Pancreaticoduodenectomy for hepatic portal lymph node metastasis after hepatic resection for hepatocellular carcinoma: A clinical case report

Abstract

Introduction: In 2018, Hepatocellular carcinoma (HCC) was predicted to be the sixth most commonly diagnosed cancer. Extra-hepatic metastasis due to HCC is a poor prognostic factor, depending on the stage of the disease.

Presentation of case: We report a case of a 52-years old male who had undergone Segment 5 (S5) hepatectomy for HCC of 4.7 × 2 cm. Transcatheter arterial chemoembolization (TACE) four times postoperatively was performed based on a preoperative diagnosis of a recurrent tumour at the S1. After 2 years, the solitary tumour (7.5 × 2.5 × 3.5 cm) is located behind the right lobe of the liver and the head of the pancreas. The tumour was abnormally supplied with blood from the superior mesenteric artery (SMA) and the gastroduodenal artery (GDA). The patient was underwent pancreaticoduodenectomy (PD) to remove a large tumour. Postoperative pathology and immunohistochemical staining showed metastatic HCC. There was no tumour recurrence after 6 months.

Discussion: The organs in the body that liver cancer cells most often spread to are the lungs (44%), the portal vein (35%), the hepatobiliary ganglion (27%), and a small number of cases of bone, eye socket, bronchus metastases. Otherwise, recurrence of lymph nodes (LNs) after hepatectomy for HCC is very rare.

Conclusions: HCC can metastasize to the hepatic pedicle LN after hepatectomy and maybe confused with recurrent liver tumours in the S1. Indications for PD are feasible for solitary metastatic at peri-pancreas. Pathology incorporating immunohistochemistry can determine the origin of metastases.

Keywords: Case report; Hepatocellular carcinoma; Liver resection; Lymph node; Metastasis; Pancreatic head; Pancreaticoduodenectomy.

Fig. 1

Liver tumour on Magnetic resonance imaging 29 × 22 mm (white arrow).

Fig. 2

The liver tumour located in the segment 5 attached to the abdominal wall after 2 times TACE therapy.

Fig. 3

Liver tumour specimens for HCC after the first S5 resection. Healthy liver parenchyma (white arrow), tumour about 2 × 4.7 cm size (yellow pointed arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 4

Computed tomography image of posterior large lymph node (yellow arrow). Upper mesenteric artery (red arrow), right renal artery (pink arrow). The lymph node metastatic close to the S1r position with size of 34 × 60 mm. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 5

Pancreaticoduodenectomy and radical systematic lymph node. (PV portal vein, SMV superior mesenteric vein, G gastric, P pancreas remain).

Fig. 6

The image demonstrating how the neighboring walls of the gallbladder neck and CBD joined by two interrupted suture. Two sutures joined side wall of the CBD to the gallbladder neck and the sketch of new biliary size with 2 cm wide.

Fig. 7

Blumgart anastomosis for pancreaticojejunostomy with 2 layers. Inner layer was duct-to-mucosa anastomosis which was constructed using interrupted sutures. Outer layer was four transpancreatic U-sutures were placed straight through the pancreatic remnant about 1 cm distal from the cut end (Monosyl 4–0, Ethicon). Js Jejunal stump, P pancreas, G gastric stump.