Upper Limb Paralysis as Presentation of Hepatocellular Carcinoma Bone Metastases

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy and predominantly affects patients with cirrhosis. Extrahepatic metastasis is unusual, and when it occurs, it most often involves the lungs. Bone metastases are rare and associated with significant morbidity. We report the case of a 73-year-old man with alcoholic liver cirrhosis and HCC, initially presenting with two hepatic nodules. He underwent curative-intent surgical resection the following year. Two years later, he presented to the emergency department with several weeks of neck and bilateral shoulder pain, accompanied by a three-day history of right upper limb weakness. Imaging revealed multiple lytic vertebral lesions, including a pathological fracture at C6 with spinal cord compression, as well as additional thoracic and lumbar involvement and newly detected hepatic nodules. The patient underwent cervical radiotherapy, resulting in improved pain control. While the liver biopsy was inconclusive, the biopsy of a lumbar paravertebral mass confirmed metastatic HCC. Bone metastases from HCC may present as hypervascular soft tissue masses with cortical bone destruction, most commonly affecting the axial skeleton. This case highlights the importance of maintaining a high index of suspicion for metastatic disease in patients with prior HCC who present with persistent bone pain or neurological symptoms, even though HCC metastases are infrequent. Since the HCC incidence of recurrence is very high, close surveillance and prompt diagnostic evaluation are essential for early detection and timely intervention.