• Users Online:1724
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
IMAGE IN EUS
Year : 2015  |  Volume : 4  |  Issue : 1  |  Page : 73-75

Unusual cause of obstructive jaundice revealed by endoscopic ultrasound guided fine-needle aspiration of mediastinal lymph node


1 Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
2 Department of Cytology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
3 Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
4 Department of Surgery, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, India

Date of Submission04-Oct-2013
Date of Acceptance01-Apr-2014
Date of Web Publication13-Feb-2015

Correspondence Address:
Surinder Singh Rana
Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2303-9027.151370

Rights and Permissions

How to cite this article:
Rana SS, Chaudhary V, Sharma V, Sharma R, Gupta N, Sampath S, Mittal BR, Gupta R, Dutta U, Bhasin DK. Unusual cause of obstructive jaundice revealed by endoscopic ultrasound guided fine-needle aspiration of mediastinal lymph node. Endosc Ultrasound 2015;4:73-5

How to cite this URL:
Rana SS, Chaudhary V, Sharma V, Sharma R, Gupta N, Sampath S, Mittal BR, Gupta R, Dutta U, Bhasin DK. Unusual cause of obstructive jaundice revealed by endoscopic ultrasound guided fine-needle aspiration of mediastinal lymph node. Endosc Ultrasound [serial online] 2015 [cited 2019 Nov 20];4:73-5. Available from: http://www.eusjournal.com/text.asp?2015/4/1/73/151370

A 65-year-old male presented to us with jaundice of 2-month duration. His liver function tests were suggestive of cholestatic jaundice with serum bilirubin of 28 mg/dL. Ultrasound of the abdomen revealed dilated intrahepatic biliary radicles with a suspicion of intra-ductal mass lesion at the hilum. Contrast-enhanced computed tomography (CT) and magnetic resonance cholangiopancreatography of the abdomen showed a soft tissue lesion in the common bile duct (CBD) extending into the right ductal system as well as distal bile duct with bilobar biliary radical dilatation [Figure 1] and [Figure 2] respectively]. Positron emission tomography CT detected a non-flourodeoxyglucose (non-FDG) avid mass in the bile duct along with a moderately FDG avid (SUV max : 5.2, measuring 1.0 cm × 1.5 cm) portocaval lymph node [Figure 3] and moderately FDG avid (SUV max : 4.7) left upper mediastinal lymph nodes [Figure 4]. Endoscopic ultrasound (EUS) demonstrated the presence of a heterogeneously echotextured mass lesion completely filling the CBD [Figure 5] with extension into the right ductal system along with enlarged left upper mediastinal lymph nodes. EUS guided fine-needle aspiration (FNA) was done using a 22-gauge needle (Echotip, Wilson-Cook, Winston-Salem, NC, USA) from the mass lesion in the bile duct [Figure 6] as well as the left upper mediastinal lymph node [station 2 L; [Figure 7] and three passes were taken from the bile duct lesion and two passes from the lymph node respectively. The cytological examination of the FNA specimen from the bile duct was noncontributory, whereas the FNA smears from the mediastinal lymph node showed polygonal tumor cells with hepatocytic differentiation with cytoplasmic and nuclear holes/vacuolation suggestive of metastatic hepatocellular carcinoma (HCC) [Figure 8]. The serum α-foeto protein was markedly elevated (12,560 ng/mL). The patient was started on sorafenib and his serum bilirubin has decreased to 5 mg/dL after 1 month of therapy.
Figure 1. Contrast-enhanced computed tomography: Soft tissue mass lesion at the confl uence of the bile ducts extending into the right ductal system (arrow)

Click here to view
Figure 2. Magnetic resonance cholangiopancreatography: Intra-ductal mass in the common bile duct extending up to confl uence (arrows)

Click here to view
Figure 3. Positron emission tomography scan: Moderately flourodeoxyglucose avid (SUVmax: 5.2, measuring 1.0 cm × 1.5 cm, arrow) portocaval lymph node (arrow)

Click here to view
Figure 4. Positron emission tomography scan: Moderate flourodeoxyglucose uptake (SUVmax: 4.7, measuring ~ 1.3 cm × 1.3 cm, arrow) in highest mediastinal lymph node on the left side (arrow)

Click here to view
Figure 5. Endoscopic ultrasound: Heterogeneously echotextured mass lesion completely filling the common bile duct

Click here to view
Figure 6. Endoscopic ultrasound guided fi ne-needle aspiration from the bile duct lesion. CBD: Common bile duct

Click here to view
Figure 7. Endoscopic ultrasound fine-needle aspiration from the left upper mediastinal lymph node. LSCA: Left subclavian artery; LCCA: Left common carotid artery

Click here to view
Figure 8. Fine-needle aspiration cytology smears from mediastinal lymph node showing polygonal tumor cells with hepatocytic differentiation with cytoplasmic and nuclear holes/vacuolation (MGG × 40)

Click here to view


Obstructive jaundice as the presenting manifestation of HCC is very rare. The bile ducts can be obstructed by tumor thrombi, hemobilia, tumor compression, or tumor infiltration. [1],[2] However, an icteric type of obstructive HCC with nondetectable primary lesion in the liver, as in the current case, has been rarely reported. [3] Furthermore, EUS-FNA is easier for lymph nodes located close to the esophagus like subcarinal, paraesophageal and lower left paratracheal. The case is also reported because EUS-FNA was done from station 2 L for which EUS-FNA is relatively difficult due to interference by presence of air in trachea and the bronchi as well as the echoendoscope being close to upper esophageal inlet.

 
  References Top

1.
Chen MF. Icteric type hepatocellular carcinoma: Clinical features, diagnosis and treatment. Chang Gung Med J 2002;25:496-501.  Back to cited text no. 1
    
2.
Qin LX, Tang ZY. Hepatocellular carcinoma with obstructive jaundice: Diagnosis, treatment and prognosis. World J Gastroenterol 2003;9:385-91.  Back to cited text no. 2
    
3.
Chang H, Xu J, Mu Q, et al. Occult hepatocellular carcinoma: A case report of a special icteric-type hepatoma and literature review. Eur J Cancer Care (Engl) 2010;19:690-3.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]


This article has been cited by
1 Accuracy of endoscopic ultrasound-guided tissue acquisition in the evaluation of lymph nodes enlargement in the absence of on-site pathologist
Yung Ka Chin,Julio Iglesias-Garcia,Daniel de la Iglesia,Jose Lariño-Noia,Ihab Abdulkader-Nallib,Hector Lázare,Susana Rebolledo Olmedo,J Enrique Dominguez-Muñoz
World Journal of Gastroenterology. 2017; 23(31): 5755
[Pubmed] | [DOI]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
   References
   Article Figures

 Article Access Statistics
    Viewed976    
    Printed22    
    Emailed0    
    PDF Downloaded173    
    Comments [Add]    
    Cited by others 1    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]