A 50-year-old Indonesian man with no previous medical illness came to our hospital for a second opinion. He first presented to a local hospital with a progressively enlarging left scapular mass for 6 months. It started with a small painless subcutaneous nodule over the left scapula which then rapidly increased in size over the next 4 months. A percutaneous biopsy was done and the initial histopathological results showed presence of poorly differentiated adenocarcinoma, with uncertain primary site.

Physical examination showed a large subcutaneous mass (24cm x 28cm) over his left scapular region with normal overlying skin (Panel A). Further investigations at our center showed that he was positive for HBsAg with a raised serum AFP level (12900 ng/mL). A triphasic abdominal CT scan confirmed hepatocellular carcinoma in S2/S3 (3.3x4x2.3cm) (Panel B) while CT thorax showed enhancing subcutaneous soft tissue mass (13.6x11x18cm) causing bony destruction of the left scapular bone (Panel C). We performed additional immunohistochemical stains on his original biopsy samples which showed them to be positive for hepatocyte specific antigen, Glypican 3 and cytokeratin, confirming their origin from liver (Panel D). A diagnosis of subcutaneous metastatic HCC secondary to chronic hepatitis B infection was reached. Clinicians should be aware of this extremely rare extrahepatic presentation of HCC, which has a dismal prognosis. Due to financial constraints, he was started on systemic therapy consisting of Docetaxel, Carboplatin and Zoledronic acid. Unfortunately, his condition responded poorly to the therapy and he finally succumbed to the disease after 10 months.