Liver Cancer Discovered Through Leg Pain

A 71-year-old man with no history of liver disease presented with progressive left leg pain. Imaging revealed a destructive tibial lesion, but the initial biopsy was inconclusive. Whole body 18 F-FDG PET/CT demonstrated moderate metabolic activity in the tibial mass and mild uptake in an unsuspected hepatic lesion. Repeated biopsy confirmed metastatic hepatocellular carcinoma in the tibia and primary HCC in the liver. This case illustrates tibial metastasis as the initial clinical manifestation of occult HCC and underscores the value of PET/CT in detecting synchronous primary and metastatic disease.