Long-term prognosis of combined hepatocellular and cholangiocarcinoma after curative resection comparison with hepatocellular carcinoma and cholangiocarcinoma

Combined hepatocellular and cholangiocarcinoma (biphenotypic) tumors: imaging features and diagnostic accuracy of contrast-enhanced CT and MRI

OBJECTIVE

The purpose of this study was to evaluate the diagnostic accuracy of preoperative imaging for diagnosis of combined hepatocellular cholangiocarcinoma tumors and to evaluate the clinical and imaging features and demographics of patients presenting to our institution with such tumors.

MATERIALS AND METHODS

From January 2001 to January 2011, 29 patients presented with pathologically proven combined hepatocellular cholangiocarcinoma tumors to our institution. A retrospective review of the imaging studies, clinical data, and demographic information in these patients was conducted. Two radiologists with 6 and 18 years of experience reviewed the imaging studies of patients with combined hepatocellular cholangiocarcinoma tumors and matched control cases of hepatocellular carcinoma (HCC) (n = 15) and cholangiocarcinoma (n = 18). The reviewers were blinded to the pathologic diagnosis. Imaging features on contrast-enhanced MRI and CT with the suggested final diagnosis were recorded.

RESULTS

The demographics of our patient population were similar to other reported U.S. populations, with cirrhosis and hepatitis present in a minority of patients. The imaging features of combined hepatocellular cholangiocarcinoma tumors overlapped with those of HCC and cholangiocarcinoma. The correct diagnosis of combined hepatocellular cholangiocarcinoma tumors was made in a minority of cases by either radiologist, with misdiagnosis more often leading to suggestion of cholangiocarcinoma than HCC. Sensitivities and specificities for diagnosis of combined hepatocellular cholangiocarcinoma tumors ranged from 33% to 34% and 81% to 100%, respectively.

CONCLUSION

Preoperative diagnosis of combined hepatocellular cholangiocarcinoma tumors on the basis of imaging features is accurate in the minority of cases. Tumor markers and risk factors may help improve accuracy; however, in the absence of classic imaging features and supportive information for HCC or cholangiocarcinoma, biopsy should be considered for confirmation of diagnosis.

Increased expression of Yes-associated protein 1 in hepatocellular carcinoma with stemness and combined hepatocellular-cholangiocarcinoma

Combined hepatocellular-cholangiocarcinoma (cHC-CC) and some hepatocellular carcinomas (HCCs) express stemness-related markers, such as epithelial adhesion molecule (EpCAM) and keratin 19 (K19), the expression of which has been reported to be associated with more aggressive behavior therein than in HCCs without. Yes-associated protein 1 (YAP1), a potential oncogene, is known to promote stem cell proliferation. In the present study, YAP1 expression and clinicopathological features were evaluated and compared among three groups comprising 36 HCCs that expressed both EpCAM and K19, 64 HCCs that did not express EpCAM and K19, and 58 cHC-CCs, which consisted of 38 cases of the classical type and 20 cases of the intermediate-cell subtype. YAP1 expression was more frequently noted in EpCAM(+)/K19(+) HCCs (55.6%) and in cHC-CCs (67.2%) than in EpCAM(−)/K19(−) HCCs (17.2%) (P<0.001 for both). In cHC-CCs, YAP1 expression was observed in 63% of classical type cHC-CCs and in 75% of the intermediate subtype; moreover, such expression was correlated with poorer histological differentiation (P = 0.017) and was more frequently noted in transition zones than in HCC areas (P = 0.060). Disease-free and overall survival showed a statistically significant difference among the three groups: disease-free survival was highest for EpCAM(−)/K19(−) HCCs and lowest for cHC-CCs, with EpCAM(+)/K19(+) HCCs falling in between (P<0.05). Overall survival rate was lower in HCCs and cHC-CCs with YAP1 expression compared to those without (P = 0.05), whereas disease-free survival showed no significant difference according to YAP1 expression. Increased YAP1 expression was more frequently found in cHC-CCs and HCCs with stemness than in HCCs without, and a YAP1 pathway is suggested to be involved in the obtainment stemness characteristics in HCCs and cHC-CCs.

Comparison of clinical characteristics of combined hepatocellular-cholangiocarcinoma and other primary liver cancers

BACKGROUND AND AIM

Combined hepatocellular-cholangiocarcinoma (CHC) is a rare liver malignancy. In this study, we compared patient characteristics and outcomes for primary CHC, intrahepatic cholangiocarcinoma (ICC), and hepatocellular carcinoma (HCC).

METHODS

Medical records of patients with tissue-proven CHC (65 cases) treated at the Chang Gung Memorial Hospital between 1991 and 2005 were retrospectively reviewed. These records were compared to records of patients diagnosed with tissue-proven HCC (1985 cases) and ICC (127 cases) during the same period.

RESULTS

Hepatitis B and C are major causes of CHC. CHC patients exhibited greater similarity to HCC than to ICC patients with respect to cirrhotic changes, age, and positive serology for hepatitis B surface antigen and anti-hepatitis C antibody. Survival was related to tumor characteristics and intervention therapies, but not to etiologies.

CONCLUSIONS

The clinical characteristics of CHC are similar to those of HCC, but overall survival is more similar to that of ICC; survival may be related to tumor biology rather than the cause. Multimodal treatment with an initial aggressive therapeutic approach can improve survival.

Prognosis of hepatocellular carcinoma expressing cytokeratin 19: Comparison with other liver cancers

AIM: To investigate whether expressing biliary phenotype predicted poor outcome after the surgical treatment in primary liver cancers.

METHODS: Out of 204 patients that underwent liver resection due to hepatocellular carcinoma (HCC), liver specimens of 70 patients with HCC were evaluated for biliary components by cytokeratin (CK) 19 immunostain (CK19^- HCC and CK19⁺ HCC). CK19 positivity was defined as membranous and/or cytoplasmic expression in ≥ 5% of tumor cells with moderate or strong intensity. Patients with other primary liver cancers, such as combined HCC and cholangiocarcinoma (cHCC-CC), intrahepatic cholangiocarcinoma (ICC) who received curative liver resection, were also included in the study. Clinical characteristics of CK19^- HCC and CK19⁺ HCC patients, including survival outcome after curative liver resection, were compared with that of cHCC-CC and ICC patients.

RESULTS: The overall survival (OS) rate of CK19^- HCC (n = 49) after the curative surgical treatment was 90.7%, and 80.4% at 1 and 5 years after the resection. OS rate of CK19⁺ HCC (n = 21) was 74.3%, 28.9% and OS rate of cHCC-CC (n = 22) was 66.7%, 32.2% at 1 and 5 years after the surgery. For ICC (n = 19), 1 and 5-year-OS rate was 50.2% and 14.3% after the curative resection. The OS rates of CK19⁺ HCC and cHCC-CC were significantly lower than that of CK19^- HCC, but higher than the OS rate of ICC (P = 0.000). There was no statistically significant difference in OS rate between CK19⁺ HCC and cHCC-CC. The disease free survival (DFS) rate of CK19^- HCC was 72.0% and 54.5% at 1 and 3 years after the surgical treatment. DFS rate of CK19⁺ HCC was 53.3%, 34.3% and DFS rate of cHCC-CC was 51.5%, 39.2% at 1 and 3 years after the resection. For ICC, 1 and 3-year-DFS rate was 28.0% and 14.0% after the curative resection. DFS rate of CK19^- HCC was significantly higher than that of ICC (P = 0.017), but marginally higher than DFS rate of either CK19⁺ HCC or cHCC-CC (P = 0.097, P = 0.089, respectively). Predictors of outcome after the surgery of primary liver cancer were pathology of the resected mass, existence of microvascular invasion and accompanying satellite nodule.

CONCLUSION: Primary liver cancers with biliary components tended to show poorer surgical outcome. This suggested that immuno-phenotype of liver cancers was as important as their morphological classification.

Combined hepatocellular carcinoma and cholangiocarcinoma: clinical features, treatment modalities, and prognosis

BACKGROUND

Combined hepatocellular carcinoma and cholangiocarcinoma (cHCC-CC) is an uncommon subtype of primary liver cancer that has rarely been reported in large-scale clinical studies. The aim of this study was to clarify the clinical features, treatment modalities, and prognosis of cHCC-CC.

METHODS

Included in this study were 113 patients who were histologically diagnosed as having Allen type C cHCC-CC, 103 of whom received liver resection, 6 transarterial chemoembolization treatment, 3 radiofrequency ablation, and 1 palliative supportive treatment. Clinicopathologic features and prognosis of 103 cHCC-CC patients after liver resection were compared with those of 6,679 patients with hepatocellular carcinoma (HCC) and 386 patients with intrahepatic cholangiocarcinoma (ICC) who underwent liver resection during the same period.

RESULTS

The proportion of cHCC-CC in primary liver cancers was 1.5 %. The 103 cases of cHCC-CC were characterized by male predominance, infection with hepatitis virus or presence of liver cirrhosis, and elevated alfa-fetoprotein-findings similar to HCC. However, serum CA19-9 elevation, incomplete capsules, and lymph node involvement were similar to ICC. The 1-, 3-, and 5-year overall survival rates after liver resection were 73.9, 41.4, and 36.4 %, respectively, for patients with cHCC-CC versus 77.5, 53.3, and 41.4 % for HCC patients, and 58.0, 29.1, and 22.3 % for ICC patients (χ(2) = 137.5, P < 0.001). Tumor, node, metastasis system stage (hazard ratio 1.27, 95 % confidence interval 1.08-1.49, P = 0.003) and radical liver resection (hazard ratio 0.31, 95 % confidence interval 0.14-0.68, P = 0.004) were independent prognostic factors for overall survival.

CONCLUSIONS

cHCC-CC has biological behavior and prognosis that are intermediate between HCC and ICC. Radical liver resection can provide a better outcome for this uncommon malignancy.

Clinicopathological analysis of 14 patients with combined hepatocellular carcinoma and cholangiocarcinoma

BACKGROUND

Combined hepatocellular carcinoma and cholangiocarcinoma (cHCC-CC) is an uncommon subtype of primary hepatic carcinoma, and its prognosis is poor. This study was undertaken to investigate the prognosis and the clinicopathological characteristics of cHCC-CC, including their possible cellular origin.

METHODS

Among 852 patients with a primary hepatic carcinoma who underwent hepatectomy from January 1998 to April 2008 at our hospital, cHCC-CC was identified in 14 patients. The clinicopathological characteristics of the 14 patients were analyzed retrospectively. The expression of the liver stem cell markers (c-kit, CD90, CD133 and CK19) in the tumor tissue was detected by immunohistochemistry, and the Kaplan-Meier method was used to evaluate survival.

RESULTS

Among the 14 patients, 9 presented with abdominal pain, 3 with anorexia and debilitation, and the remaining two patients were asymptomatic. The mean age was 53.6+/-3.0 (range 38-74) years. Among the included patients, 11 had an elevated serum alpha-fetoprotein level, 13 were infected with hepatitis B virus, 9 had vascular invasion and 1 had lymph node metastasis. The average diameter of the tumors was 9.9+/-1.1 (range 5.0-16.0) cm. The median overall survival time was 7.9+/-1.0 months. In addition, the presence of the liver stem cell markers, c-kit, CD90, CD133 and CK19 was 71.4%, 85.7%, 92.9% and 78.6%, respectively. All four markers were simultaneously expressed in eight cases.

CONCLUSIONS

cHCC-CC has aggressive characteristics and the prognosis is extremely dismal. The high expression of liver stem cell markers in the tumor tissue suggests that these tumors may derive from liver stem cells.

Combined hepatocellular-cholangiocarcinoma had poor outcomes after hepatectomy regardless of Allen and Lisa class or the predominance of intrahepatic cholangiocarcinoma cells within the tumor

BACKGROUND

We evaluated the surgical outcomes of combined hepatocellular-cholangiocarcinoma (CHC) in relation to Allen and Lisa class and the predominance of intrahepatic cholangiocarcinoma (ICC) cells within the tumor.

METHODS

We retrospectively studied 44 patients with CHC who underwent hepatectomy between 1987 and 2010. Clinicopathologic characteristics and surgical outcomes were compared in relation to Allen and Lisa class (33 combined type, 11 mixed type) and the predominance of ICC cells within the tumor (cases in which ICC cells accounted for 50% or less of all cells within the tumor, n = 22; cases in which ICC cells accounted for more than 50%, n = 22).

RESULTS

The survival rate for 42 patients with CHC who underwent curative surgery was 24% at 5 years, and median survival was 15.4 months. According to Allen and Lisa class, the number of cases with portal invasion was far higher in patients with the mixed type than in patients with the combined type. The 5-year survival rates of patients with the combined type and mixed type who underwent curative surgery were 27% and 13%, respectively, showing no statistically significant difference. According to the predominance of ICC cells, there was no difference in clinicopathologic findings between the groups. The 5-year survival rates of patients with ≤50% and >50% ICC cells within the tumor who underwent curative surgery were 21% and 26%, respectively, showing no statistically significant difference.

CONCLUSIONS

CHC had poor outcomes after hepatectomy regardless of Allen and Lisa class or the predominance of ICC cells within the tumor.

Mixed hepatocellular cholangiocarcinoma and intrahepatic cholangiocarcinoma in patients undergoing transplantation for hepatocellular carcinoma

Mixed hepatocellular cholangiocarcinoma (HCC-CC) and intrahepatic cholangiocarcinoma (I-CC) are increasingly being reported in patients with cirrhosis. The aims of this study were (1) to evaluate the incidence, imaging features, and posttransplant outcomes for patients who underwent transplantation for hepatocellular carcinoma (HCC) and were found to have HCC-CC or I-CC in the explant and (2) to compare the outcomes of these patients with those of controls with HCC who were matched (1:3) by the tumor size and the number of nodules in the explant. In the explant specimens of 10 of 302 patients (3.3%) who underwent liver transplantation (LT) for HCC, mixed HCC-CC or I-CC was identified. There were 4 additional incidental cases of HCC-CC. After a median follow-up period of 32 months, 8 of the 14 patients (57%) suffered from tumor recurrence, and the median disease-free survival time was 8 months. The cumulative risk of tumor recurrence was 40% and 70% at 1 and 5 years, respectively, for these 14 patients. When the 4 incidental cases were excluded, the study group with HCC-CC or I-CC (n = 10) had a significantly lower incidence of well-differentiated tumors (11.1% versus 43.3%, P < 0.02) and a higher rate of recurrence (60% versus 16.7%, P = 0.008) in comparison with the control group of patients with HCC (n = 30). The 1- and 5-year cumulative risks of tumor recurrence were 42% and 65%, respectively, in the study group and 10% and 17%, respectively, in the control group (P < 0.002). The actuarial 1- and 5-year patient survival rates without recurrence were also significantly lower in the study group (79% and 32% in the study group and 90% and 62% in the control group, P < 0.03). Dynamic contrast-enhanced computed tomography or magnetic resonance imaging showed progressive contrast enhancement throughout the arterial and portal venous phases without washout in 8 of the 10 patients. In conclusion, HCC-CC and I-CC are associated with a poor prognosis and a high rate of tumor recurrence after LT, and both tumors exhibit radiographic features that are distinct from those observed with HCC.

Clinicopathologic study on combined hepatocellular carcinoma and cholangiocarcinoma: with emphasis on the intermediate cell morphology

Combined hepatocellular carcinoma and cholangiocarcinoma (combined HCC-CC) is a rare subtype of primary liver cancer. We investigated the histopathologic features of transitional or intermediate areas in 21 combined HCC-CCs and immunophenotypes using different hepatic progenitor cell markers (CK7, CK19, c-kit, NCAM, and EpCAM). Major histologic findings of transitional or intermediate areas of 21 combined HCC-CCs included strands/trabeculae of small, uniform, oval-shaped cells with scant cytoplasm and hyperchromatic nuclei embedded within an abundant stroma, small cells with an antler-like anastomosing pattern, and solid nests of intermediate hepatocyte-like cells surrounded by small cells in periphery, in order of frequency. The intermediate area of one tumor was composed predominantly of spindle cells arranged in short fascicles. Immunophenotype of tumor cells with intermediate morphology suggested a progenitor cell origin for this tumor. Clinical findings of combined HCC-CC showed a closer resemblance with those of HCC than those of CC. In univariate analysis, tumor size, TNM stage, and serum alpha-fetoprotein levels showed a significant association with poor patient survival. Serum alpha-fetoprotein level was an independent prognostic indicator in multivariate analysis. In conclusion, an awareness of the clinicopathologic features, specifically the various morphologic features of intermediate areas in this tumor, is essential for prevention of potential misdiagnosis as another tumor.

Pathology of combined hepatocellular-cholangiocarcinoma

Combined hepatocellular-cholangiocarcinoma is a rare primary neoplasm in the liver. It has gained increasing recognition recently, which in part may be due to more extensive sampling of the explants and surgical resection specimens, the diagnostic challenges encountered in the clinical practice, and the yet to be determined clinical outcome, but partly may be attributed to its intriguing histogenesis/cells of origin. This review aims to update combined hepatocellular-cholangiocarcinoma with an emphasis on the pathological diagnosis, including the differential diagnosis and its diagnostic pitfalls, the possible cell of origin of this neoplasm, and its clinical outcome.