Primary cancers of liver represent the 5^th most common cancer in men worldwide [1]. There is an increase in the incidence of Hepatocellular cancer (HCC) in areas endemic for chronic viral hepatitis. Most cases of HCC present at an advanced stage and extrahepatic metastasis commonly occur in lung, bone, peritoneum and intra-abdominal lymphnodes [2]. We report a case of multiple soft tissue and bony metastasis in a patient with HCC, who presented with a mass in the right scapular region.

A 46 year old man presented to us with painless swelling in the right scapular region which gradually increased in size over 1 month and dull aching right upper quadrant pain for 20 days duration. He also gave history of loss of appetite and loss of weight. History of passing high colored urine was there, but no history of clay colored stools or generalized pruritis.

There was history of similar lump in his abdomen which was excised 4 years back, but records were not available. During the course of workup, he developed sudden onset painless loss of vision in the left eye. He was a chronic alcoholic and smoker but had no co morbidities. On evaluation, he was icteric.

There was an 8 × 8 cm well defined firm non tender swelling over the right scapular region and the skin overlying was normal. Abdomen examination revealed hepatomegaly 10 cm below right costal margin with irregular nodular surface and mild ascites (Figure 1).

Figure 1: Swelling in the right scapular region.

Laboratory investigations showed normal complete hemogram and no coagulation disorders. Serum HCV was positive. Liver function test showed Bilirubin total-1.6 mg/dL and direct-0.9 mg/dL. AST-71 IU/L, ALT-60 IU/L, ALP-1224 IU/L and GGT-421IU/L. Serum alpha fetoprotein level was normal (3.68). A Fine Needle Aspiration Cytology (FNAC) was done from the right scapular swelling, which was reported as metastatic hepatocellular carcinoma with the cellular smear showing cohesive clusters and sheets of atypical hepatocytes (Figure 2).

Figure 2: Clusters of atypical hepatocytes.

A triple phase CT was done which showed multifocal HCC in the background of cirrhosis with ascites and multiple metastatic lesions in the vertebra. There was a small enhancing focal lesion in the stem of left adrenal gland. There were no lung lesions (Figure 3).

Figure 3: CECT showing multifocal HCC with arterial phase enhancement and T11 vertebral metastatic lesion compressing the cord.

An 8.5 × 7 cm large lytic lesion with extremely vascular surrounding soft tissue noted in the right scapula and one more similar lesion at the level of manubriosternum (Figure 4).

Figure 4: CECT showing lytic soft tissue lesions in the scapula and manubriosternum.

CECT of the head showed, a well defined enhancing lesion in the extraconal aspect of left orbit with loss of fat plane with left lateral rectus and eroding the left greater wing of sphenoid. Another similar lesion in the left orbital apex with encasement of intracanalicular portion of left optic nerve (Figure 5).

Figure 5: CECT showing soft tissue lesion in the left orbital apex encasing the left optic nerve.

A diagnosis of hepatocellular carcinoma with multiple soft tissue and bony metastasis with adrenal metastasis was made. Oncology board discussion was done and patient was planned to start on Sorafenib therapy in view of disseminated disease.

Hepatocellular carcinoma is the 5^th most common malignancy in men and 9^th in women and the 2^nd most common cause of cancer death [1], which occurs in the background of cirrhosis, commonly caused by Hepatitis B or C infection or alcohol consumption. Untreated HCC has a dismal prognosis with a 5 year survival rate below 10%. The median survival was 4.9 months (0 to 37 months). The incidence of extrahepatic metastasis from HCC vary from 13.5 to 42%. Dissemination of malignancy occurs through hematogenous routes and frequently involve the lung (47%), bone (37%), intra-abdominal lymphnodes (45%) and adrenal glands (12%) [2]. Natsuizaka et al. reported that patients with advanced HCC develop extrahepatic metastasis more frequently than those with less advanced HCC [3]. Soft tissue metastasis from HCC is unusual. It usually originates from needle tracts or surgical wound contamination. Non iatrogenic metastasis from HCC is very rare and there does not seem to be a clear predisposing factor that contributes to the incidence [4]. To our knowledge, there are only a few case reports in the literature regarding soft tissue metastasis from HCC. Only one case has been reported with HCC patient developing monocular blindness due to skull base metastasis [5]. Systemic therapy should be the mainstay of care in metastatic disease and localized cutaneous or soft tissue metastatic lesions can be palliated with either surgical resection or radiotherapy. Radiation treatment was found to have satisfactory results with low toxicity profile in patients with soft tissue metastasis [6]. A low risk and effective treatment modality is required for good palliation of such metastatic lesions as the expected survival is measured in months. Our patient was a 46 years old man with HCV hepatitis and had a metastatic HCC with multiple soft tissue metastasis, bony metastasis and adrenal metastasis. In view of disseminated disease, it was planned to start on Sorafenib therapy.

The first sign of liver cancer may be an extrahepatic metastasis. Metastatic HCC should be a consideration in patients presenting with unexplained rapidly growing soft tissue lesions with a history of HCC or risk factors for the disease [7] and should be evaluated with appropriate radiologic investigations and sampling of the mass for histopathological examination.