ABSTRACT
Objectives: Cannonball metastasis refers to well-circumscribed, spherical nodules scattered over both lungs, usually occur due to hematogenous spread of tumor, classically seen in germ cell tumor, renal cell carcinoma, choriocarcinoma, endometrial cancer but it is a rare and an unusual phenomenon in hepatocellular carcinoma. Materials and Methods: Case description: Results: We report a case of hepatocellular carcinoma with unusual presentation of pulmonary cannonball lesions. A 41-year-old Chinese man who attended to ED on 8.10.2021 with one month duration of abdominal discomfort and progressive dyspnea. He has past history of chronic hepatitis B infection since the age of 16 years but he did not receive any treatment. He denied fever and no history of TB contact. His oxygen saturation was 89% on room air. On examination, he was dyspneic, tachypneic, few crepitations in both lungs, hepatomegaly was noted. Covid PCR test was negative. Imaging tests revealed cannonball lesions were seen in both CXR and CECT chest (Figure-1) and infiltrative type of hepatocellular carcinoma both lobes of liver with portal vein thrombosis detected in CECT Liver (Figure-1). Blood tests showed elevated bilirubin (3.5 g/dl), AST 122, ALT 30, hypoalbuminemia (3.2), AFP 8421, HBeAg negative, antiHBeAb negative, qHBsAg 2793 IU/ml. His Child Pugh stage B (score 9), MELDNa 12 and BCLC stage C. Therefore, we diagnosed him to have advanced hepatocellular carcinoma with cannonball pulmonary metastasis with underlying chronic hepatitis B infection, for which we started Tenofovir (TDF) 300 mg OD and Lenvatinib 4 mg OD. Unfortunately, he expired on 17.10.2021. Conclusion: Hepatocellular carcinoma is one of the commonest cancers in the world with chronic hepatitis B and C infection. Extrahepatic spread to lung is common and about one third of these patients developed pulmonary metastasis. However, cannonball pulmonary metastasis is rare and is an unusual presentation in hepatocellular carcinoma. Moreover, prognosis of these patients is poor and survival is usually only days. (Figure Presented).