Hepatocellular carcinoma (HCC) accounts for two-thirds of liver malignancies and fourth highest number of cancer-related deaths. Extrahepatic metastasis in HCC at presentation is uncommon (14 to 36.7%) [1] Skeletal metastases are third most common site of metastasis after lung and lymph node, with an incidence of 16.1 to 38.5%. Most common affected bones are vertebrae, pelvis, ribs, skull, humerus, and sternum [2].

We describe a rare presentation of HCC with calvarial metastasis (CM) as a forehead swelling. The incidence of CM in HCC is low (0.5–1.6%), and it is speculated to spread via the Batson’s plexus. In a Japanese autopsy study, only 17 skull metastases were seen (6.1%) among 278 cases of bone involvement. CM as a presenting symptom of HCC is rare, 38 such cases have been reported till date of which 14 cases had solitary CM [3, 4]. CM are found commonly in cancers of breast, follicular and papillary thyroid cancers, lung, prostate, melanoma, Ewing’s sarcoma, and hematological conditions like multiple myeloma, plasmacytoma and cutaneous T cell lymphomas, and rarely endometrial cancer and cholangiocarcinomas [2, 5].

The local treatment option ranges from surgical resection for solitary lesions with neurological deficit, radiotherapy for symptomatic lesions and bleeding ulcers, gamma knife, and ablative therapies [3]. Targeted therapy and immunotherapy such as sorafenib, lenvatinib, atezolizumab and bevacizumab, atezolizumab and cabozantinib, durvalumab and tremelimumab, and pembrolizumab have been reported to improve median survival from 6 to 11 weeks even in bone metastases [4, 6, 7].