Small cholangiolocellular carcinoma that was difficult to distinguish from cholangiocellular carcinoma: a case report

Gradually progressive cholangiolocellular carcinoma: a case report

BACKGROUND

Cholangiolocellular carcinoma (CoCC) is a relatively rare primary liver tumor. We present a literature review and case report of a patient who presented with a slow-growing CoCC that was completely resected after a 5-year follow-up period.

CASE PRESENTATION

The patient was a 66-year-old man with a history of inflammatory thoracic and intra-abdominal pseudo-tumors. He was regularly followed up at our hospital for partial dilation of the pancreatic duct branch located in the body of the pancreas. Five years earlier, computed tomography (CT) demonstrated a small tumor in liver segment 4. Radiological findings were suggestive of hemangioma. Tumor size gradually increased during the 5-year follow-up period. CT scans showed that the tumor had progressed in size from 10 to 20 mm. Positron emission tomography CT revealed an accumulation of fluorodeoxyglucose (standardized uptake value max 5.3) at the tumor site. The tumor exhibited high intensity on T2-weighted and diffusion-weighted images of ethoxybenzyl magnetic resonance imaging. The tumor showed high intensity during the early phase but low intensity during the hepatobiliary phase. Tumor markers were within their respective normal ranges. Suspecting intrahepatic cholangiocarcinoma, left hepatectomy was performed. The tumor was diagnosed as CoCC based on pathological findings. The patient's post-operative course was uneventful. The patient survived for a year, without any recurrence.

CONCLUSIONS

In cases dealing with small tumor sizes, it is difficult to distinguish between CoCC and hemangioma due to their similar radiological findings. Thus, it is important to consider the diagnosis of CoCC in small benign hepatic tumors. As such, follow-up radiological examination is recommended.

Intrahepatic cholangiocarcinoma mimicking a liver abscess

Intrahepatic cholangiocarcinoma masquerading as liver abscess, and presenting with fever, is a very rare situation and should be considered in nonresolving liver abscess. Only few cases were reported in the literature. This entity is characterized by late diagnosis and poor prognosis.

Application of new ultrasound techniques for focal liver lesions

Ultrasonography (US) has the overwhelming advantages of not entailing radiation exposure and being a noninvasive, real-time, convenient, easy-to-perform, and relatively inexpensive imaging modality. It is used as the first-line imaging modality for screening, detection, and diagnosis of focal liver lesions (FLLs) [small hepatocellular carcinomas (HCCs), in particular]. However, with the increasing demand for accurate and early diagnosis of small HCCs, newer radiologic methods need to be explored to overcome certain limitations of US. For example, the imaging is easily negatively affected by the presence of gas, rib cage, and subcutaneous fat, and is insensitive for capturing the subtle but vital information on the blood flow. It was in response to this need that new promising technologies such as contrast-enhanced ultrasound and fusion imaging were introduced for the detection of liver lesions. This paper presents an overview of the epidemiology and mechanisms of the development of HCCs, with an emphasis on the application of US in the diagnosis and treatment of FLLs. The aim of this article is to provide the state-of-the-art developments in the imaging diagnosis of FLLs and evaluation of ablation treatment of early HCCs. By keeping abreast of these recent advances, we hope that doctors and researchers working in the field of diagnosis/treatment of liver diseases will be able to discriminate benign FLLs such as regenerative nodules and focal nodular hyperplasia from HCCs, so as to avoid unnecessary repeated tumor biopsies and overtreatment. In particular, we expect that small HCCs or precancerous nodules (such as dysplastic nodules) can be accurately diagnosed and appropriately treated even at an early stage.

Clinical and pathological characteristics of cholangiolocellular carcinoma

Cholangiolocellular carcinoma (CLC), due to its special cell origin, has dual clinical and radiological features of hepatocellular carcinoma and cholangiocellular carcinoma, and has a relatively good prognosis due to the characteristics of inert growth. Its growth characteristics and clinical characteristics are obviously different from those of traditional intrahepatic cholangiocarcinoma (ICC). Therefore, CLC is a special type of primary liver malignancy. With regard to cell origin, clinical pathology, growth characteristics, and prognosis, CLC is a distinct disease from traditional hepatic cholangiocarcinoma; however, it is often confused with ICC in the relevant research worldwide. In this paper, we review the clinical and pathological characteristics of CLC to raise the attention to this problem and strengthen the relevant research.

A case of intrahepatic cholangiocarcinoma that was difficult to diagnose prior to surgery: A case report

The present study reports a case of mass-forming intrahepatic cholangiocarcinoma (ICC), which mimicked cholangiocellular carcinoma (CoCC) during imaging and a needle biopsy examination. A 51-year-old female with no relevant medical history was referred to the National Defense Medical College hospital with an intrahepatic tumor. Computed tomography demonstrated non-homogeneous enhancement in the early arterial phase and persistent enhancement in the portal and equilibrium phases, together with notable swelling of the para-aortic lymph nodes. Gadolinium-ethoxybenzyl diethylenetriamine-pentaacetic acid-enhanced magnetic resonance imaging revealed low signal intensity in the hepatobiliary phase. The liver tumor and lymph nodes exhibited increased radiotracer uptake (maximum standardized uptake value=14.0) with positron emission tomography. A histological examination of a percutaneous needle biopsy specimen of the liver tumor indicated a diagnosis of CoCC. The patient underwent left hepatectomy and lymphadenectomy. The surgical specimen contained a poorly differentiated adenocarcinoma with anaplastic changes, which was immunohistochemically positive for epithelial membrane antigen (at the luminal membrane), cytokeratins 7 and 19, and negative for α-fetoprotein, hepatocyte-specific antigen, cluster of differentiation 56 and KIT. Based on these histopathological and immunohistochemical findings, the patient was diagnosed with ICC.

A Case of Cholangiolocellular Carcinoma Preoperatively Diagnosed With Typical Imaging Findings

Introduction:

Cholangiolocellular carcinoma (CoCC) is a rare primary liver neoplasm. A recent integrative genomic analysis has revealed that CoCC represents a distinct biliary-derived molecular entity. Several cases of CoCC have been reported so far, but accurate preoperative diagnosis was difficult in most cases.

Case presentation:

We report a case of 70-year-old woman with CoCC. Preoperative imaging findings revealed several typical signs of CoCC (i.e., thick early ring enhancement in the peripheral area of the tumor and its prolongation, vessel penetration through the tumor, no dilatation of the peripheral bile ducts, and dot-/band-like internal enhancement or a target appearance on contrast-enhanced magnetic resonance imaging). We strongly suspected CoCC from these preoperative imaging findings of the tumor and performed extended left hepatectomy. Pathologic diagnosis was CoCC, and the histologic findings such as peripheral highly cellular areas, central abundant hyalinized/edematous fibrotic stroma, and retained Glisson's sheath structures in the tumor, corresponded closely to each preoperative imaging finding. Immunohistochemical study revealed the tumor cells were positive for cytokeratin 7 and epithelial membrane antigen. The postoperative course was uneventful, and the patient is alive without recurrence for 15 months. The prognosis of CoCC is known to be better than that of cholangiocellular carcinoma, indicating the importance of preoperative differential diagnosis of these tumors.

Conclusion:

Even though preoperative diagnosis of CoCC is difficult because of its rarity, cautious investigation of preoperative typical imaging findings can possibly lead to accurate diagnosis of CoCC.