A case of small hepatocellular carcinoma with an extensive lymph node metastasis at diagnosis

which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. A 41-year-old man was admitted to our hospital for investigation of a liver mass with extensive lymph node (LN) enlargement that was detected during follow-up abdominal computed tomog-raphy (CT) for chronic viral hepatitis B. Laboratory investigations showed a serum alanine aminotransferase level was 31 IU/L (normal range 10–40 IU/L), the aspartate aminotransferase level was 23 IU/L (normal range 6–40 IU/L) and the γ-glutamyltransferase level was 44 IU/L (normal range 5–63 IU/L). Alkaline phosphatase, total bilirubin and albumin levels were all within normal limits. The patient had an elevated serum α-fetoprotein level of 3580 ng/mL (normal range≤10 ng/mL) and a PIVKA-II level of 489 mAU/mL (normal range 0–40 mAU/mL); moreover, the carcinoembryonic antigen level was high level of 31.1 ng/mL (normal range 0-5 ng/ mL). Serum hepatitis e antigen was negative and HBV PCR DNA level was 156 IU/mL. Abdominal CT showed hypodense mass, 2 cm, with necrosis at the medial portion, at the liver S7. Adding to this, CT demonstrated multiple conglomerated LN enlargement at the celiac axis, superior mesenteric artery (SMA), and para-aortic area (Fig. 1). In addition to CT, magnetic resonance imaging (MRI) also showed 2 cm sized mass with necrosis at the medial portion, at the liver S7 and extensive LN enlargement. And FDG-PET/CT and chest CT were performed to evaluation of extrahepatic metas-tasis. FDG-PET/CT showed isometaoblic mass, S7 of the liver with extensive LN metastasis at neck, axilla, mediastinum, and retro-peritoneum (Fig. 1). Based on these findings, we could suspected hepatic lymphoma or combined hepatocellular and lymphoma and liver biopsy was performed for confirmation of liver mass. However , because of no evidence of malignancy on histologic findings of liver mass, cervical excisional LN biopsy was conducted. Histologic findings revealed metastatic hepatocellular carcinoma (HCC) and we confirmed small hepatocellular carcinoma with extensive LN metastasis (Fig. 2). Base upon the diagnosis of HCC metastasis to the LN, we started therapy with sorafenib. Two months later after sorafenib administration, an abdomen CT revealed new multiple hypodense masses with central necrosis at the liver and unfortunately , the patient died 3.5 months after the detection of the liver mass. The rate of extrahepatic metastases from hepatocellular carci-noma (HCC) is relatively lower than that in other hepatic cancers. 1 Lymph node (LN) metastasis is observed in only 1.7% of patients undergoing surgery, …