LAUSR

Background Hepatocellular Carcinoma (HCC) is the second leading cause of cancer death worldwide, especially in Asia and Africa.2–4 HCC commonly metastasizes to regional lymph nodes and lungs, and less commonly to bone.6 Cutaneous metastases are extremely rare with only a few reports in the literature. Methods A 56-year-old male diagnosed case of chronic hepatitis B for 9 years previously on Adefovir. A magnetic resonance imaging of the liver with contrast revealed a mass in segment 5 and 6 (11.2x14.4x10.8 cm), and an elevated alpha fetoprotein >1000 IU/ml, he underwent transcatheter arterial chemoembolization. One week after the procedure he noted a painless parietal scalp lump and rapidly enlarging in a span of three weeks. Examination revealed a soft, fluctuant, subcutaneous lump in the right parietal area measuring 2.5x3 cm. A cranial CT scan with contrast revealed an enhancing expansile lytic lesion with a soft tissue component at the right parietal bone measuring 2.4x3.5x3.2 cm seen at both parietal bone shown in figures 1, 2 and 3 (figures 1,2, and 3 CT scan image of a patient with scalp and skull metastasis). He was given palliative management. He developed hepatorenal syndrome and eventually died on the fourth hospital day.Abstract IDDF2019-ABS-0092 Figure 1 Bone window Lytic lesion was noted in the right parietal bone (arrows)Abstract IDDF2019-ABS-0092 Figure 2 Soft tissue window. A soft tissue component of the lytic lesion was noted (arrows)Abstract IDDF2019-ABS-0092 Figure 3 Three Dimensional (3D) window. A hollytic lesion was noted in the right parietal area (arrow) Results Intrahepatic metastasis is the most common metastasis of HCC. Extrahepatic metastases usually occur in the regional lymph nodes (16%-40%) and lungs (34%-70%), but less commonly in the skeleton (1.6%-16%). In skeleton metastasis, common sites are a vertebral column, pelvis, femora, and ribs, but rarely the skull. The incidence of skull metastases from HCC is 0.4%-1.6%. Among cases of skull metastases as the first symptom (24/59, 41%) and those with solitary skull metastases (14/59, 24%) were identified. In all 24 cases, 71% were misdiagnosed because the incidence of skull metastasis is low.15 Conclusions HCC is a debilitating condition leading to increased mortality and poor prognosis. It is important to educate patients with chronic hepatitis B to have regular follow-ups to catch early stages of HCC and provide appropriate treatment strategies, improve prognosis and quality of life. A high index of suspicion in patients with scalp lesion is warranted as this can be an initial presentation of HCC and decrease misdiagnosis rate.