Spontaneous rupture of peripancreatic lymph node with hepatocellular carcinoma metastasis: report of an autopsy case with massive peritoneal bleeding.

Hepatocellular carcinoma (HCC) has a tendency for fatal spontaneous rupture leading to massive hemorrhage. The majority of such ruptures of HCC occur in the liver, while a few previous studies showed that such HCC rupture developed at metastatic sites including the lung, pleura, spleen, and peritoneum. We here report a case of hepatitis C virus-related HCC with spontaneous rupture of a peripancreatic lymph node with HCC metastases. A 61-year-old Japanese man died of hepatic failure after therapy for cirrhosis and HCC for 6 years. At autopsy, the liver showed diffuse multinodular HCC in both lobes. Metastases were found in lumbar vertebral bones and abdominal lymph nodes of the hepatic hilar, peripancreatic and perigastric regions. One lymph node (4 cm in diameter) around the pancreatic head was found ruptured, and blood coagula (100 g) was present around the ruptured node. Pure blood of 2000 ml was noted in the peritoneal cavity. Cirrhosis was not recognized. Histologically, the liver tumors and metastases in the lumbar vertebral bones and abdominal lymph nodes were poorly-differentiated HCC of Edmondson's grade III. The ruptured lymph node was almost replaced by poorly-differentiated HCC, and the ruptured site showed hemorrhage, breakdown of the capsule, and ischemic changes. Non-tumorous liver showed chronic hepatitis C. The immediate cause of death was suggested to be circulatory insufficiency due to rupture of the lymph node and/or hepatic failure. The present case showed that abdominal lymph nodes with HCC metastases may rupture and cause severe hemorrhage in the peritoneal cavity, leading to death.