Metastatic Hepatocellular Carcinoma Presenting as Bulky Lymphadenopathy Mimicking Lymphoma

Abstract

Introduction: A 66-year-old Hispanic man with hepatitis C (HCV) cirrhosis presented to the emergency department with complaints of several weeks of epigastric/left upper quadrant abdominal pain, night sweats, and an 18-lb weight loss. Physical examination revealed no jaundice, no palpable lymphadenopathy, nor cutaneous stigmata of chronic liver disease. On abdominal examination, there was evidence of tender hepatomegaly with a fullness in the epigastrium and right upper quadrant. A CT scan revealed cirrhotic liver morphology with a 4-cm arterially-enhancing mass in segment 2 of the left hepatic lobe with delayed-phase washout, suspicious for a hepatocellular carcinoma (HCC). In addition, there was a confluent nodular mass in the gastrohepatic space measuring 6.5 x 5 cm with encasement of the celiac trunk, its branches, the portal venous confluence, and splenic vessels. A similar mass was seen in the retroperitoneum with encasement of the renal vessels. Mild ascites was noted with no evidence of portal vein thrombosis. Percutaneous biopsy of the hepatic mass revealed a moderately differentiated HCC. The patient’s alpha-fetoprotein (AFP) was 9.3. A CT scan of the chest and a nuclear medicine bone scan were negative for distant metastases. Due to the CT findings of bulky lymphadenopathy and associated “B symptoms” the patient underwent an endoscopic ultrasound (EUS) to rule out a concomitant lymphoma. The EUS confirmed the presence of widespread malignant-appearing abdominal adeopathy. Fine needle aspiration demonstrated carcinoma that was morphologically identical to the liver pathology, thus confirming a locally advanced metastatic HCC. There was no evidence of lymphoma on flow cytometry. The patient has since been treated with a combination of loco-regional transarterial chemoembolization of the primary hepatic HCC lesion and systemic sorafenib. Given his advanced disease, he was not deemed a suitable liver transplant candidate. Although lymph node metastases may be seen in HCC, the size and isolated extent of abdominal lymphadenopathy seen in this case were distinctly unusual and the presentation mimicked that of a lymphoma.