Abstract
We describe the case of an 80-year-old man with hepatocellular carcinoma (HCC) who developed tracheal obstruction due to peritracheal lymph node metastasis. A metastatic tumor that protruded into the airway was ablated using a neodymium yttrium-aluminium-garnet laser and then a self-expandable metallic stent (SEMS) was deployed in the trachea. Stenting resolved symptoms of severe dyspnea upon mild exertion and in the supine position. Three months later, the patient is alive and has resumed normal activities as an outpatient, despite having metastatic HCC. Peritracheal lymph node metastasis arising from HCC is very rare and a polypoid tumor growing from a metastatic lymph node into the trachea is also extremely unusual. Tracheal obstruction in this patient was successfully treated by airway stenting.
Peritracheal lymph node metastasis from hepatocellular carcinoma (HCC) and polypoid tumors arising from HCC metastasis to lymph nodes that protrude into the trachea are extremely unusual. We describe a patient with HCC accompanied by tracheal obstruction due to peritracheal lymph node metastasis that was successfully treated by airway stenting.
Case Report
An 80-year-old man diagnosed with HCC accompanied by peritracheal lymph node and lung metastases was referred to our hospital. The disease had metastasized to the peritracheal lymph nodes after the primary HCC had been treated by liver segmentectomy (segments 5 and 8). Lymph node recurrence was treated with surgical resection, radiation, interferon and chemotherapy. Lung metastases that subsequently occurred were treated with further chemotherapy, interferon and molecular-target therapy using sorafenib. These processes occurred over a period of eight years.
However, the peritracheal lymph node metastases gradually enlarged and invaded the trachea. A polypoid tumor protruded from a metastatic lymph node and obstructed the trachea (Figures 1 and 2), causing the patient to frequently develop dyspnea upon even mild exertion, and particularly in the supine position. Oxygen was delivered through a mask or nasal cannula upon hospitalization. A total dose of 45 Gy of radiation administered as a second emergency therapy to treat for the metastatic peritracheal lymph nodes did not diminish the tumor or improve his symptoms.
We, therefore, decided to deploy an airway stent in the trachea to improve the patient's symptoms. Under general anesthesia, an external cylinder was inserted through the mouth into the trachea to allow the manipulation of rigid and flexible bronchoscopes and forceps in the operating theatre. The base of a tumor arising from the anterior wall of trachea was ablated using a neodymium yttrium-aluminium garnet laser and removed piecemeal, which restored the airway caliber. A 4-cm long self-expandable metallic stent with a diameter of 20 mm (SEMS; Covered Ultraflex Esophageal Stent System; Boston Scientific Co., Natick, MA, USA) was inserted into the trachea under fluoroscopic guidance (Figure 3). The surgical duration was 47 min, with minimal blood loss and no complications. The histopathological diagnosis of the excised specimen was metastatic HCC (Figure 4). The postoperative course was uneventful and the stent improved the patient's symptoms. Three months later, the patient is alive and continues with normal activities despite having metastatic HCC. He is presently under follow-up as an outpatient.
Chest contrast-enhanced computed tomography images. A: Transverse sections, arrow shows tumor arising from mediastinal lymph node metastases protruding into the trachea. B: Coronal section, arrow shows polypoid tumor in the trachea. C: Sagittal section, arrow shows tumor with stalk arises from mediastinal lymph node metastases in the anterior wall of trachea.
Discussion
HCC is the sixth most prevalent type of cancer and the third most frequent cause of cancer-related death worldwide (1). This aggressive cancer frequently recurs, mainly in residual liver after hepatectomy (2-4). The frequency of extrahepatic metastases of HCC is relatively low. That to mediastinal lymph nodes is even lower, with a reported incidence of 4.7-6.6% for HCC with extrahepatic metastasis, and 0.7% for that of peritracheal lymph nodes (5, 6).
Although some patients with mediastinal lymph node metastasis of HCC have been described (7, 8), none have presented with airway obstruction due to a protruding tumor arising from a lymph node metastasis. A clinicopathological study of 16 endotracheal/endobronchial metastases from non-pulmonary neoplasms, such as of the colon/rectum, bone, breast and uterus (9), found bronchial invasion by mediastinal or hilar lymph node metastases in four patients and no metastasis from HCC. Therefore, a developmental morphology accompanied by polypoid growth from lymph node metastatses of HCC into the trachea seems extremely unusual.
Tumors reportedly metastasize from the liver to the mediastinal lymph nodes via pathways running from the left lobe of the liver through the anterior phrenic lymph nodes to the parasternal or subcarinal nodes, from the liver in the vicinity of the falciform ligament through this ligament to the parasternal or peritracheal lymph nodes, and from the right lobe of the liver through the right triangular ligament to the peritracheal lymph nodes (10). This pathway might have been associated with the mediastinal lymph node metastasis in our patient because peritracheal lymph node metastases developed after a tumor had been resected from the right lobe of the liver.
Bronchoscopy findings of the endotracheal tumor occupying the tracheal lumen.
The quality of life of patients with airway obstruction and dyspnea due to benign or malignant disease is extremely poor. Furthermore, the survival of patients with malignant central airway obstruction is very limited. Therefore, prompt therapies are needed for such patients. Stents are considered a useful modality for managing airway complications such as obstructions and fistulae (11, 12). Stent deployment has reportedly improved not only symptoms in 65-98% of patients with airway obstruction (13, 14), but also survival (15).
To our knowledge, developmental morphology accompanied by polypoid growth from lymph node metastases of HCC into the trachea is very rare. This is the first report of a patient with airway obstruction caused by lymph node metastasis from HCC that was managed by stenting. Our patient has a better quality of life as an outpatient despite having metastatic HCC.
Chest computed tomography findings after airway stenting. The image shows the self-expandable metallic stent deployed in the trachea. A: Transverse, and B: coronal sections.
Microscopic findings from excised specimen (H&E stain, A: ×100, B: ×200). Tumor in tracheal mucosa has alveolar configuration or sheet formation. Large tumor cells with clear cell body and enlarged oval nuclei indicate metastatic hepatocellular carcinoma.
- Received February 13, 2013.
- Revision received March 16, 2013.
- Accepted March 19, 2013.
- Copyright© 2013 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved
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