examinations revealed multiple hepatocellular carcinomas in the cirrhotic liver, and tumors at the skull base and vertebra. A pathological and immunochemical study of specimens obtained by endoscopic transnasal tumor biopsy and laminectomy revealed them to be metastatic hepatocellular carcinomas (HCCs). Although the patient underwent radiation therapy and chemotherapy, he died 5months after admission to our hospital. The cranial HCC, involving only the optic canal, may have disturbed the optic nerve in preference to the other cranial nerves. This is the first report of a HCC patient with monocular blindness as the initial presentation of the disease.

Solitary skull metastasis as initial manifestation of hepatocellular carcinoma

BackgroundA solitary skull metastasis from hepatocellular carcinoma (HCC) prior to diagnosis of the primary tumor without liver dysfunction is a very rare event.Case presentationA 71-year-old male, without known liver disease, presented to our institution with a palpable occipital scalp mass. On brain magnetic resonance imaging (MRI), a highly enhanced and osteolytic skull tumor was observed. The histological diagnosis obtained from the percutaneous needle biopsy was a cranial metastasis from HCC. The metastatic tumor was removed via occipital craniectomy, and the two primary liver mass lesions were subsequently treated by transarterial chemoembolization.ConclusionAn isolated skull metastasis may be the sole initial presentation of HCC. Early diagnosis is essential in order to treat the primary disease. A skull metastasis from HCC should be considered in the differential diagnosis in patients with subcutaneous scalp mass and osteolytic defects on X-ray.

Occult hepatocellular carcinoma metastasising to the left temple diagnosed by fine-needle aspiration biopsy

Although hepatocellular carcinoma (HCC) is relatively rare in Western countries, it is one of the most prevalent cancers worldwide. Metastatic spread outside the liver is common and typically occurs in the setting of advanced disease. Metastatic disease is the initial presentation of HCC in less than 5% of cases and even fewer are diagnosed by cytology. We present the cytological findings in an 85-yr-old man of a soft tissue mass in the left temple, which suggested the diagnosis of an occult HCC. Fine-needle aspiration biopsy showed moderately cellular smears with large malignant epithelial cells present in fragments, with apposition of endothelial cells to the tumour cells. Deposits of non-refractile green pigment consistent with bile were present. Investigations revealed abnormal liver function tests, and a large mass replacing much of the liver. In view of the cytology and clinico-radiological correlation, a diagnosis of metastatic HCC was made.