Late supra-diaphragmatic lymph node recurrence following resection of a fibrolamellar hepatocarcinoma: an unusual case

CT and MRI of primary and metastatic fibrolamellar carcinoma: a case series of 37 patients

OBJECTIVE

Fibrolamellar carcinoma (FLC) is a rare disease, with limited radiographic reported information. We assessed the imaging patterns of primary and metastatic FLC.

METHODS

CT and MR examinations of patients with FLC were retrospectively reviewed. Imaging features were assessed for primary and recurrent liver tumours, including dimension, enhancement characteristics, and presence or absence of central scars. Locations of nodal and extranodal metastases were also recorded.

RESULTS

Of 37 patients (18 males and 19 females; average age, 23.5 years) with FLC, 24 had imaging of their primary tumour; 13 had metastases at presentation and 7 developed metastases on follow-up. The remaining 13 patients had follow-up imaging of metastatic disease. Primary FLC had a mean diameter >11 cm, with central scars in ten (46%) patients. Most tumours enhanced heterogeneously (96%) and showed arterial enhancement (81%). On MRI, 62% of FLCs were hypointense on T1 weighted imaging and 54% were hyperintense on T2 weighted imaging. 13 patients (54%) had nodal metastases at presentation, mostly in the upper abdomen (92%) and commonly in the chest (38%). Extrahepatic metastases were most frequently pulmonary or peritoneal. Predominantly small and homogeneous intrahepatic recurrences were detected on follow-up in 15 patients.

CONCLUSION

FLC often presents as a large hepatic tumour with nodal and distant metastases. Thoracic adenopathy and lung metastases were frequently found in our series, suggesting the need for pre-operative and follow-up chest imaging.

ADVANCES IN KNOWLEDGE

Thoracic nodal and lung metastases are common in FLC; therefore, dedicated chest imaging should be part of the evaluation of a patient with FLC.

Pure and mixed fibrolamellar hepatocellular carcinomas differ in natural history and prognosis after complete surgical resection

BACKGROUND

The purpose of the current study was to describe pure and mixed fibrolamellar hepatocellular carcinoma (FL-HCC).

METHODS

Consecutive patients with pure and mixed FL-HCC were identified from a central pathological review using Edmondson's criteria. Clinical, pathological, and epigenetic characteristics of patients who underwent curative surgery were evaluated. Overall and disease-free survival as well as patterns of disease recurrence were examined. Methylation levels of L1 retrotransposon (LINE-1) repetitive elements and Ras association domain family 1A gene (RASSF1) promoter were also assessed using pyrosequencing.

RESULTS

Forty of 53 patients with a median age of 22 years (range, 9 years-;65 years) met the criteria for analysis. Central pathological review found that 30 patients (75%) had pure and 10 patients (25%) had mixed FL-HCC. Pure FL-HCC typically occurred in patients aged < 30 years. These patients often presented with lymph node metastasis at the time of diagnosis and frequently experienced extrahepatic recurrences (n = 16). Conversely, mixed FL-HCC appeared to resemble to classic HCC, occurring in patients aged > 40 years and frequently involving the liver as the primary site of disease recurrence. With a median follow-up of 7.8 years, the median overall survival from the time of diagnosis in all patients was 6.4 years (range, 3.2 years-12 years). Multivariate analysis found that the risk of death was increased in patients with higher American Joint Committee on Cancer disease stages (P = .003) and those with mixed FL-HCC (P = .03). Methylation analysis of LINE-1 repetitive elements and RASSF1 promoter revealed different methylation levels between pure and mixed FL-HCC, suggesting a different epigenetic background.

CONCLUSIONS

Pure and mixed FL-HCC display distinct clinical presentations and epigenetic backgrounds leading to different prognoses and as such may be regarded as separate clinical entities.