Atypical Appearance of Hepatocellular Carcinoma and Its Mimickers: How to Solve Challenging Cases Using Gadoxetic Acid-Enhanced Liver Magnetic Resonance Imaging

Hepatocellular carcinoma (HCC) can be diagnosed noninvasively with contrast-enhanced dynamic computed tomography, magnetic resonance imaging, or ultrasonography on the basis of its hallmark imaging features of arterial phase hyperenhancement and washout on portal or delayed phase images. However, approximately 40% of HCCs show atypical imaging features, posing a significant diagnostic challenge for radiologists. Another challenge for radiologists in clinical practice is the presentation of many HCC mimickers such as intrahepatic cholangiocarcinoma, combined HCC-cholangiocarcinoma, arterioportal shunt, and hemangioma in the cirrhotic liver. The differentiation of HCCs from these mimickers on preoperative imaging studies is of critical importance. Hence, we will review the typical and atypical imaging features of HCCs and the imaging features of its common mimickers. In addition, we will discuss how to solve these challenges in practice.

A Case of Combined Hepatocellular-cholangiocarcinoma Mimicking Pyogenic Liver Abscess

Heterogeneous features of liver cancer can mimic liver abscess. Therefore it is essential to double-check tumor markers in the diagnosis of liver abscess. Herein, we report a case of combined hepatocellular-cholangiocarcinoma (cHC) occurred in an unrecognized chronic hepatitis B patient initially misdiagnosed as liver abscess. A 49-year old male initially presented with chill, right upper quadrant pain, and a liver mass. Mass showed peripheral enhancement in arterial phase of computed tomography, which was not typical for hepatocellular carcinoma (HCC). Strikingly elevated alpha-fetoprotein and fine needle aspirated pathology revealed HCC. Despite discordant image findings he was treated with transarterial chemoembolization. He was treated with sorafenib due to metastatic retrocaval lymphadenopathy afterwards. The mass presumed to be HCC progressed with sorafenib. It was surgically resected and he was finally confirmed as cHC. Discordant tumor markers with presumptive image findings should prompt the suspicion of rare type of primary liver cancer, the cHC.

A Case of Curative Resection of Advanced Combined Hepatocellular-cholangiocarcinoma after Neoadjuvant Chemotherapy / 대한췌담도학회지

Combined hepatocellular-cholangiocarcinoma (HCC-CC) is a primary liver cancer with histopathologic features of both hepatocelluar carcinoma and cholangiocarcinoma. As combined HCC-CC has been associated with poor outcomes, accurate diagnosis and proper treatment planning for patients are considered to be important for improving survival. Currently, surgery is known as the only treatment modality offering potential cure for localized disease. However, there are little published treatment options for advanced or recurrent disease. Furthermore, no published reports exist in respect to the applying successful curative resection after neoadjuvant therapy for advanced combined HCC-CC. Here, we report a case of combined HCC-CC subtype with stem cell feature, intermediate type who underwent curative surgical resection after neoadjuvant chemotherapy consisting of cisplatin and gemcitabine. Pathologic report revealed negative resection margin and follow-up imaging study shows no evidence of tumor recurrence.

Cancer Stem Cells in Primary Liver Cancers: Pathological Concepts and Imaging Findings

There is accumulating evidence that cancer stem cells (CSCs) play an integral role in the initiation of hepatocarcinogenesis and the maintaining of tumor growth. Liver CSCs derived from hepatic stem/progenitor cells have the potential to differentiate into either hepatocytes or cholangiocytes. Primary liver cancers originating from CSCs constitute a heterogeneous histopathologic spectrum, including hepatocellular carcinoma, combined hepatocellular-cholangiocarcinoma, and intrahepatic cholangiocarcinoma with various radiologic manifestations. In this article, we reviewed the recent concepts of CSCs in the development of primary liver cancers, focusing on their pathological and radiological findings. Awareness of the pathological concepts and imaging findings of primary liver cancers with features of CSCs is critical for accurate diagnosis, prediction of outcome, and appropriate treatment options for patients.

Combined Hepatocellular-Cholangiocarcinoma: Recent Progress in Pathology and Classification / 영남의대학술지

Primary liver carcinomas have been classified into hepatocellular carcinoma, cholangiocarcinoma, and combined hepatocellular-cholangiocarcinoma (CHC). CHC is a tumor containing unequivocal, intimately mixed elements of both hepatocellular carcinoma and cholangiocarcinoma. It forms a small but significant proportion of primary liver carcinomas. The origin and pathogenesis of CHC have not been well established. According to the 2010 WHO classification, CHCs are categorized into 2 groups: the classical type and a subtype with stem cell features. This review describes recent progress in pathology and classification of CHC.

Metastatic Small Bowel Perforation Caused by Intrahepatic Cholangiocarcinoma in a Patient with Combined Hepatocellular-cholangiocarcinoma

Advances in chemotherapy and radiation therapies for malignant tumors have resulted in the identifications of various novel features of intestinal metastasis. The common causes of small bowel metastasis are malignant melanoma and lung cancer, and this has also been rarely reported to uterine cervical cancer, malignant lymphoma of the larynx, malignant lymphoma of soft palate, and hepatocellular carcinoma (HCC). The Combined HCC-cholangiocarcinoma (HCC-CC) is a rare primary liver malignancy, and is composed of cells with the histopathological features of both HCC and CC, but metastatic small bowel perforation by CC in a patient with combined HCC-CC has not been reported previously. The authors describe the case of a 51-year-old man with a metastatic small bowel perforation caused by an intrahepatic CC in combined HCC-CC with a review of the literature.

Intermediate hepatic carcinoma mimicking intrahepatic cholangiocarcinoma: A case report / 대한내과학회지

Primary liver cancer has traditionally been classified as either hepatocellular carcinoma (HCC) or cholangiocarcinoma (CCC). However, primary liver cancer occasionally consists of elements from both HCC and CCC. Intermediate hepatic carcinoma and primary liver cancer of the intermediate type are extremely rare subtypes of primary liver cancer that show features intermediate between HCC and CCC. First reported in 1998, the clinical, radiologic, and histopathologic characteristics of this entity remain unclear. In this case report, we describe the clinical, magnetic resonance imaging, histopathological, and immunohistochemical findings in a patient with intermediate hepatic carcinoma who was initially thought to have intrahepatic cholangiocarcinoma.

Combined Hepatocellular-cholangiocarcinoma / 대한간학회지

No abstract available.

A Case of Sarcomatoid Combined Hepatocellular-Cholangiocarcinoma / 대한소화기학회지

Combined hepatocellular-cholangiocarcinoma (HCC-CC) with sarcomatoid features is an extremely rare primary liver cancer, of which only four cases have been reported. We report a case of sarcomatoid combined HCC-CC in a 60-year-old woman who complained of right upper quadrant pain and presented with a 7 cm mass in the S4 region of the liver in abdominal CT. Ultrasonography-guided needle biopsy diagnosed it as HCC, and left lobectomy of the liver followed. Microscopically, the tumor consisted of two portions: HCC portion showing trabecular pattern, which had partially sarcomatous area with spindle-shaped tumor cells, and CC portion with glandular pattern. Immunohistochemically, HCC portion reacted positively with alpha-fetoprotein while CC portion demonstrated positive reactivity with carcinoembryonic antigen and mucicarmine. Sarcomatoid cells reacted positively for cytokeratin. She died of tumor recurrence and hepatic failure 12 months after the operation. Combined HCC-CC has poor prognosis, and sarcomatoid HCC has high metastatic potential and poor prognosis compared with ordinary HCC.

A Case of Combined Hepatocellular-Cholangiocarcinoma with Sarcomatous Transformation and Second Primary Colon Cancer / 대한간학회지

Combined hepatocellular-cholangiocarcinoma is a rare form of primary liver cancer, featuring both hepatocellular and biliary epithelial differentiations. An intrahepatic tumor may be considered as a metastatic lesion. It has been suggested in the literature that the likelihood of metastasis in the cirrhotic liver is lower than that in the non-cirrhotic liver. A rare case of combined hepatocellular-cholangiocarcinoma and second primary colon adenocarcinoma in a 67-year-old male patient with liver cirrhosis is presented. Histologically, the intrahepatic mass was composed of a spindle cell sarcomatous component; a hepatocellular carcinoma component; and a cholangiocarcinoma component. There were focal transitional regions among the different components. Immunohistochemically, the cholangiocarcinoma component of the intrahepatic mass showed positive reactions for CK-7 but negative reactions for CK-20. The adenocarcinoma of the colon showed positive reactions for CK-20 but negative reactions for CK-7.

Combined Hepatocellular-Cholangiocarcinoma: Analysis of 8 cases with special reference to their growth patterns

Eight cases of combine hepatocellular-cholangiocarcinoma(HCC-CC) of the liver were analysed along with their growth patterns and histologic subtypes to draw a possible implication in understanding of their histogenesis. The relative incidence of combined HCC-CC among the surgically resected primary carcinomas of the liver(485 cases) was 1.6%. The combination patterns varied and were classified as follows; the multinodular tumor, each consisting of HCC or CC element(type 1) was found in 1 case, the single tumor mass with two distinct compartments of HCC and CC(type 2) in 3, and the single tumor with random mixture of two elements(type 3) comprised the remaining 4 cases. Of the 7 cases of single tumor mass(type 2 and 3) HCC and CC comprised the major component in 5 and 2 cases, respectively. The histologic features of both HCC and CC elements were not different from those of isolated HCC and CC, except for two of CC element in type 3 which disclosed the intermediated differentiation or socalled cholangiolocellular carcinoma in part. We conclude that there is no significant difference in the relative incidence of combined HCC-CC among primary carcinomas of the liver and their subtypes compared to that in other countries, regardless of high incidence of both HCC and CC in Korea. Also, we discussed a possible histogenisis along a hypothesis that some of the combined HCC-CC be the consequence of interposition of different cell type from a new subclone into the growth of an initial single cell type of primary carcinoma of the liver.