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+A female outpatient in her 50s had routinely visited our hospital because of liver cirrhosis resulting from hepatitis B virus and biliary duct stones.
+At 65 years of age, she suffered from HCC with BCLC early stage A.
+Her liver function was well preserved, and Child-Pugh score was A.
+She underwent left lateral segmentectomy for HCC, without other preoperative treatments.
+Histopathological findings revealed bridging fibrosis and pseudolobule formation.
+Serum levels of alpha-fetoprotein (AFP) and protein induced by vitamin K absence-II normalized after primary resection (Figure 1).
+In imaging studies, no LN metastasis was detected at the time of primary resection of HCC.
+Two and a half years postoperatively, the patient’s AFP level increased dramatically to 780.2 ng/ml.
+A lobular lesion with fine enhancement was detected by contrast-enhanced magnetic resonance imaging.
+The tumor measured 27 mm in diameter and was located caudally on the left kidney.
+In contrast-enhanced computed tomography, the tumor showed strong enhancement in the arterial phase (Figure 2A, 2B) and a relatively low density in the portal phase (Figure 2C, 2D).
+These enhancement findings appeared consistent with a typical HCC pattern.
+Detailed imaging studies of both magnetic resonance imaging and computed tomography were performed in this case because a very rare metastatic LN initially seemed to be debatable and we needed to rule out exclusion diagnoses.
+Three-dimensional imaging proved that the tumor was fed by a main vessel from the inferior mesenteric artery (red arrow) and by an accessory feeder from the superior mesenteric artery (Figure 3).
+Fluorine-18-fluorodeoxyglucose positron emission tomography (FDG-PET) and positron emission tomography-computed tomography did not detect the tumor (Figure 4), although we thought positron emission tomography-computed tomography was helpful to identify other metastatic tumors.
+Further imaging findings revealed no other intrahepatic or extrahepatic metastasis.
+Based on the tumor location, the clinical diagnosis was solitary metastasis to a mesocolic LN or HCC dissemination.
+Determining the ideal therapeutic strategy for solitary but extrahepatic rare metastasis was difficult.
+Although rapid growth was a critical concern in this case, the tumor was solitary and not accompanied by other metastases.
+Considering both diagnostic and therapeutic viewpoints, we finally chose surgical resection in this case.
+No disseminative nodules, lymphadenopathy, or ascites was observed during surgery.
+The tumor was located in the mesocolon nearly at the wall of the descending colon, and partial resection of the descending colon with regional mesocolon was performed.
+The patient’s postoperative course was uneventful, and she was discharged on postoperative day 8.
+Serum levels of tumor marker decreased immediately after surgery (Figure 1).
+Macroscopically, the mesocolic tumor was a solid and elastic mass with a smooth surface (Figure 5A).
+A yellowish nodule was encapsulated in the cut surface (Figure 5B).
+The enlarged LN contained metastatic HCC with a ductal structure (Figure 6A), and immunohistochemically, the tumor was positive for AFP and negative for CK-20, which was consistent with the pattern of primary HCC (Figure 6B).
+The histopathological diagnosis was metastatic HCC to a mesocolic LN.
+As of the writing of this report, the patient has remained free of recurrence for 13 months after the second surgery, and has also been carefully followed up.
+No adjuvant therapies have been performed.