Teaching Case

A patient with hepatocellular carcinoma was treated with transcatheter arterial chemoembolisation. One year later he reported a sore solid mass at the right shoulder.

The patient, affected with chronic hepatopathy and hepatitis C, presented with a hepatocellular carcinoma (HCC) nodule in the seventh hepatic segment. He was treated with transcatheter arterial chemoembolisation (TACE) and subjected to CT follow up.

One year later he reported a sore solid mass at the right shoulder. US and MRI were performed, showing a metastasis from the HCC to the shoulder blade.

HCC is an aggressive tumour with different treatment options depending on the stage of the tumour. The incidence of HCC is increasing, not only in Japan but also in the United States, because of an increased rate of viral hepatitis, in particular from previously undiagnosed hepatitis C. An incidental extrahepatic lesion discovered at imaging in a patient with HCC may in fact be benign. If such lesions are assumed to be malignant, curative surgical therapies such as orthotopic liver transplant or resection may not be offerd and the patient will be left with only palliation. In both clinical settings, knowledge of the local and radiographic appearances of metastatic HCC is important in assuring the patient the most appropriate therapy and the best chance of survival.

Bone metastases from HCC are fairly rare, their average occurence rate being 7.3%. All bone metastases are lytic and involve the lumbosacral or the thoracic spine; more rarely, at initial presentation, some patients have rib lesions, or lytic lesions of the lumen acetabulum or ilium and lytic destruction of the sternum, shoulder blade or femur. The meatstases are demonstrated by radiography, CT, and nuclear scintigraphy, in patients with skeletal pain; CT scans demonstrate the destructive nature of the lesions, which are associated with bulky soft-tissue masses.

The authors believe that bone scintigraphy should be included in the staging protocols of the HCCs which need a potentially curative therapy. Bone metastases are frequently detected in the early stages of cirrhosis and HCC, which suggests that patients might experience long survival if adequately treated with radio-chemotherapy.