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Year : 2021  |  Volume : 36  |  Issue : 2  |  Page : 233-234  

18F-fluorodeoxyglucose positron-emission tomography/computed tomography detected inguinal lymph nodal metastasis from hepatocellular carcinoma


1 Department of Nuclear Medicine and PET/CT, VPS Lakeshore Hospital, Kochi, Kerala, India
2 Department of Radiology, VPS Lakeshore Hospital, Kochi, Kerala, India
3 Department of Pathology, VPS Lakeshore Hospital, Kochi, Kerala, India
4 Department of Medical Gastroenterology, VPS Lakeshore Hospital, Kochi, Kerala, India
5 Department of Comprehensive Liver Care, VPS Lakeshore Hospital, Kochi, Kerala, India

Date of Submission24-Dec-2020
Date of Acceptance07-May-2021
Date of Web Publication21-Jun-2021

Correspondence Address:
Dr. Raja Senthil
Department of Nuclear Medicine and PET/CT, VPS Lakeshore Hospital, Kochi - 682 040, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnm.ijnm_241_20

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   Abstract 


Hepatocellular carcinoma (HCC) usually metastasizes to the regional abdominal lymph node, lungs, and bones. Nonregional lymph node involvement by HCC in the absence of regional lymph nodes is rare. We describe the 18F-fluorodeoxyglucose positron-emission tomography-computed tomography findings of an HCC patient with histopathologically proven inguinal lymph nodal metastasis in the absence of regional lymph nodal metastases.

Keywords: 18F-fluorodeoxyglucose positron emission tomography-computed tomography, hepatocellular carcinoma, inguinal lymph node metastasis, sister Mary Joseph's nodule, umbilical nodule


How to cite this article:
Ramachandran Nair AV, Pratap T, Mahadevan P, Mukkada RJ, Yadav A, Senthil R. 18F-fluorodeoxyglucose positron-emission tomography/computed tomography detected inguinal lymph nodal metastasis from hepatocellular carcinoma. Indian J Nucl Med 2021;36:233-4

How to cite this URL:
Ramachandran Nair AV, Pratap T, Mahadevan P, Mukkada RJ, Yadav A, Senthil R. 18F-fluorodeoxyglucose positron-emission tomography/computed tomography detected inguinal lymph nodal metastasis from hepatocellular carcinoma. Indian J Nucl Med [serial online] 2021 [cited 2021 Jul 27];36:233-4. Available from: https://www.ijnm.in/text.asp?2021/36/2/233/318892



Hepatocellular carcinoma (HCC) usually metastasizes to regional abdominal lymph nodes. Nonregional lymph node involvement by HCC has been described earlier in mediastinum, juxtaphrenic and internal mammary regions.[1] Metastatic involvement of inguinal lymph node from HCC has not been documented in literature. We report a case of HCC with histopathologically proven metastasis in the inguinal lymph node.

A 61-years-old man with chronic liver disease and HCC, status post 3 sittings of TACE with favorable response, who was on lenvatinib underwent 18F-fluorodeoxyglucose (FDG) positron-emission tomography/computed tomography (PET/CT) for elevated AFP level. FDG PET/CT [Figure 1]a demonstrated cirrhotic liver with a metabolically inactive hypodense lesion in segments VIII/IVa of the liver showing post TACE changes [Figure 1]b. No significant enlarged lymph nodes were identified in the abdomen. PET/CT also showed few non-FDG-avid enhancing nodular soft-tissue lesions in peritoneum involving subphrenic/perihepatic location [Figure 1]c, left iliac fossa [Figure 1]d and along pelvic peritoneum suggestive of metastases. In addition, mildly FDG avid enhancing nodular soft-tissue lesion was seen at umbilicus [Figure 1]e and [Figure 1]f along with mild FDG avid enlarged lymph node in the left inguinal region [Figure 1]h and [Figure 1]i, and suspicion of metastases was raised. Fine needle aspiration cytology from left iliac fossa deposit [Figure 1]g and tru-cut biopsy from left inguinal lymph node [Figure 1]j were done. Findings of histopathological examination in both samples were consistent with metastasis from HCC. HCC metastasizing to the inguinal lymph node is very rare. Review of the literature revealed no documentation of inguinal lymph node metastasis from HCC, including two large autopsy series published in populations with a high incidence of this tumor.[2],[3] The possible route of metastasis to inguinal lymph nodes in the absence of other regional nodal involvement could be through the spread of malignant cells to the umbilical region (through the portal venous system via a patent umbilical vein, or by direct spread from the anterior peritoneum), which could then drain through superficial lymphatic pathways along the inferior epigastric artery into inguinal lymph nodes.[4] The finding of the umbilical nodule (Sister Mary Joseph's nodule) in a patient with HCC has been previously reported.[5] The presence of peritoneal lesions and umbilical nodule in this patient makes this pathway more likely route of spread to the inguinal lymph node. Even though 18F-FDG PET/CT shows variable uptake in HCC depending on the degree of differentiation of primary tumor, it is very useful in the detection of extrahepatic (lymph nodal and distant) metastases even in clinically unsuspected sites. A systematic review and meta-analysis study demonstrated 18F-FDG PET/CT had a pooled sensitivity and specificity of 76.6% and 98.0%, respectively, for the detection of metastatic HCC.[6]
Figure 1: 18F-fluorodeoxyglucose (FDG) positron-emission tomography-computed tomography images [a; Maximum intensity projection image] showing non-FDG-avid lesion in segments VIII/IVa of the liver with post-TACE changes (b), soft-tissue peritoneal lesions in subphrenic/perihepatic location (c) and left iliac fossa (d). FDG-avid enhancing nodular soft tissue lesion in the umbilicus (e and f) and enlarged lymph node in the left inguinal region (h and i). Fine-needle aspiration cytology from left iliac fossa deposit showing neoplastic hepatocytes (g) and tru-cut biopsy from left inguinal lymph node showing neoplastic hepatocytes arranged in trabecular pattern with intervening prominent sinusoidal like spaces and focal areas showing cells with intracytoplasmic bile pigment (j), consistent with metastasis from hepatocellular carcinoma

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Senthil R, Ramesh H, Visakh RA, Pratap T, Mahadevan P. 18F-FDG PET/CT of internal mammary lymph node hepatocellular carcinoma metastases. Clin Nucl Med 2018;43:e482-3.  Back to cited text no. 1
    
2.
Yuki K, Hirohashi S, Sakamoto M, Kanai T, Shimosato Y. Growth and spread of hepatocellular carcinoma. A review of 240 consecutive autopsy cases. Cancer 1990;66:2174-9.  Back to cited text no. 2
    
3.
Nakashima T, Okuda K, Kojiro M, Jimi A, Yamaguchi R, Sakamoto K, et al. Pathology of hepatocellular carcinoma in Japan. 232 Consecutive cases autopsied in ten years. Cancer 1983;51:863-77.  Back to cited text no. 3
    
4.
Rains AJ, Ritchie HD. Bailey and Love's Short Practice of Surgery. 16th ed. London: Lewis; 1975. p. 1055.  Back to cited text no. 4
    
5.
Raoul JL, Boucher E, Goudier MJ, Gestin H, Kerbrat P. Umbilical metastasis of an hepatocellular carcinoma. Gastroenterol Clin Biol 1998;22:470-1.  Back to cited text no. 5
    
6.
Lin CY, Chen JH, Liang JA, Lin CC, Jeng LB, Kao CH. 18F-FDG PET or PET/CT for detecting extrahepatic metastases or recurrent hepatocellular carcinoma: A systematic review and meta-analysis. Eur J Radiol 2012;81:2417-22.  Back to cited text no. 6
    


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