Shoulder Mass as the Initial Presentation of Metastatic Hepatocellular Carcinoma

A 70-year-old man with chronic hepatitis C, alcohol abuse, and an active cigarette smoking habit presented to our clinic with left shoulder pain and a soft tissue mass without history of prior trauma. Physical examination revealed a disheveled man, scleral icterus, palmar erythema, and abdominal shifting dullness. Neurological exam was significant for right arm weakness. Laboratory studies showed aspartate transaminase 2,309 IU/L, alanine transaminase 2,879 IU/L, alkaline phosphatase 570 IU/L, and total bilirubin 1.6 mg/dL. Computed tomography (CT) of the shoulder showed a 9.1 × 5.6 × 5.5 cm destructive expansile lesion at the proximal humeral metaphysis with pathologic fracture and extraosseous soft tissue extension (Figure 1). Further work-up with subsequent chest CT showed a 3.2 × 2.4 × 2.4 cm heterogeneously enhancing soft tissue mass with associated osseous destruction of the fifth right rib at the costochondral junction. A 2 × 2 cm lytic lesion of the high parietal calvarium near the vertex was identified on head CT (Figure 1). Abdominal CT showed cirrhotic liver with portal hypertension, moderate perihepatic free fluid, and multiple ill-defined hepatic parenchymal hypodensities abutting the gallbladder fossa (Figure 1)