Hepatic angiomyolipoma-misdiagnosis as hepatocellular carcinoma: A report of 14 cases

Huge Hepatic Angiomyolipoma Mimicking Low Grade Hepatocellular Carcinoma

A 41-year-old man was diagnosed with a huge symptomatic liver mass and was referred to our hospital for liver biopsy and further evaluation. He presented with right upper quadrant tenderness. Enhanced abdominal computed tomography and magnetic resonance imaging revealed a 12.5-cm relatively well-defined heterogeneous enhancing mass in the right inferior liver with a large exophytic component containing a fat component and progressive delayed enhancement. The patient underwent right inferior sectionectomy. The pathological diagnosis was confirmed as angiomyolipoma, 12.3×9.2×5.0 cm in size, with tumor necrosis in 20% of the tissue. Hepatic angiomyolipoma is known as a benign tumor, but in our case, because of the large tumor size and coagulative necrosis, this tumor had malignant potential; surgical resection was deemed to be appropriate, and close follow-up monitoring was essential postoperatively.

Giant hepatic angiomyolipoma: a case report

Hepatic angiomyolipoma (AML) is a rare mesenchymal tumour with an undetermined malignant potential. Clinical symptoms are non-specific. The radiological hallmarks are high vascularization of lesion and presence of macroscopic fat. The proportion of fatty tissue varies significantly and discrepancies between pre-operative imaging and histological findings are observed in more than 50% of cases. Visualization of the draining vein may aid in differentiation between AML and hepatocellular carcinoma with abundant fatty component. Biopsy is indicated in ambiguous cases. Presence of clinical symptoms warrants surgical treatment. We present a clinical case of giant hepatic AML, discuss its typical features and treatment options.

Hepatic angiomyolipoma: differential diagnosis from other liver tumors in a special reference to vascular imaging - importance of early drainage vein

A 51-year-old female had been diagnosed with a hemangioma in the hepatic segment 6 (S6). After a 6-year follow-up, enlargement of the tumor was detected. The tumor was clearly enhanced in the arterial phase, and the enhancement remained in the portal phase on computed tomography (CT). Although the primary differential diagnosis on CT was hepatocellular carcinoma (HCC), we worried about the possibility of other vessel system tumors because the tumor remained to be enhanced at the portal phase for HCC and all tumor markers of HCC were negative. We performed angiography to determine the tumor nature and to seek other tumors. Angiography showed tumor stain at the hepatic S6 with an early obvious drainage vein from the tumor flowing through the right hepatic vein into the inferior vena cava. In addition to tumor stain and the drainage vein, there were many small poolings of contrast medium in the whole liver, which were suspected as dilatation of the hepatic peripheral artery. We suspected the tumor as a benign tumor such as hepatocellular adenoma or focal nodular hyperplasia, but the possibility of HCC could not be ruled out. Hepatic posterior sectionectomy was done to completely remove the drainage vein with the tumor. Intraoperative histological examination revealed the tumor as not malignant and not HCC. Later, immunohistochemical analysis uncovered that the tumor had high expression of HMB-45 and, therefore, the final diagnosis was angiomyolipoma. We think that detecting an early drainage vein from the tumor would be a key point for diagnosing hepatic angiomyolipoma.

Diagnosis and treatment of hepatic angiomyolipoma

BACKGROUND

Hepatic angiomyolipoma (HAML) is a rare liver tumor. This paper summarized the clinical, radiological and pathological features of HAML.

METHODS

Seventeen cases of HAML were analyzed retrospectively. All patients were subjected to surgical resection of tumor, one of which was performed emergency surgery because of hemorrhage of tumor.

RESULTS

There are 13 females and 4 males, most of whom were asymptotic except 4 had minimal abdominal discomfort. US, CT and/or MRI were taken and corresponding data was comprehensively analyzed with other clinical signs and symptoms. Correct preoperative diagnosis was able to be achieved in 9 patients. Pathological analysis and immunohistochemistry of HMB-45 was used as final diagnosis. All patients were followed up and survived without recurrence.

CONCLUSIONS

Preoperative diagnosis of HAML can be benefited from comprehensive analysis of clinical manifestations. The malignant potential and fast growth of tumor suggested surgical removal of tumor while it was diagnosed.

Inflammatory angiomyolipoma of the liver: an unusual case suggesting relationship to IgG4-related pseudotumor

Hepatic angiomyolipoma (AML) is rare. Based on its wide histomorphological range, several distinctive histological variants have been delineated. However, hepatic AML displaying predominantly or exclusively inflammatory pattern closely mimicking inflammatory pseudotumor (IPT) is exceptionally rare with only 7 cases reported so far. We herein describe a new case of hepatic inflammatory AML in a 51-year-old woman who presented with unexplained constitutional symptoms suggesting an infectious disease. A liver mass was detected during imaging examination and resected (4.3 cm in maximum diameter). The patient's symptoms resolved completely after surgery. Currently, she is alive and well 7 years after surgery. She has no evidence of other organ manifestations of IgG4-related systemic disease. The tumor displayed a pure IPT-like histological pattern with dense infiltrates of plasma cells, lymphocytes and histiocytes admixed with scattered few adipocytes, irregularly distributed thick-walled vessels (some of them showed obliterative phlebitis) as well as aggregates and fascicles of histiocytoid and spindle-shaped myoid cells that were immunoreactive for HMB45 and Melan A with focal expression of alpha smooth muscle actin. Lesional cells were negative for desmin, protein S100, CD21, CD23, CD15, CD30, HepPar-1, pankeratin (KL-1), ALK1, and EBV in situ hybridization (EBER). The surrounding liver parenchyma showed striking lymphoplasmacytic non-destructive pericholangitis. Numerous scattered and aggregated IgG4 positive plasma cells were seen within the mass and in the peritumoral inflammatory lesions (mean, 37 cells/HPF; IgG4: IgG ratio = 28%). To our knowledge, this is the first report of hepatic inflammatory AML closely resembling IgG4-related IPT of the liver. A possible role for IgG4 seems likely to explain the peculiar histological features and the unusual clinical presentation in this case.

Hepatic angiomyolipoma: a series of six cases with emphasis on pathological-radiological correlations and unusual variants diagnosed by core needle biopsy

Hepatic angiomyolipoma is rare and may pose differential diagnostic difficulty, particularly if encountered in core needle biopsy. We studied 6 cases from 5 males and one female (median age, 48.6 yrs). All presented with non-specific symptoms or an incidentally discovered tumor mass. Two patients had a remote history of chemotherapy for hematological neoplasms (acute lymphoblastic leukemia and Hodgkin lymphoma respectively) and another had clear cell renal cell carcinoma and anaplastic pancreatic carcinoma diagnosed at autopsy without definable syndrome. None of the patients had evidence of the tuberous sclerosis complex or renal or other extra-renal angiomyolipoma. Three tumors were resected completely and three have been only biopsied and followed up. None of the resected cases recurred at a mean follow-up of 35 months. Histologically, tumors were classified as classical triphasic (1), lipomatous (2), epithelioid/oncocytoid (1), epithelioid trabecular (1) and myelolipoma-like (1). The adjacent liver parenchyma was normal in 3 cases, showed pigment cirrhosis in one case and mild fatty change in another case. One case had clinically diagnosed but histologically unverified cirrhosis. The initial diagnostic impression/frozen section was misleading in 5 of the cases and included vascular lesion, focal fatty change, myelolipoma, hepatocellular tumor and oncocytic neoplasm. All tumors expressed HMB45 and variably desmin. One epithelioid lesion expressed HMB45 and TFE3, but lacked desmin expression. In conclusion, hepatic angiomyolipomas are increasingly recognized as incidental findings during surveillance for cirrhosis or investigations for unrelated conditions. Awareness of their diverse morphological spectrum in liver biopsy is necessary to avoid misdiagnosis as hepatocellular carcinoma, metastatic melanoma or other malignant neoplasms.

A case of hepatic angiomyolipoma which was misdiagnosed as hepatocellular carcinoma in a hepatitis B carrier

We report a rare case of resected hepatic AML, which was misdiagnosed as hepatocellular carcinoma in a chronic hepatitis B carrier. A 45-year-old woman who was a carrier of hepatitis B virus infection presented with a hepatic tumor. Her serum alpha-fetoprotein level was normal. Ultrasonography revealed a round and well-circumscribed echogenic hepatic tumor measuring 2.5 cm in the segment VI. On contrast-enhanced computed tomography, a hypervascular tumor was observed in the arterial phase and washing-out of the contrast medium in the portal phase and delayed phase. On MR T1-weighted in-phase images, the mass showed low signal intensity, and on out-of-phase images, the mass showed signal drop and dark signal intensity. On MR T2-weighted images, the mass showed high signal intensity. The mass demonstrated high signal intensity on arterial phase after contrast injection, suggestive of hepatocellular carcinoma. The patient underwent hepatic wedge resection and histopathological diagnosis was a hepatic angiomyolipoma.

Hepatic angiomyolipoma: a clinical experience in diagnosis and treatment

BACKGROUND

Hepatic angiomyolipoma is a rare mesenchyme-derived neoplasm often misdiagnosed as hepatocellular carcinoma, and the treatment for it remains controversial.

AIMS

To develop the optimal preoperative diagnoses means and treatment modalities of hepatic angiomyolipoma.

METHODS

Retrospective analysis of the clinical features, treatment, and prognostic data of 17 hepatic AML patients admitted to Chinese People's Liberation Army Generation Hospital between 1996 and 2006.

RESULTS

Most hepatic angiomyolipoma were solitary. The overall preoperative diagnostic rate was 18% and the most common misdiagnosis was hepatocellular carcinoma (10/17, 59%). In three patients, observation was performed for 2-3 years before being admitted. The tumors increased 1-9 cm in size in all patients. All of the 17 patients finally received various liver resection procedures, and postoperative mortality and morbidity was 0 and 12% (2/17). After a median follow-up period of 73 months, the tumor recurred only in one patient 9 years post-operatively.

CONCLUSIONS

Hepatic angiomyolipoma should be suspected in liver tumor patients with normal α-fetoprotein levels and no concomitant hepatitis. Preoperative MRI combined with percutaneous fine-needle biopsy should be the diagnostic methods of choice. Small hepatic AML proved through pathologic examination (<5 cm) may be managed by observation with close follow-up, but surgery is indicated in patients suffering from large tumors or significantly larger tumors during follow-up.

Management of hepatic angiomyolipoma

Preoperative diagnosis of hepatic angiomyolipoma is difficult, and the treatment for it remains controversial. The aim of this study is to review our experience in the treatment of hepatic angiomyolipoma and to propose a treatment strategy for this disease. We retrospectively collected the clinical, imaging, and pathological features of patients with hepatic angiomyolipoma. Immunohistochemical studies with antibodies for HMB-45, actin, S-100, cytokeratin, vimentin, and c-kit were performed. Treatment experience and long-term follow-up results are summarized. During a period of 9 years, 10 patients with hepatic angiomyolipoma were treated at our hospital. There was marked female predominance (nine patients). Nine patients received surgical resection without complications. One patient received nonoperative management with biopsy and follow-up. One patient died 11 months after surgery because of recurrent disease. We propose all symptomatic patients should receive surgical resection for hepatic angiomyolipoma. Conservative management with close follow-up is suggested in patients with asymptomatic tumors and meet the following criteria: (1) tumor size smaller than 5 cm, (2) angiomyolipoma proved through fine needle aspiration biopsy, (3) patients with good compliance, and (4) not a hepatitis virus carrier.

Hepatic angiomyolipoma with trace amounts of fat: a case report and literature review

Hepatic angiomyolipoma (AML), a rare benign mesenchymal tumour, is characterised by the presence of mature adipose tissue, smooth-muscle cells and thick-walled blood vessels. Increasing attention to hepatic AMLs has led to the discovery that sufficient proportions of fat often allow for definite diagnoses preoperatively. However, the proportion of fatty tissue in these tumours is highly variable. One case of hepatic AML is reported, where the amount of fat was <1%. In this case, the viral hepatitis markers, including hepatitis B antigen and anti-hepatitis C virus antibody, were negative. The serum alpha-fetoprotein level was 3.4 ng/ml and in the normal range. Abdominal ultrasonography showed a hypoechoic mass measuring 5 cm in diameter and without an obvious capsule in the left lobe of the liver. A dynamic computed tomography scan showed a well-defined and slightly enhanced mass in the medial segment of the left lobe of the liver. Angiography showed that the mass was hypervascular in character. As hepatocellular carcinoma was highly suspected from these preoperative image studies, a left lobectomy was carried out. Microscopically, the amount of fat was too low to establish a diagnosis of hepatic AML. However, positive homatropine methylbromide 45 immunoreactivity of the smooth-muscle cells seemed to assist in arriving at the diagnosis.

Extrarenal retroperitoneal angiomyolipoma: management of a rare benign tumour

BACKGROUND

Extrarenal retroperitoneal angiomyolipomas are benign tumours of mesenchymal tissue origin. The diagnosis of these tumours is usually based on the perioperative findings and confirmed by the resultant specimen's histology. The main differential diagnosis is liposarcoma, and accurate preoperative imaging combined with fine-needle aspiration cytology may permit a non-operative approach to these tumours.

CASE PRESENTATION

We describe a single case of extrarenal retroperitoneal pelvic angiomyolipoma and provide the first case of magnetic resonance imaging of these extremely rare tumours.

CONCLUSION

This article discusses the presentation, management, and outcome associated with these tumours.

Signal transduction of gap junctional genes, connexin32, connexin43 in human hepatocarcinogenesis

AIM

To investigate gap junctional intercellular communication (GJIC) in hepatocellular carcinoma cell lines, and signal transduction mechanism of gap junction genes connexin32(cx32),connexin43(cx43) in human hepatocarcinogenesis.

METHODS

Scarped loading and dye transfer (SLDT) was employed with Lucifer Yellow (LY) to detect GJIC function in hepatocellular carcinoma cell lines HHCC, SMMC-7721 and normal control liver cell line QZG. After Fluo-3AM loading, laser scanning confocal microscope (LSCM) was used to measure concentrations of intracellular calcium (Ca(2+))i in the cells. The phosphorylation on tyrosine of connexin proteins was examined by immunoblot.

RESULTS

SLDT showed that ability of GJIC function was higher in QZG cell than that in HHCC and SMMC-7721 cell lines. By laser scanning confocal microscopy, concentrations of intracellular free calcium (Ca(2+))i was much higher in QZG cell line (108.37 nmol/L) than those in HHCC (35.13 nmol/L) and SMMC-7721 (47.08 nmol/L) cells. Western blot suggested that only QZG cells had unphosphorylated tyrosine in Cx32 protein of 32 ku and Cx43 protein of 43 ku; SMMC-7721 cells showed phosphorylated tyrosine Cx43 protein.

CONCLUSION

The results indicated that carcinogenesis and development of human hepatocellular carcinoma related with the abnormal expression of cx genes and disorder of its signal transduction pathway, such as decrease of (Ca(2+))i, post-translation phosphorylation on tyrosine of Cx proteins which led to a dramatic disruption of GJIC.

The analysis of γ-glutamyl transpeptidase gene in different type liver tissues

AIM: To probe the value of γ-glutamyl transpeptidase (GGT) messenger RNA in monitoring canceration of liver cells and for early diagnosis of hepatocellular carcinoma (HCC), by researching the types of GGT messenger RNA (GGTmRNA) in liver tissues and peripheral blood of different hepatopathy.

METHODS: The three types of GGTmRNA (A, B, C) in liver tissues and peripheral blood from the patients with HCC, noncancerous hepatopathy, hepatic benign tumor, secondary carcinoma of liver, and healthy persons were detected by reverse-transcription polymerase chain reaction (RT-PCR).

RESULTS: (1) In normal liver tissues, type A was predominantly found (100.00%), type B was not found, type C was found occasionally (25.00%); (2) The distribution of types of GGTmRNA in liver tissues with acute hepatitis, chronic hepatitis, cirrhosis, alcoholic hepatopathy was similar as in normal liver tissues (P > 0.05), but type B was found in 3 of 18 patients with chronic hepatitis (16.67%), and also in 3 of 11 patients with cirrhosis (27.27%); (3) There was no significant difference of types of GGTmRNA between liver tissues with hepatic benign tumor, secondary carcinoma of liver and normal liver tissues (P > 0.05); (4) Type B was predominant in cancerous tissues with HCC (87.5%), the prevalence of type B in cancerous tissues was significantly higher than that in normal liver tissues (0/12) (P < 0.05), but the prevalence of type A in cancerous tissues (46.88%) was significantly lower than that in normal liver tissues (100.00%) (P < 0.05), and the prevalence of type C (6.25%) in cancerous was the same as that in normal liver tissues (25.00%) (P > 0.05). In noncancerous tissues of livers with HCC, the main types were type A and type B, the prevalence of type A (85.71%, 90.48%) and type C (14.29%, 9.52%) in noncancerous tissues of liver with HCC was similar as that in normal liver tissues (A: 100.00%; C: 25.00%) (P > 0.05), but the prevalence of type B (80.95%, 76.19%) in noncancerous tissues of livers with HCC was significantly higher than that in normal liver tissues (0/12) (P < 0.05); (5) The prevalence of type B (37.5%) in peripheral blood with HCC was higher than that in normal person (0/12) (P < 0.05). In peripheral blood, type B was found in 4 of 11 cases of HCC with serum AFP negative.

CONCLUSION: The shift of types of GGTmRNA from A to B in liver tissues may be closely related to the development of HCC, and the analysis of GGT gene may provide a useful tool for early diagnosis of HCC.

Expression of gap junction genes connexin32 and connexin43 mRNAs and proteins, and their role in hepatocarcinogenesis

AIM

To investigate the relationship between hepatocarcinogenesis and the expression of connexin32 (cx32), connexin43 (cx43) mRNAs and proteins in vitro.

METHODS

Gap junction genes cx32 and cx43 mRNA in hepatocellular carcinoma cell lines HHCC, SMMC-7721 and normal liver cell line QZG were detected by in situ hybridization (ISH) with digoxin-labeled cx32, and cx43 cDNA probes. Expression of Cx32 and Cx43 proteins in the cell lines was revealed by indirect immuno-fluorescence and flow cytometry (FCM).

RESULTS

Blue positive hybridization signals of cx32 and cx43 mRNAs detected by ISH with cx32 and cx43 cDNA probes respectively were located in cytoplasm of cells of HHCC, SMMC-7721 and QZG. No significant difference of either cx32 mRNA or cx43 mRNA was tested among HHCC, SMMC-7721 and QZG (P=2.673, HHCC vs QZG; P=1.375, SMMC-7721 vs QZG). FCM assay showed that the positive rates of Cx32 protein in HHCC, SMMC-7721 and QZG were 0.7%, 1.7% and 99.0%, and the positive rates of Cx43 protein in HHCC, SMMC-7721 and QZG were 7.3%, 26.5% and 99.1% respectively. Significant differences of both Cx32 and Cx43 protein expression existed between hepatocellular carcinoma cell lines and normal liver cell line (P=0.0069, HHCC vs QZG; P=0.0087, SMMC-7721 vs QZG). Moreover, the fluorescent intensities of Cx32 and Cx43 proteins in HHCC, SMMC-7721 were lower than that in QZG.

CONCLUSIONS

Hepatocellular carcinoma cell lines HHCC and SMMC-7721 exhibited lower positive rates and fluorescent intensities of Cx32, Cx43 proteins compared with that of normal liver cell line QZG. It is suggested that lower expression of both Cx32 and Cx43 proteins in hepatocellular carcinoma cells could play pivotal roles in the hepatocarcinogenesis. Besides, genetic defects of cx32 and cx43 in post-translational processing should be considered.