Skull metastasis from hepatocellular carcinoma with hepatitis C.

To the Editor: Hepatocelluler carcinoma (HCC) commonly metastasizes to the lung, regional lymph nodes, peritoneum and adrenal glands. The incidence of bone metastases from HCC is very low. The most common sites are the vertebrae, followed by the pelvis and ribs. HCC very rarely metastasizes to the skull.1,2 We report a case of skull metastasis from HCC with chronic hepatitis C.

A 72-year-old man with a diagnosis of chronic hepatitis C was referred to our outpatient clinic with a blunt right upper quadrant abdominal pain. Dynamic abdominal MRI showed a mass lesion of 6×8 cm in the right lobe in the eighth liver segment protruding left to fourth segment. The mass was heterogenous, hipovasculer and showed periportal contrast enhancement. Satellite lesions were seen in the right and the left lobe. There was a thrombus in the right anterior branch of the portal vein related to the mass, which was compatible with hepatocelluler carcinoma (HCC) (Figure 1a). Liver biopsy was compatible with well differentiated HCC, macrotrabecular type. During his follow up period, in the sixth month a subcutaneous mass lesion in his head localized in right fronto-parietal lobe was examined. A cerebral CT revealed a 6×3 fusiform mass lesion in the right fronto-parietal lobe which was localized both intracranially and extracranially. Lytic lesions were also seen in the skull (Figure 1b). T1-weighted coronal MR imaging also showed a significantly enhanced metastatic mass lesion in the right fronto-parietal lobe in the skull protruding to the scalp (Figure 1c). Tru-cut scalp biopsy was compatible with HCC metastasis. In the whole body scintigraphy with technetium-99m-methylene diphosphonate (99mTc-MDP) there was an increased radioactive uptake as a ring pattern around the middle hypoactive area in the right frontoparietal region. There were also increased radioactive uptake areas like the thoracic vertebrae, ribs, sternum and right sacroiliac joint (compatible with metastasis of primary disease). Focal increased uptake in the left medial tibial plateau was also observed and was thought to be associated with degenerative changes (Figure 1d).

Figure 1

Metastasis from hepatocellular carcinoma with hepatitis C.