In June 2025, a 67-year-old man walked into a neurosurgery department with a strange trio of complaints: episodes of double vision, a drooping left eyelid, and nosebleeds. Nothing about that combination suggests the liver.
Oncologists in Naples have now published his case as an example of how far a cancer can travel before anyone notices it exists. The report appeared August 26 in Frontiers in Oncology, from Istituto Nazionale Tumori IRCCS Fondazione G. Pascale.
Cranial Nerves, Nosebleeds and a Mass Behind the Eye
Neurological examination found palsy of the third and fourth cranial nerves on the left, with the eyelid drooping, impaired eye movement, and no pupil response to light. The same nerves on the right showed partial involvement, limited to impaired eye movement.
Contrast-enhanced MRI of the face found the reason. A mass occupied the middle and left portions of the sphenoid sinus, an air space that sits deep behind the eyes at the base of the skull. It had grown into the upper clivus, measuring 42 by 22 millimeters, and into the left cavernous sinus, where those cranial nerves run.
His medical history included one relevant item: chronic liver disease from hepatitis C, previously treated with antivirals. He did not smoke or drink and had no metabolic risk factors. The report notes that despite that history, no liver imaging or tumor marker testing was done at this stage.
In July 2025 he had endoscopic surgery through the nose to sample and partially remove the sphenoid mass. The pathology came back in September.
The Biopsy Pointed to the Liver
Under the microscope, the tumor had a mixed solid and trabecular architecture. Immunohistochemistry showed multifocal positivity for hepatocyte antigen and glypican-3, markers consistent with a liver cell origin. The diagnosis was hepatocellular carcinoma.
A CT scan then revealed what no one had looked for: a hypervascular mass in segment VI of the liver, with the washout pattern and pseudocapsule characteristic of the disease. A PET scan showed uptake in the sphenoid lesion, a lymph node near the jaw, and liver segments VI and VII.
The tumor in his head, in other words, had been the first announcement of a liver cancer that had never caused a symptom.
Skull base metastases from this cancer are reported in roughly 0.4 to 1.6 percent of cases, and among the sinonasal cavities, the maxillary sinus is the one most often involved. Sinonasal metastatic hepatocellular carcinoma had been documented in only 103 cases as of a 2007 report. Sphenoid involvement is rarer still, described mainly in isolated reports.
A Surveillance Program He Had Stopped Attending
One detail carries more weight for readers than any of the anatomy. After his hepatitis C was cured, he had been enrolled in a liver cancer surveillance program. He reported poor adherence to the scheduled follow-up visits.
That matters because clearing the hepatitis C virus does not erase the cancer risk that years of liver damage created. Surveillance in high-risk patients exists precisely to catch tumors while they are small and silent. This one was found by a cranial nerve.
By February 2026, when he transferred his care to Naples, his alpha-fetoprotein was 590 ng/mL, compared with a reference value of under 7. Liver function was still well preserved, and neither clinical nor radiological findings showed signs of cirrhosis or portal hypertension.
Treatment has been palliative. He received radiotherapy to the sphenoid sinus for severe pain around the left eye socket, 37.5 Gray in 15 fractions. When nosebleeds recurred badly enough to cause anemia requiring transfusion, interventional radiologists blocked the sphenopalatine arteries on both sides with coils, which stopped the bleeding.
In March 2026, new bone lesions appeared in the left collarbone and a thoracic vertebra. He had more palliative radiation and began atezolizumab plus bevacizumab, the combination that improved survival over sorafenib in the IMbrave150 trial. He completed four cycles without treatment-related side effects.
By June 2026, the sphenoid mass had grown to 86 by 60 millimeters, and bone disease had spread further. He started lenvatinib as second-line therapy and had completed one cycle at the most recent follow-up in July.
How a Liver Tumor Reaches the Skull
The route is not settled. The conventional explanation is that tumor cells enter the venous system, pass through the heart and lungs, and then travel through the arteries to the head. That usually means lung metastases should be present, and here they were not.
The authors raise two alternatives. One is Batson's vertebral venous plexus, a valveless network running from the skull base to the tailbone. Under a sharp rise in abdominal or chest pressure, blood can flow backward through it, potentially carrying cells past the lungs directly toward the skull. The other is lymphatic spread via the thoracic duct. They are explicit that both mechanisms are hypothetical.
The report's own limitations are stated: one patient, short follow-up, incomplete records from the referring hospital, and a long gap between diagnosis and treatment of the underlying cancer, which may have shaped the course. The practical message is narrower than the anatomy. Anyone with chronic liver disease who has drifted out of a surveillance program should talk to their clinician about restarting it.
Key Questions Answered
What was the first sign of cancer?
Episodes of double vision, a drooping left eyelid, and nosebleeds, caused by a mass in the sphenoid sinus pressing on cranial nerves at the base of the skull.
How did doctors trace it to the liver?
Tissue from the sinus mass stained positive for hepatocyte antigen and glypican-3, markers of liver cell origin. Follow-up imaging then found a tumor in the liver.
How rare is this?
Skull base metastases from liver cancer are reported in about 0.4 to 1.6 percent of cases, and sphenoid sinus involvement specifically has been described mainly in isolated reports.
Does curing hepatitis C eliminate the risk of cancer?
No. Patients who clear the virus can still develop liver cancer, which is why surveillance programs continue after treatment. This patient reported poor adherence to his follow-up visits.
How were the nosebleeds treated?
After conservative management failed and bleeding caused anemia requiring transfusion, interventional radiologists blocked the sphenopalatine arteries on both sides with coils.
What should readers with liver disease take from this?
Nothing about their own symptoms. The relevant point is that surveillance appointments after hepatitis C treatment are worth keeping, a decision to discuss with a clinician.
