By Dr. Qurat. Ul. Ainn Hashmi
Abstract:
Introduction:
Hepatocellular carcinoma (HCC) is one of most
common malignancies in the world and a major cause of
cancer-related mortality globally. In Pakistan, according to
GLOBOCAN 2022, HCC new cases were 3.3%, while death
rate was 5%. Common sites of metastasis include the lungs,
bones and lymph nodes, while metastasis to brain is
exceptionally uncommon, occurring in less than 1 % of cases.
When cerebral metastasis is the first manifestation, diagnosis
can be delayed because neurological symptoms are often
attributed to primary intracranial tumors. Early recognition of
such atypical presentations is essential for appropriate
multidisciplinary management. This report describes a unique
case of 60-year-old female in whom metastatic brain disease
led to the discovery of an undiagnosed HCC.
Case:
A 60-years old female with no prior history of liver
disease, hepatitis B, or hepatitis C infection presented with
complaints of severe headache, nausea, vomiting and vertigo.
Neurological examination was unremarkable. Magnetic
resonance imaging (MRI) of the brain showed well defined
lobulated mass lesion of 56mmx32.3mm x 52mm along right
occipital region causing underlying bone erosion with
producing mild mass effect on cerebellar hemisphere. A biopsy
was suggested, which revealed metastatic carcinoma with
immunohistochemical staining positive for HepPar-1 and
Glycipan-3 and negative for CK7 and CK20, confirming HCC.
Further evaluation with contrast-enhanced computed
tomography (CT) of the abdomen demonstrated 8×7 cm mass
in liver with arterial enhancement and venous washout, typical
of HCC. Serum Alpha-protein level (AFP) level was 1210
ng/mL and PIVKA II was 2225 ng/mL .The patient was
discussed in multidisciplinary tumor board and planned for
palliative whole brain radiotherapy 30 Gy/10 fractions
followed by Tablet Sorafenib as a systemic therapy. The
symptoms improved significantly with palliative radiotherapy,
and corticosteroids. The patient’s overall performance
remained stable with supportive and palliative therapy.
Discussion:
Our case had HCC with normal liver function tests.
The absence of chronic liver disease even with hepatitis C in
this patient further obscured the diagnosis. This case
emphasizes the importance of considering HCC in the differential diagnosis of intracranial lesions particularly in the
regions with high prevalence of viral hepatitis like Pakistan.
Although prognosis remains poor, early multidisciplinary
intervention combining radiotherapy, targeted therapy, and
palliative care can improve quality of life. Reporting such rare
cases enhances awareness among clinicians and supports
earlier recognition of atypical disease patterns.