Hepatocellular carcinoma with mediastinal lymph node metastasis manifesting as bleeding esophageal ulcer: Report of a surgical resection

Abstract

A 47-year-old male man with hepatocellular carcinoma (HCC) underwent anterior segmentectomy of the liver in 1993 diagnosed by microscopy as moderately differentiated HCC. Following 1 year of observation, serum AFP rose, revealing intrahepatic metastasis. We implemented sequential transarterial embolization. Sudden massive hematemesis hospitalized him in March 1995, and a huge metastatic mediastinal lymph node was found, penetrating the midesophageal wall and causing a hemorrhagic esophageal ulcer. Radiation therapy to the mediastinum with a total dose of 59.4Gy lowered AFP to normal, but it rose again and a deep ulcer remained in the esophagus. Subtotal esophagectomy with lymph node dissection through a right thoracotomy, laparotomy, and neck incision was successful. The enlarged metastatic subcarinal lymph node involved the esophageal wall, pericardium, and thoracic duct, which proved to be HCC microscopically. In metastasis of HCC to the thorax, hematogenous metastasis to the lung occurs frequently but lymphatic metastasis to the mediastinal node is rare. This is, to our knowledge, the first report to demonstrate mediastinal lymph node metastasis from HCC causing esophageal penetration and being removed surgically. In our experience, radiation therapy is somewhat effective in reducing mediastinal lymph node metastasis and surgical resection including adjacent structures may be considered if locoregional cure or improved QOL is to be expected.