Appendicular skeleton multiple bone metastasis as first manifestation of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy. It is the fourth leading cause of cancer related deaths in the world. Major risk factors for HCC occurrence are Alcoholic liver disease, viral hepatitis B and C, and nonalcoholic fatty liver disease. In westerns countries, patients with such risk factors are followed up regularly, to avoid late detection and complications of HCC. Bony metastasis of HCC are a usually considered a late presentation in the course of HCC disease, and are associated with poor prognosis. They occur most frequently on the axial skeleton. Appendicular skeletal bony metastasis are not frequent, and it is rare to have it as first manifestation of the disease, without a known primary liver lesion. We present the case of a 55 year old male with known hepatitis B viral infection, who came consulting for elbow and thigh pain since 8 months. X-rays and subsequent computed tomography (CT) scans and positron emission tomography (PET) CT revealed multiples appendicular skeletal bony metastasis of a primary unknown liver HCC. This denotes poor follow up of this patient with risk factors of HCC. The medical team should therefore be more aggressive in their investigation methods whenever faced with skeletal unusual painful areas, in patients with high risk of HCC even if primitive liver lesion is not yet diagnosed, and not hesitate to use MRI or CT scans if X-rays are not contributory.