CASE REPORT Metastasis from Hepatocellular Carcinoma Masquerading as a Jugular Paraganglioma Debashish Chaudhary 1 & Shraddha Patkar 1 & Shailesh V. Shrikhande 1 & Mahesh Goel 1 # Springer Science+Business Media New York 2017 Introduction Hepatocellular carcinoma (HCC) is the most common malig- nant tumor of the liver. It is the sixth most common cancer in the world, with 782,000 new cases occurring in 2012 world- wide. In 2012, there were 746,000 deaths from liver cancer [1]. HCC is the third most fatal cancer in the world [2]. Hepatocellular carcinoma commonly metastasizes to the lungs, abdominal lymph nodes, adrenal glands, or bones [3]. Distant lymph node metastases are rare in hepatocellular car- cinoma. We present an unusual case of HCC with isolated metastasis to temporal bone in the absence of metastatic dis- ease elsewhere which resulted in change in management from a surgically resectable temporal lesion to a palliative therapy for metastatic disease. Case History A 65-year gentleman with history of chronic alcohol intake and no co-morbidities presented to outpatient department of head neck surgical oncology with hoarseness of voice and dysphagia since 2 months and right-sided headache since 15 days. Clinically, the oral cavity and neck was normal, ex- cept for right 10th and 12th cranial nerve palsy. Computed tomography (CT) scan (Fig. 1) and magnetic resonance imaging (MRI) showed an enhancing mass lesion in the right jugular fossa and erosion of the posterior wall of the carotid canal and squamous portion of occipital bone involving the adjacent basi-occiput. The lesion was clinicoradiologically di- agnosed as glomus jugulare and the patient was planned for surgical excision. On further investigations, patient was found to have deranged liver functions with an alanine aminotrans- ferase (ALT) level of 160 U/L, aspartate aminotransferase (AST) level of 126 U/L, and a total bilirubin level of 1.6 mg/dL. Hepatitis B surface antigen (HBsAg) and hepatitis C antibodies (anti-HCV) were non-reactive. An ultrasonogra- phy of the abdomen was done which showed a 10 × 10 cm mass in the segment V and VIII of liver. MRI abdomen (Fig. 2) revealed a non-cirrhotic liver with a large solitary mass involving segment V and VIII which was hypointense on T1 weighted and heterogeneously hyperintense on T2- weighted sequences with heterogenous post-contrast enhance- ment. The lesion was compressing the intra-hepatic part of the inferior vena cava. The right and the middle hepatic veins and the right portal vein and its branches were displaced by the lesion without any vascular involvement. In view of two sep- arate lesions, one in the temporal fossa and another in the liver a biopsy of the liver lesion were done which revealed it to be a well-differentiated hepatocellular carcinoma. On immunohis- tochemistry (Fig. 3), tumor cells were positive for Hepar-1 and negative for CK7 (cytokeratin) and CEA (carcinoembryonic antigen). A serum alfa feto protein level was done which was in normal limits—5.8 ng/mL. It was decided in multidisciplin- ary clinic to biopsy the neck mass to differentiate a second primary cancer from a metastatic lesion. The biopsy of the neck mass was reported as metastatic hepatocellular carcino- ma. In view of rare finding of extrahepatic disease in the temporal fossa from a large HCC in the liver, the intent of * Debashish Chaudhary debashish.chaudhary@gmail.com 1 Tata Memorial Centre, Mumbai, India J Gastrointest Canc DOI 10.1007/s12029-017-9943-8