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Among the patients who complain of neuralgia in the upper extremities, it is very rare to be caused by the first thoracic (T1) spinal nerve dermatome.A 65-year-old presented with neuropathic pain of the left medial antebrachial cutaneous nerve and the medial brachial cutaneous nerve for 2 months.Electrodiagnostic study revealed left thoracic radiculopathy mainly involving the T1 nerve root. Cervical spine magnetic resonance imaging revealed a metastatic tumor of T1 vertebral body compressing the left spinal cord and nerve root. After a systemic diagnostic work-up, he was finally diagnosed with primary hepatocellular carcinoma.He received transarterial chemoembolization in the liver and radiotherapy to the T1 spine.After radiotherapy, the neuropathic pain was slightly improved.If the patient is suspected of having thoracic radiculopathy, the physician should consider not only a herniated disc disease but also systemic disease. Because the prevalence of thoracic radiculopathy is very low and there is a high incidence of cancer that can spread to the spine in the elderly.