Hemothorax Caused by Spontaneous Rupture of a Metastatic Mediastinal Lymph Node in Hepatocellular Carcinoma: a Case Report

LETTER TO THE EDITOR

Korean J Intern Med 2013;28:622-625 http://dx.doi.org/10.3904/kjim.2013.28.5.622

Hemothorax caused by spontaneous rupture of a metastatic mediastinal lymph node in hepatocellular carcinoma: a case report

Ssang Yong Oh1, Kwang Won Seo1, Yangjin Jegal1, Jong-Joon Ahn1, Young Joo Min1, Chang Ryul Park2, and Jae Cheol Hwang3

Departments of 1Internal To the Editor, the surgery and the patient received 2 Medicine, Thoracic and The frequency of massive hemo- six cycles of a cisplatin-based chemo- Cardiovascular Surgery, and 3Radiology, Ulsan University peritoneum caused by spontaneous therapy regimen over 6 months. Con- Hospital, Ulsan, Korea rupture of hepatocellular carcinoma trast-enhanced computed tomography (HCC) has been reported to be 10% to (CT) scanning showed complete dis- 18% because of the extensive vascular appearance of the multiple metastatic structure and relatively small amount lung nodules after chemotherapy. At of fibrous tissue in these tumors [1]. 8 months after finishing the chemo- Hemothorax caused by rupture of a therapy, however, he was readmitted lung or pleural metastasis of HCC to our hospital due to a single met- occurs less frequently. Although one astatic nodule in the left lower lobe case of cardiac tamponade caused by of the lung and underwent metasta- spontaneous rupture of a metastatic sectomy with video-assisted thoraco- mediastinal lymph node (MLN) has scopic surgery (VATS). Pathological been described [2], to our knowledge, examination of the lung nodule re- no case of hemothorax due to sponta- moved showed results consistent with neous rupture of a metastatic MLN of metastatic HCC. HCC has been reported in the Kore- At 1 year before admission, CT an- or English-language literature. images of the chest showed a single We describe here a case of massive enlarged lymph node (LN) in the left hemothorax due to spontaneous rup- inferior pulmonary ligament, regard- ture of a metastatic MLN in HCC. A ed as a metastatic MLN of HCC (Fig. 60-year-old male Korean farmer was 1B). Two weeks before this admission, Received : October 31, 2008 brought to the Department of Emer- follow-up CT images showed enlarge- Revised : November 18, 2008 gency, Ulsan University Hospital with ment of the metastatic MLN, and the Accepted : November 24, 2008 dyspnea and left pleuritic chest pain patient was scheduled for additional Correspondence to within 6 hours after symptom onset. chemotherapy. Kwang Won Seo, M.D. Six years earlier, he was diagnosed On the day of admission, the pa- Department of Internal with chronic hepatitis B-related cir- tient experienced an abrupt onset of Medicine, Ulsan University Hospital, 877 rhosis and 4 years earlier he had been dyspnea and left pleuritic chest pain. Bangeojinsunhwan-doro, diagnosed with HCC (Fig. 1A) and Physical examination on admission Dong-gu, Ulsan 682-714, Korea underwent a right hepatic lobecto- revealed an acutely ill-looking man Tel: +82-52-250-8861 Fax: +82-52-251-8235 my. Multiple metastatic pulmonary with body temperature of 36.5°C, E-mail: [email protected] nodules were detected 3 months after pulse rate of 130 beats per minute,

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blood pressure of 100/70 mmHg, and a respiration rate X-rays showed a massive left-sided pleural effusion, of 32 breaths per minute. Laboratory test results in- with the trachea deviated to the right side. cluded hemoglobin 12.3 g/dL, hematocrit 33.4%, white Massive hemothorax was diagnosed by thoracente- blood cell count 4.37 × 103/µL, platelet count 9.9 × 104/ sis. CT images of the chest revealed a 73 × 84 mm-sized µL, aspartate aminotransferase 47 IU/L, alanine ami- ruptured low-attenuated central necrotic mass with notransferase 60 IU/L, total bilirubin 2.0 mg/dL, albu- massive left side hemothorax (Fig. 1C). A chest tube min 3.2 mg/dL, and α-fetoprotein 819.2 ng/mL. Chest was inserted and approximately 1,200 mL of bloody

A B

C D

Figure 1. Chest computed tomography scans showing (A) a 10-cm sized intrahepatic peripheral capsular enhanced mass, (B) a single enlarged lymph node (white arrow) in the left inferior pulmonary ligament, and (C) a 73 × 84-mm ruptured low- attenuated central necrotic mass with a large amount of pleural fluid in the left hemithorax. (D) Chest X-ray showing bronchial arterial angiography after injection of lipiodol ultrafluide and adriamycin (doxorubicin hydrochloride) with polyvinyl alcohol particles (contour emboli).

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fluid was drained. Arteriography of the bronchial ar- gically or by TAE, with the latter now used widely for teries revealed a massive ruptured LN in the left infe- HCC ruptured into the peritoneal cavity. Masumoto et rior pulmonary ligament, to which blood was supplied al. [5] first reported hemothorax due to HCC rupture by an accessory bronchial artery originating 10 cm successfully controlled by TAE and our case was also beneath the left bronchial artery. successfully controlled using TAE. On the other hand, These findings indicated that the massive hemotho- surgically treated and untreated failures have been rax was caused by a spontaneous rupture of a metastat- reported and drainage-only cases do allow complete ic MLN of HCC into the intrapleural space. Transcath- control [3]. eter arterial embolization (TAE) of the left bronchial Our patient had been diagnosed with HCC 4 years artery was performed successfully, injecting 13 mL earlier and had undergone various treatments, includ- of lipiodol ultraf luide (Guerbet, Aulnay-sous-Bois, ing right hepatic lobectomy, six cycles of chemothera- France) and 30 mg of adriamycin (doxorubicin hydro- py for multiple lung metastases, VATS metastasectomy chloride) with polyvinyl alcohol particles (contour em- for a single metastasis in the lung, and TAE for rup- boli, Interventional Therapeutics Corp., Fremont, CA, ture of metastatic MLN causing massive hemothorax. USA) (Fig. 1D). No complication was observed and the TAE was effective, in that bleeding was successfully pleural effusion gradually disappeared thereafter. controlled and pleural effusion did not recur. Our The patient’s dyspnea improved, as did his physical findings suggest that patients with HCC should be condition. Following removal of the chest tube, he was closely monitored and suitably managed to improve discharged after 15 days in the hospital and was fol- survival. lowed monthly as an outpatient at the department of In conclusion, this is the first report of hemothorax oncology for 3 months. Serial chest X-rays revealed a secondary to spontaneous rupture of metastatic MLN decrease in the size of the MLN with lipiodol emboli- of HCC in the Korean- or English-language literature. zation. Four months later, however, the patient died at The hemothorax was successfully treated with TAE. home. The various manifestations observed in patients with Due to its vascular structure and relatively small HCC suggest the need for careful monitoring and amount of fibrous tissue, spontaneous rupture of HCC suitable management. is not uncommon [1]. Rupture of HCC is considered a medical emergency and is associated with high mor- tality. HCC frequently metastasizes, most often to the Keywords: Carcinoma, hepatocellular; Neoplasm me- lungs, LNs, bones, and adrenal glands. Moreover, HCC tastasis; Hemothorax metastases, like the primary tumors, may rupture spontaneously. Conflict of interest Sohara et al. [3] reviewed 10 cases with HCC compli- No potential conflict of interest relevant to this article cated by hemothorax, including four case reports in is reported. Japanese, describing patients with metastasis to the chest wall and rib, lung, pleura, diaphragm, and MLN [4]. Those reports included the first case of hemotho- REFERENCES rax from spontaneous rupture of a mediastinal metastasis [4]. 1. Miyamoto M, Sudo T, Kuyama T. Spontaneous rupture Common clinical presentations are chest pain and of hepatocellular carcinoma: a review of 172 Japanese dyspnea initially [3]. Other signs are palpitations and cases. Am J Gastroenterol 1991;86:67-71. hypotension, consistent with hypovolemic shock. 2. Seki S, Kitada T, Sakaguchi H, et al. Cardiac tamponade Reported rare signs included massive hemoptysis caused by spontaneous rupture of mediastinal lymph and respiratory failure. Our patient also developed node metastasis of hepatocellular carcinoma. J Gastro- hemothorax with sudden-onset chest pain, dyspnea, enterol Hepatol 2001;16:702-704. and tachycardia. Ruptured HCC can be treated sur- 3. Sohara N, Takagi H, Yamada T, Abe T, Mori M. Hepato-

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