A Case of Recurring Hepatocellular Carcinoma with a Solitary Virchow ’ s Lymph Node Metastasis

A 73-year-old male with C type liver cirrhosis and poor liver function reserve was diagnosed with hepatocellular carcinoma(HCC)(Segment V, 2 × 2 cm in diameter)and underwent open microwave coagulation therapy(MCT). Ten months later, a movable hard mass about the size of a quail egg was palpable at the left supra-clavicular lymph node(LN) (Virchow’s LN)and blood tests revealed an elevated serum α-fetoprotein(AFP)level of 26.7 ng dl . Abdominal and chest CT showed no evidence of recurrence in liver or lung, and no metastases of abdominal LN. Barium and bone scintigraphy revealed no abnormal spots. The affected left supra-clavicular LN was extirpated. The tumor was confirmed to be an LN metastasis from HCC by histopathological examination. After the operation, the patient developed uncontrollable pleural effusion and ascites, and intrahepatic and abdominal LN metastases were visible on abdominal CT with great haste. He died 1.5 months after the LN was extirpated. We herein report a case of HCC treated by MCT which later resulted in a solitary Virchow’s LN metastasis in the absence of any abdominal LN or recurrence in the liver or lung. (J Nippon Med Sch 2005; 72: 245―249)


Introduction
Hematogenous metastases from hepatocellular carcinoma (HCC) are well known.The most frequent site of hematogenous metastases is the lung, followed by the adrenal gland and skeleton 1,2 .On the other hand, lymph node(LN)metastases from HCC are considered to be uncommon.A prevalence of 2.2％ was reported in a series of Japanese patients who underwent hepatic resection 2 .We report a "10 ng! ml ) .Howevere, PIVKA-II was normal.
Abdominal CT showed an enhanced tumor measuring 2×2 cm in diameter in the early phase and a washed-out tumor in the late phase at the anterior-superior segment(S5)of the liver(Fig.1A and B, respectively) .Angiography revealed a hypervascular tumor mainly fed by the anteriorsuperior branch of the right hepatic artery(A5) .
Based on these findings, the patient was diagnosed with HCC at segment V with liver  The hepatic lymphatic system has been well elucidated 6 .Much of the lymph flow towards the hepatic hilum runs through the hepatoduodenal ligament, while smaller amounts communicate with the diaphragmatic and intrathoracic lymphatic system through the bilateral triangular ligaments.
Here we must note that some of HCCs lead to what has been termed skip LN metastases, that is, LN patient treated for HCC by open microwave coagulation therapy(MCT)who later developed a solitary left supra-clavicular LN(Virchow s LN) metastasis in the absence of any abdominal LN or recurrence in the liver or lung.Case Report An intrahepatic tumor was detected by follow-up abdominal computed tomography(CT)in a 73-yearold male under treatment for C type liver cirrhosis at the Department of Internal Medicine in our hospital.The patient was promptly admitted to the -Report on Experiments and Clinical Cases-A Case of Recurring Hepatocellular Carcinoma with a Solitary Virchow s Lymph Node Metastasis A A B B Department of Surgery for investigation of the tumor.He appeared to be in excellent health on admission, with no remarkable findings on physical examination.Laboratory investigations on admission showed a white blood cell count of 4,100!mm 3 , a red blood cell count of 422×10 4 !mm 3 , a hemoglobin concentration of 13.4 g! dl with a normal differential, and a platelet count of 8.0×10 4 !mm 3 .Tests on serum enzymes revealed an aspartate aminotransferase level of 87 IU! L, alanine aminotransferase level of 78 IU! L, γ-glutamyltransferase level of 80 IU! L, and cholinesterase level of 182 U! L. Other laboratory tests revealed a serum total bilirubin level of 2.4 mg! dl , serum direct bilirubin level of 1.7 mg! dl , albumin level of 2.9 g! dl , and prothrombin time of 39.6％, indicating a Child-Pugh class C status.ICGR15 estimated by the indocyanine green dye retention rate 15 min after injection of a 0.5-mg!kg dose was 35.5％.The patient had a poor liver function reserve and an elevated serum α-fetoprotein (AFP) level of 40.9 ng! ml (normal range cirrhosis, and sent to surgery.Laparotomy revealed heavy adhesion of the liver, duodenum, and transverse colon as a remnant effect from an operation for acute peritonitis due to duodenal ulcer perforation performed three years earlier.The surface of the liver appeared roughened and irregular due to the liver cirrhosis.The patient underwent MCT in lieu of a hepatectomy in view of the heavy adhesion and poor liver function reserve.Histopathological examination of the biopsied tissue revealed a pattern of abnormal cell growth.The tumor cells exhibited a compact(solid)growth pattern without a distinct trabecular arrangement (Fig. 2) .The patient s postoperative course was uneventful and he was discharged from the hospital 14 days after the operation.He remained in what appeared to be good condition for 10 months after the surgery with no signs of recurrence.Ten months after the operation, a movable hard mass about the size of a quail egg was palpable at the left supra-clavicular LN and blood tests revealed an elevated serum AFP level of 26.7 ng! dl .A neck CT revealed an irregular enhanced mass measuring 3×4 cm in diameter at the left supra-clavicula(Fig.3A) .Abdominal and chest CT showed no metastases of abdominal LN and no evidence of recurrence in the liver or lung (Fig. 3B) .Barium and bone scintigraphy revealed no abnormal spots.The left supra-clavicular LN was extirpated and closely inspected.Histopathological examination of the LN revealed a trabecular structure of abnormal

Fig. 1
Fig. 1 Abdominal computed tomography showed an enhanced tumor measuring 2×2 cm in diameter in the early phase(A)and a washed-out tumor in the late phase(B)in the anterior-superior segment(S5)of the liver.

Fig. 2
Fig. 2 Histopathological examination of biopsied tissue revealed a pattern of abnormal cell growth.The tumor cells were arranged in a compact(solid)growth pattern without a distinct trabecular pattern.

Fig. 3
Fig. 3 Neck computed tomography revealed an irregular enhanced mass measuring 3×4 cm in diameter at the left supra-clavicula(A) .Abdominal and chest computed tomography taken at the same time showed no metastases of abdominal lymph nodes or evidence of recurrence in the liver or lung(B) .

Fig. 4
Fig. 4 Histopathological examination of the extirpated lymph node revealed a thickened trabecular structure of abnormal cell growth with massive necrosis.The tumor was confirmed to be a lymph node metastasis from hepatocellular carcinoma.