Case report
Lymph node metastasis diagnosed by EUS-FNA in four cases with hepatocellular carcinoma☆

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Summary

Hepatocellular carcinoma (HCC) rarely accompanies lymph node (LN) metastasis. As lymphadenopathy is observed in a variety of diseases, definitive diagnosis of metastasis of HCC is difficult without histological evidence. This report presented four cases of HCC associated with LN metastasis diagnosed using endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and analyzed characteristics of CT image and histology of metastatic nodes. In current cases, metastatic nodes commonly demonstrated ill-enhanced masses with marginal enhancement on computed tomography (CT). Before FNA, nodal lymphoma or metastasis from the unknown origin tumor had been also suspected, but histology of the aspirated nodal tissues all demonstrated poorly differentiated HCC. No complication was recognized during and after FNA procedures. EUS-FNA is thought to be a safe and effective modality for obtaining histological evidence of lymphadenopathy in cases with HCC.

Introduction

Lymph node (LN) metastasis is rarely recognized in patients with hepatocellular carcinoma (HCC) and Liver Cancer Study Group of Japan reported a prevalence of LN metastasis only in 2.2% [1]∼7.4% [2] of resected cases of HCC. In such cases, accurate diagnosis of nodal lesion was difficult only with clinical images and serum tumor markers. Although usefulness of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was reported for the diagnosis of lymphadenopathy in the last few years [3], [4], there is no report in cases with HCC. HCC is one of the most vascular-rich human tumors and is often affected by repetitive interventional therapies at the stage with metastasis. The purpose of this study is to evaluate the efficacy and safety of EUS-FNA of LN metastasis in patients with HCC and to determine the characteristic CT image of nodal metastasis of HCC in correlation with histology.

Section snippets

Materials and methods

In Shizuoka Cancer Center, 17 cases with lymphadenopathy were finally diagnosed using EUS-FNA from April 2003 to December 2009 and all revealed to be malignant. Four out of these 17 (23.5%) cases were accompanied with HCC (Table 1). In these cases, before EUS-FNA, dynamic compute tomography (CT) was performed for the assessment of possible access route to the target LN, and CT value was analyzed to clarify characteristics of metastatic LN in cases with HCC.

Case presentation

Clinicopathological findings of four patients were summarized in Table 1. In these cases, three cases were positive hepatitis-C antibody. In three cases, metastasis was recognized at the posterior region of the pancreatic head. One case (Case 1) had a history of interventional therapies for primary cancer. Before EUS-FNA, nodal lymphoma and metastasis from unknown primary tumor had been also suspected. In EUS-FNA, target LN was well visualized and enough amount of sample was obtained even with

Discussion

For the important treatment choice, accurate diagnosis is necessary. In current four cases, two cases changed their treatments and the remaining two cases could stay away from adding unbeneficial treatment by a technically easy method, EUS-FNA. In the previous reports on EUS-FNA in the cases with lymphadenopathy, the methodology was quite similar except for the caliber size of the needles. For instance, a 19-gauge needle was used for the cases of malignant lymphoma, for which diagnosis a large

Conflict of interest statement

No conflict of interest.

Acknowledgements

Authors are grateful to Ms. Asami Nakagawa and Ms. Satomi Koizumi for their faithful nursing and managements on the patients.

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IRB Approval: Institutional Review Board of Shizuoka Cancer Center approved this study (Institutional code no.: 22-J48-22-1-3).

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