Combined hepatocellular-cholangiocarcinoma: a case report

State-of-the-art MR Imaging of Uncommon Hepatocellular Tumours: Fibrolamellar Hepatocellular Carcinoma and Combined Hepatocellularcholangiocarcinoma

BACKGROUND

Fibrolamellar Carcinoma (FLC) and Combined Hepatocellular- Cholangiocarcinoma (CHC) are rare primary liver tumours, which are related to different clinical settings. In both tumours, correlation with clinical data and laboratory tests are extremely important.

DISCUSSION

Typically, FLC is diagnosed in young patients without any chronic disease and with normal biochemical tests, whereas CHC arises in cirrhotic patients with elevated tumour markers: AFP and/or CA 19-9. The review describes epidemiology, aetiology, pathogenesis, radiological features and treatment of these tumours. Imaging features typical for FLC are: The presence of central scar, calcifications, the large size, heterogeneous and early contrast-enhancement.

CONCLUSION

The diagnosis of CHC may be suggested in case of elevation of both AFP and CA 19- 9 or inconsistency between elevated tumour markers and imaging findings (i.e., elevated CA 19-9 and radiological features of HCC, or elevated AFP with imaging findings characteristic of ICC).

Positive expression of Midkine predicts early recurrence and poor prognosis of initially resectable combined hepatocellular cholangiocarcinoma

Background

Post-surgical prognosis is usually poor for combined hepatocellular cholangiocarcinoma (CHCC-CC), a rare primary liver cancer. Although midkine (MK) is a prognostic biomarker for several known cancers, it is not known whether it can be used as such in resectable CHCC-CC. This study examined whether MK expression can predict recurrence and survival in patients with resectable CHCC-CC.

Methods

We retrospectively enrolled 52 patients with resectable CHCC-CC who had received curative hepatic resections. MK expression was assessed in post-surgical immunohistochemical studies of specimens in paraffin blocks. Clinical outcomes were analyzed from medical records.

Results

Two-year disease-free and three-year overall survival rates were 42.1% and 44.6%. MK was expressed in 30 patients. Univariate analysis showed patients positively expressing MK had a significantly poorer 2-year disease free and three-year overall survival. Multivariate analysis found positive MK expression independently predicted recurrence.

Conclusions

Positive expression of MK predicts poor prognosis in patients with resectable CHCC-CC.

Biphenotypic hepatic tumors: imaging findings and review of literature

PURPOSE

To describe imaging findings in biphenotypic hepatic tumors (BPT) and a proposal for new imaging classification based on contrast-enhanced imaging.

METHODS

Retrospective review of CT, MRI, PET/CT, and ultrasound findings in 39 patients with histologically confirmed BPT was performed. Tumor markers including AFP, L3 fraction, CA 19.9, CA 125, and CEA were recorded. Based on the dynamic enhancement features, BPT were categorized into 4 enhancement patterns (Types 1-4). Enhancement patterns were correlated with other imaging findings and tumor markers. Imaging features and tumor markers that were not consistent with diagnosis of hepatocellular carcinoma or intrahepatic cholangiocarcinoma based on enhancement pattern were considered discordant findings.

RESULTS

Enhancement patterns in 29 patients (CT/MR) included 23 Type 2 (continuous peripheral rim of late arterial hyperenhancement with washout or fade in portal venous and/or delayed phases, ±delayed central enhancement) and 2 of each Types 1, 2, and 3. Discordant imaging findings were present in two patients with Type 2 pattern and in one patient with Type 1 pattern. Both AFP and CA 19.9 were elevated in 15 of 33 of patients. Tumor markers AFP and CA 19.9 were discordant in 17 of 21 patients with Type 2 pattern, two of two patients with Type 3 pattern. Most BPTs were markedly PET avid with average SUV max of 8.2. Most frequent ultrasound appearance is peripheral hypoechogenicity and central hyperechogenicity.

CONCLUSIONS

BPT most commonly present with imaging features similar to cholangiocarcinoma or metastases. BPT can be suggested when imaging findings or tumor markers are discordant with the most likely diagnosis based on enhancement pattern.

Current update on combined hepatocellular-cholangiocarcinoma

Combined hepatocellular-cholangiocarcinoma is a rare but unique primary hepatic tumor with characteristic histology and tumor biology. Recent development in genetics and molecular biology support the fact that combined hepatocellular-cholangiocarcinoma is closely linked with cholangiocarcinoma, rather than hepatocellular carcinoma.

Combined hepatocellular cholangiocarcinoma tends to present with an more aggressive behavior and a poorer prognosis than either hepatocellular carcinoma or cholangiocarcinoma. An accurate preoperative diagnosis and aggressive treatment planning can play crucial roles in appropriate patient management.

Combined hepatocellular carcinoma-cholangiocarcinoma: report of MR appearance in eleven patients

PURPOSE

To describe the magnetic resonance imaging (MRI) appearance of hepatic combined hepatocellular-cholangiocarcinoma (cHCC-CC) in 11 patients.

MATERIALS AND METHODS

The database of the Department of Pathology was cross-referenced with the MRI database to identify patients with confirmed cHCC-CC who had undergone MRI. Eleven consecutive patients were included (seven female, mean age 57.6 years). All patients were Caucasian. Five of 11 had a clinical history of chronic liver disease. Two radiologists retrospectively analyzed the images in consensus.

RESULTS

cHCC-CC was a single mass in 10/11 patients. Margins were well-defined in 6/11. All tumors showed heterogeneous hyperintensity on T2. On postcontrast imaging, 6/11 showed early ring-enhancement (four noncirrhotic), with progressive enhancement in central portions, and 5/11 patients showed a diffuse heterogeneous early enhancement. Three of these five were cirrhotic and displayed partial washout with portions of contrast retention on later phases. Other findings included: late capsule enhancement (two patients), biliary dilatation (one), venous invasion (three), lymphadenopathy (six), and findings of cirrhosis (five).

CONCLUSION

cHCC-CC presents most commonly as a single mass. Five of 11 had MR findings of cirrhosis. Clues to the diagnosis were moderately high signal on T2, portions of tumor that show progressive enhancement/contrast retention, and frequent lack of capsule. Early enhancement patterns included early ring-enhancement and diffuse heterogeneous enhancement.

Combined hepatocellular and cholangiocellular carcinoma presenting with radiological characteristics of focal nodular hyperplasia

Combined hepatocellular and cholangiocellular carcinoma (cHCC-CC) is a rare tumor type containing unequivocal elements of both hepatocellular carcinoma and cholangiocarcinoma that are intimately mixed. Although these tumors are usually considered to be more related to hepatocellular carcinoma than to cholangiocarcinoma, they sometimes, in contrast to hepatocellular carcinoma, contain a significant amount of fibrous stroma. This might in some cases explain atypical radiological features. We report a case of a cHCC-CC in a 47-year-old female that resembled focal nodular hyperplasia on Magnetic Resonance Imaging. Correlation of imaging and serum levels of α-fetoprotein and CA19.9 can help to make the correct diagnosis preoperatively.

Combined hepatocellular cholangiocarcinoma: prognostic factors investigated by computed tomography/magnetic resonance imaging

This study was designed to assess the clinical usefulness of imaging for predicting the prognosis of patients with combined hepatocellular cholangiocarcinoma (cHCC-CC). Between 1999 and 2004, 30 patients with histopathologically proven cHCC-CC underwent computed tomography (CT) or magnetic resonance imaging (MRI). The imaging data and survival were analysed. Univariate log-rank analysis of imaging findings revealed that tumour necrosis, bile duct invasion, major vascular branch invasion, multiplicity, bilobar distribution, regional lymph node involvement, regional organ invasion, distant metastasis and ascites had adverse influences on overall survival. Multivariate Cox proportional hazard analysis demonstrated that major vascular branch invasion, regional organ invasion, nodal and distant metastases were independent prognostic factors that adversely affected overall survival rates. Overall cumulative survival rates at 1, 3 and 5 years were 53%, 26% and 12%, respectively. Analysing the survival of our patients by using clinical stages of the newly updated American Joint Committee on Cancer (AJCC) classification for liver neoplasm based on the imaging findings, we found significant differences between stages I/II and III (p < 0.001) and between stages III and IV (p = 0.040). We conclude CT or MRI can be used to identify the prognostic factors and to estimate the outcomes of patients with cHCC-CC.