Surgical resection of a solitary para-aortic lymph node metastasis from hepatocellular carcinoma

Abstract

Lymph node (LN) metastases from hepatocellular carcinoma (HCC) are considered uncommon. We describe the surgical resection of a solitary para-aortic LN metastasis from HCC. A 65-year-old Japanese man with B-type liver cirrhosis was admitted for the evaluation of a liver tumor. He had already undergone radiofrequency ablation, transcatheter arterial chemoembolization, and percutaneous ethanol injection therapy for HCC. Despite treatment, viable regions remained in segments 4 and 8. We performed a right paramedian sectionectomy with partial resection of the left paramedian section of the liver. Six months later, serum concentrations of alpha-fetoprotein (189 ng/mL) and PIVKA-2 (507 mAU/mL) increased. Enhanced computed tomography of the abdomen revealed a tumor (20 mm in diameter) on the right side of the abdominal aorta. Fluorine-18 fluorodeoxyglucose positron emission tomography revealed an increased standard uptake value. There was no evidence of recurrence in other regions. Esophagogastroduodenoscopy and colonoscopy revealed no malignant tumor in the gastrointestinal tract. Para-aortic LN metastasis from HCC was thus diagnosed. We performed lymphadenectomy. Histopathological examination revealed that the tumor was largely necrotic, with poorly differentiated HCC on its surface, which confirmed the suspected diagnosis. After 6 mo tumor marker levels were normal, with no evidence of recurrence. Our experience suggests that a solitary para-aortic LN metastasis from HCC can be treated surgically.

Keywords: Hepatectomy; Hepatocellular carcinoma; Lymph node metastasis; Positron emission tomography; Surgical resection.

Figure 1

An abdominal computed tomography angiographic scan, showing a diffuse high-density area. A: An abdominal computed tomography angiographic scan including a lesion previously treated by radiofrequency ablation in segment 8 of the right hepatic lobe, in the arterial phase (arrow); B: The area was washed out on late-phase images (arrow).

Figure 2

Histopathological examination revealed the presence of considerable necrosis and fibrosis in the tumor. The hepatocellular carcinoma (HCC) was graded as moderate-grade funicular type. A: Poorly differentiated HCC was present in some regions; B: Peripheral portal vein invasion was detected (hematoxylin and eosin, ×600).

Figure 3

An enhanced computed tomographic scan of the abdomen revealed a tumor (20 mm in diameter, arrow) on the right side of the abdominal aorta.

Figure 4

Fluorine-18 fluorodeoxyglucose positron emission tomography revealed that the tumor had an elevated standard uptake value (arrow).

Figure 5

Histopathological examination revealed that the tumor consisted of a broad region of necrosis with poorly differentiated hepatocellular carcinoma on its surface (hematoxylin and eosin, ×600).