The majority of the lymph flow toward the hepatic hilum passes through the hepatoduodenal ligament. Clinically, lymph node metastasis is rare, and distant lymph nodes are rarely involved. However, in patients who underwent hepatic resection, the frequency of lymph node metastasis has been reported to be only 1.0%. Autopsy studies have showed that the frequency of lymph node metastasis in HCC is 30.3%. In HCC, hematogenous metastasis is more common than lymph node metastasis. The patient survived 43 months after the detection of recurrence and 79 months after liver resection. The tumor enlarged rapidly, and the patient died 15 months later. However, because renal function worsened as an adverse effect of lenvatinib treatment, its administration was discontinued. After receiving radiotherapy at a dose of 47.7 Gy for the subdiaphragmatic lymph node, the patient was started on lenvatinib, a tyrosine kinase inhibitor, following which all metastatic lymph nodes reduced in size and maintained for 15 months (Fig. However, the size of the metastatic subdiaphragmatic lymph node gradually increased. The patient was started on sorafenib, a tyrosine kinase inhibitor, and the sizes of metastatic right cervical and mediastinal lymph nodes in imaging studies decreased 2 months later. Based on these findings, the patient was diagnosed with recurrent HCC characterized by multiple lymph node metastases. The patient underwent an excisional biopsy of the cervical lymph node, and the pathological findings were compatible with those of metastatic HCC, with swollen nuclei and eosinophilic follicles in tumor cells showing a chordate or alveolar pattern (Fig. 1c), and a right cervical lymph node (Fig. 1b), an upper mediastinal lymph node (Fig. Positron emission tomography (PET) revealed dense fluorodeoxyglucose uptake in a subdiaphragmatic lymph node (Fig. Due to the elevated alpha-fetoprotein level, abdominal computed tomography (CT) was performed and a recurrent lesion was revealed lymphadenopathy with a tendency to increase in size below the right diaphragm. Three years postoperatively, alpha-fetoprotein (preoperative vs postoperative, 656 vs 8.9 ng/ml) was slightly elevated at 36.7 ng/ml in a routine laboratory examination. No lymph node metastasis or evidence of intrahepatic metastasis was found. There were no suspicious findings of extrahepatic metastasis, and pathological examination revealed HCC with moderately differentiated, confluent multinodular type, H2, St-AP 40 mm, pseudoglandular type, e.g., fc(−), fc-inf(−), sf(+), s0, vp1, vv0, va0, b0, sm(−) 30 mm, f1, pT3 (the Japanese classification of primary liver cancer sixth edition). The patient was a 63-year-old male who underwent right hepatic lobectomy for tumor 5 cm in diameter located at the border of segments 8 and 7 of the liver (Fig. ConclusionsĪfter resection of HCC in the right upper lobe, there is the possibility of metastatic lymph node recurrence in unusual sites, including the cervical region, and lenvatinib may be effective in those recurrences. Lenvatinib reduced the size of all metastatic lymph nodes and the patient survived for a relatively long period of 43 months after the recurrence was detected. The patient underwent excisional biopsy of the cervical lymph node, followed by molecular-targeted therapy and radiation therapy. Three years after resection, metastatic lymph node recurrence was detected in the subdiaphragm, superior mediastinum, and right cervical lymph nodes. The patient was a 63-year-old male who underwent right hepatectomy for HCC of the right upper lobe. Hence, there have been no reports of metastatic cervical lymph node recurrence indicated after a long postoperative surveillance period. Hepatocellular carcinoma (HCC) patients with metastases to the cervical lymph nodes are extremely rare, and its clinical course is characterized by rapidly progressive disease.
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