Isolated calvarial lesion as the initial presentation of metastatic hepatocellular carcinoma: A case report and review of the literature.

Background: Hepatocellular carcinoma (HCC) contributes significantly to global cancer-related mortality, often because patients present at advanced stages of the disease. HCC commonly metastasizes to the lung, abdominal lymph nodes, and bone. However, even among bony metastases, calvarial lesions are exceptionally rare, especially in the initial presentation. Case Description: We describe a unique case of a 65-year-old African American woman who presented with a rapidly growing skull lesion as her first clinical sign of metastatic HCC. Imaging revealed an extensive soft-tissue mass involving the left calvaria and partially obstructing the superior sagittal sinus. We suspected that the lesion was a meningioma and offered surgery. Histological examination and further systemic workup later confirmed HCC. She was started on adjuvant therapy but unfortunately deteriorated from complications secondary to disease progression. We also reviewed the literature on cases of isolated calvarial metastases as the initial presentation of HCC. A total of 36 case reports were reviewed which included 38 patients. There were 32 males (84.2%), and the mean age was 58.97 ± 9.09 years old. The most common location of presentation was the parietal or occipital region (13, 34.2%), and 18 patients (47.4%) underwent neurosurgical treatment of the lesion. Among the 26 cases that had a follow-up, 84.6% ( Conclusion: Isolated calvarial lesions are rarely the initial presenting sign of metastatic HCC. Often, these lesions may be misdiagnosed as benign tumors, such as meningiomas or hemangiopericytomas, given their appearance on imaging. However, early identification of HCC skull lesions is crucial to initiating treatment, including resection, radiation, and immunotherapy, which may help improve symptoms and extend survival. Our case report adds to the limited literature on this exceedingly rare entity.