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Purpose: To demonstrate many uncommon, non-classical clinical presentations of HCC that have been gathered from an endemic region in the Nile Basin. Patients and methods: We will highlight cases of high quality MDCT performed for various clinical symptoms not classically associated with advanced or metastatic HCC and the role of image-guided biopsy in diagnoses. These include: (a) gradual progressive weakness of lower limbs; (b) Retrosternal pain not responding to medications; (c) severe right hip pain; (d) progressive cheek swelling. These symptoms further corresponded to musculoskeletal abnormalities, not typically associated with HCC, including: (a) lumbar spinal cord compression by expansile vertebral body lesion; (b) direct invasion of chest wall; (c) large expansile metastasis of right acetabulum; (d) expansible rib lesions with rib destruction, (e) painful cheek swelling. Results: In numerous patients with a range of non-specific musculoskeletal complaints and various clinical presentations, the final diagnosis was HCC. The clinical presentation was dependent on uncommon skeletal deposits which were often expansile with the local effect of compression as underlying cause for the odd presentation. The important role of MDCT and Histopathological assessment in making correct diagnosis will be stressed. Conclusion: HCC can often grow silently and may present late with odd non-classic clinical presentation.

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