Spontaneous complete necrosis of hepatocellular carcinoma: A case report and review of the literature

Spontaneous vanishing of hepatocellular carcinoma: A case report of an extremely rare incident

One of the very uncommon clinical conditions is the spontaneous remission of tumors, with scarce reports around the world in various types of tumors. Spontaneous remission of hepatocellular carcinoma (HCC) is extremely rare, but it is well documented with a still unclear underlying mechanism. In this case report, we present one of those exceptional incidents of HCC regression with a trial to tackle possible explanations. Our case, which has a history of successfully treated hepatitis C virus, presented with a large infiltrative right lobar mass invading the main portal vein, with markedly elevated alpha fetoprotein (AFP). According to the applied diagnostic and treatment guidelines, the patient was scheduled for conservative management. Although he did not receive any specific treatments for his condition, the mass regressed in size with recanalization of the portal vein and normalization of AFP after 6 months of follow-up and keep the same for the following 3 years. The mechanisms by which spontaneous regression of HCC can occur are still unknown and should be furtherly investigated better to understand the behavior of such aggressive neoplastic disease.

Tumor Microenvironment: Necroptosis Switches the Subtype of Liver Cancer While Necrosis Promotes Tumor Recurrence and Progression

Liver cancer is a heterogeneous group of solid tumors that include mainly epithelial tumors. As with other solid carcinomas, tumor development results from an accumulation of genetic and epigenetic alterations. Hepatocellular carcinoma and intrahepatic cholangiocarcinoma, derived from malignant transformation of hepatocytes and cholangiocytes, respectively, are 2 primary types of liver cancers. However, it has been shown that the same kind of cell can give rise to different types of cancer, depending on manner of cell death in the tumor microenvironment. In a recent animal study, hepatocytes gave rise to both hepatocellular carcinoma and intrahepatic cholangiocarcinoma. Oncogenically activated hepatocytes were shown to give rise to intrahepatic cholangiocarcinoma or hepatocellular carcinoma depending on cell death type of neighboring cells. Hepatocytes within the necroptotic microenvironment gave rise to intrahepatic cholangiocarcinoma; however, hepatocytes harboring the same oncogenic driver gave rise to hepatocellular carcinoma within the apoptotic microenvironment. The hepatic cytokine microenvironment structured by the necroptosis can also switch hepatocellular carcinoma to intrahepatic cholangiocarcinoma independently of the oncogenic drivers. Cell death by necrosis in damaged livers can also lead to development of carcinoma. Cancer cells are known to be resistant to apoptosis as a result of p53 mutation. Therefore, necrosis is the primary cell death pathway in cancer therapy. Necrosis is associated with high levels of angiogenesis, tumor-associated macrophages, and increased inflammation in the tumor microenvironment. Patients with hepatocellular carcinoma or intrahepatic cholangiocarcinoma characterized by necrosis and tumor-associated macrophages have reduced overall survival and recurrence-free survival. Cytotoxicity from anticancer therapy can also lead to accelerated necrosis. The content of cells undergoing necrosis triggers cytokine secretion, which designs cancer progression via inflammatory and noninflammatory pathways. Thus, the tumor microenvironment and manner of cell death (necrosis, apoptosis, or necroptosis) are crucial factors in the development of primary liver cancers and tumor progression.

Feeding Vessel Ablation: A Novel Subsegmental Devascularization Technique for the Treatment of Hepatocellular Carcinoma Located at the Liver Marginal Angle

This pilot clinical study evaluated primarily the efficacy of feeding vessel ablation (FVA) in the treatment of hepatocellular carcinoma (HCC) located at the liver marginal angle (LMA). Nine patients with nine unresectable HCC lesions were prospectively included in this study. The target tumors (mean: 3.0 cm, interquartile range: 2.4-3.6 cm) were located at the LMA (segment 2/3/6) and adjacent to the gastrointestinal tract. Artificial ascites was attempted and failed. Multimode ultrasound technologies, including 2-D and real-time 3-D contrast-enhanced ultrasound, were used to identify the morphology and structure of the feeding vessels for the target tumors. During the treatment, a unipolar cool-tip electrode was used to ablate the feeding vessels, and the target ablation point was set in subsegmental or more distal vessels to induce a downstream ischemia region. Therapeutic outcomes were assessed after FVA, including the rates of technical success, tumor response, local tumor progression (LTP), overall survival (OS) and major complications. Cumulative LTP and OS were estimated with the Kaplan-Meier method. The technical success rate determined immediately after radiofrequency ablation was 7 of 9 (77.8%). Complete response (CR) was achieved in 7 of 7 tumors (100%) at the 1-mo evaluation. During a median follow-up period of 15.6 mo (range: 4.3-53.3 mo), CR remained in 6 of 7 tumors (85.7%), with LTP observed in 1 of 7 tumors (14.3%) 4.7 mo after treatment. The cumulative 1-, 3- and 5-y LTP-free rates were all 83.3%, and the cumulative 1-, 3- and 5-y OS rates were 42.9%, 28.6% and 0%, respectively. No major complications occurred. We concluded that FVA can induce subsegmental devascularization and has the potential to serve as an effective and safe alternative technique for local control of unresectable HCC located at the LMA when artificial ascites fails.

Tumor Lysis Syndrome in Patients With Hepatocellular Carcinoma: A Systematic Review of Published Case Reports

Tumor lysis syndrome (TLS) is a life-threatening oncologic emergency. It is characterized by massive tumor cell death leading to metabolic derangements and multiple organ failure. It is a rare complication of hepatocellular carcinoma (HCC) with only a few cases have been reported in the literature to date.

We collected and summarized published case reports of tumor lysis syndrome in patients with HCC. We also reported one additional case who developed TLS after sorafenib therapy and wrote a clinical vignette. A comprehensive and current search for relevant articles was conducted in Medline and EMbase through May 2018. A systematic review was performed following the guideline of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). 

A total of 28 cases of TLS associated with HCC were enrolled in our review. The median age of included cases was 55.5 years with a male to female ratio of 25:3. The two most common attributed factors of TLS were transcatheter arterial chemoembolization (TACE) (12 cases, 42.9 %) and sorafenib (nine cases, 32.1%). Among enrolled cases, the diameter of the largest tumor was 12 cm. Regarding Barcelona Clinic Liver Cancer (BCLC) staging, seven cases were at least stage A (22.6%), 11 cases were at least stage B (35.5%), and 10 cases were at least stage C (32.3%). The median time of onset of TLS was three days. As for uric acid-lowering agents, nine cases (32.1%) used allopurinol and four cases (14.3%) used rasburicase. Ten cases (35.7%) did not specify the medication prescribed. The overall mortality rate of this cohort was 67.9%.

Compared with patients developing TLS following TACE, patients who had TLS following sorafenib therapy had a later onset of TLS (two days versus seven days, p < 0.001) and a more advanced stage of HCC (p = 0.002). There was a trend toward increased mortality of patients in the sorafenib group in comparison with those in the TACE group (77.8% versus 41.7%, p = 0.18).

The results of this current review suggest that TLS rarely occurs in HCC but carries significantly higher mortality compared to TLS occurring in hematologic malignancies. It may occur shortly after TACE or with a delayed onset following sorafenib therapy. Considering the kaleidoscope of novel therapies and diverse pathogenesis of HCC, it is crucial for clinicians to recognize the clinicolaboratory derangements suggestive of TLS and initiate appropriate management. The present review highlights the need for clinicians to consider TLS within differentials when caring for patients with HCC.

Spontaneous regression of lung metastases in hepatocellular carcinoma: A case report

•

The prognosis of patients with advanced HCC remains poor even if appropriate treatments are administered.

•

Spontaneous regression of lung metastases of hepatocellular is a rare condition.

•

We discuss the mechanism for spontaneous regression of multiple pulmonary recurrences of hepatocellular carcinoma.

Introduction

Spontaneous regression of hepatocellular carcinoma (HCC) is a rare condition. However, although there have been multiple reports of spontaneous regression, the definitive pathogenic mechanism of this phenomenon is still unclear.

Case presentation

We encountered a case of a 78-year-old man who was undergoing dialysis for end-stage kidney disease with hepatitis C virus-associated chronic hepatitis presenting with HCC. The patient had previously undergone right lobectomy of the liver, but the cancer recurred with multiple lung metastases after 5 months. Approximately 13 months after the initial diagnosis of recurrence, the lung metastases decreased in size and eventually resolved without any anticancer therapy. The patient remains alive for over 41 months after recurrence.

Discussion

Based on our case and literature, Hypoxia with hypotension due to hemodialysis can reduce the blood and oxygen supply of the body, which may lead to the spontaneous regression of the metastatic tumors.

Conclusion

We herein reported a case of spontaneous regression of HCC undergoing dialysis.

A hepatic sclerosed hemangioma with drastic changes in contrast-enhanced ultrasonography

Hepatic sclerosed hemangioma is a rare benign liver tumor that originated from hepatic cavernous hemangioma; however, the process of its formation has been unclear. We herein present the patient of a histologically proven hepatic sclerosed hemangioma that showed drastic changes in diagnostic images in a short period. A 56-year-old man was referred to our hospital for the treatment of suspicious hepatocellular carcinoma with hepatitis C, approximately 2 cm in diameter in liver segment 8. Initially, the tumor manifested as early entire enhancement with mildly delayed washout in contrast-enhanced ultrasonography; however, it manifested as continuous peripheral enhancement with the central non-enhanced area after 1 month in various diagnostic images. He completely quit drinking and smoking 1 month preoperatively. No special symptoms and signs were found to suggest tumor ischemia. Anatomical resection of segment 8 was completed. Histological examination confirmed the final diagnosis of common type hepatic sclerosed hemangioma, derived from atypically enhancing cavernous hemangioma. No signs of impaired blood flow were observed in both diagnostic images and histological examination. Sclerosing changes in hepatic cavernous hemangioma may be completed in a relatively short time with no apparent reason.

Risk Factors of Tumor Recurrence After Liver Transplantation for Combined Hepatocellular Carcinoma and Cholangiocarcinoma

BACKGROUND

Combined hepatocellular carcinoma and cholangiocarcinoma (cHCC-CC) is commonly diagnosed as hepatocellular carcinoma (HCC) preoperatively. Therefore, unexpected recurrence occurs in some patients after liver transplantation (LT). The aim of this study was to identify the risk factors of recurrence.

METHODS

We retrospectively reviewed the data of 20 patients who underwent LT for cHCC-CC from January 2005 to December 2015.

RESULTS

Of the 20 patients, 11 (55%) had concurrent HCC and 10 (50%) had multiple cHCC-CCs. Before LT, 13 patients had undergone transarterial chemoembolization (TACE, n = 9), radiofrequency ablation, and TACE (n = 3) or surgical resection (n = 1). Four of the patients (20%) had the classical type, whereas 16 (80%) had subtypes with stem cell features. Six of the 16 patients (37.5%) with subtypes with stem cell features and 3 of the 4 patients (75%) with the classical type showed recurrence after LT. In multivariate analysis, the classical type was significantly associated with poorer recurrence-free survival (RFS) (hazard ratio [HR]: 8.65, confidence interval [CI]: 1.25-60.05, P = .03) and poorer overall survival (HR: 8.89, CI: 1.37-57.84, P = .02). Spontaneous tumor necrosis also showed significance on RFS (P = .03) among 11 patients with nontreated lesions.

CONCLUSION

In cHCC-CC, the classical type and spontaneous tumor necrosis were associated with recurrence. If these risk factors are found after LT, short-interval follow-up and strategies such as chemotherapy and/or use of mammalian target of rapamycin inhibitors to prevent recurrence are needed.

Complete spontaneous necrosis of hepatocellular carcinoma accompanied by portal vein tumor thrombosis: A case report

INTRODUCTION

We report a rare case of complete spontaneous necrosis of a hepatocellular carcinoma (HCC) accompanied by portal vein tumor thrombosis (PVTT), as confirmed by resection.

CASE PRESENTATION

A 64-year-old man was referred to our hospital for suspected HCC. Contrast-enhanced computed tomography (CECT) findings before admission revealed a 53-mm tumor in the posterior segment of the liver and were suspicious for PVTT in the right posterior PV. Both alpha-fetoprotein (AFP) and proteins induced by vitamin K absence or antagonist-II (PIVKA-II) were elevated at 17,562 ng/mL and 153 mAU/mL, respectively. We diagnosed the findings as HCC with PVTT. Seven days after the first CECT scan, we performed CECT volumetry, which revealed that the tumor had regressed to 30 mm, along with regression of the PVTT. We performed portal vein ligation (PVL), and 10 days later, CECT revealed that the tumor had shrunk to 20 mm. AFP and PIVKA-II levels were 643 ng/mL and 14 mAU/mL, respectively. We suspected spontaneous regression of the patient's HCC, but performed a hepatectomy. Histopathology revealed a 22-mm tumor with a thin fibrous capsule and a tumor thrombus in the PV. Trabecular and pseudoglandular structures consisting of denucleated HCC epithelial cells made up both the tumor and thrombus, and the finding confirmed the spontaneous necrosis of HCC.

CONCLUSIONS

We present an extremely rare case of complete spontaneous necrosis of HCC with PVTT. When spontaneous necrosis is suspected, surgery should be considered because of the potential risk of residual viable cancer cells.

Radiogenomics of hepatocellular carcinoma: multiregion analysis-based identification of prognostic imaging biomarkers by integrating gene data-a preliminary study

Our objective was to identify prognostic imaging biomarkers for hepatocellular carcinoma in contrast-enhanced computed tomography (CECT) with biological interpretations by associating imaging features and gene modules. We retrospectively analyzed 371 patients who had gene expression profiles. For the 38 patients with CECT imaging data, automatic intra-tumor partitioning was performed, resulting in three spatially distinct subregions. We extracted a total of 37 quantitative imaging features describing intensity, geometry, and texture from each subregion. Imaging features were selected after robustness and redundancy analysis. Gene modules acquired from clustering were chosen for their prognostic significance. By constructing an association map between imaging features and gene modules with Spearman rank correlations, the imaging features that significantly correlated with gene modules were obtained. These features were evaluated with Cox's proportional hazard models and Kaplan-Meier estimates to determine their prognostic capabilities for overall survival (OS). Eight imaging features were significantly correlated with prognostic gene modules, and two of them were associated with OS. Among these, the geometry feature volume fraction of the subregion, which was significantly correlated with all prognostic gene modules representing cancer-related interpretation, was predictive of OS (Cox p  =  0.022, hazard ratio  =  0.24). The texture feature cluster prominence in the subregion, which was correlated with the prognostic gene module representing lipid metabolism and complement activation, also had the ability to predict OS (Cox p  =  0.021, hazard ratio  =  0.17). Imaging features depicting the volume fraction and textural heterogeneity in subregions have the potential to be predictors of OS with interpretable biological meaning.

Spontaneous regression of hepatocellular carcinoma: A mini-review

Spontaneous tumor regression is an extremely rare phenomenon in the oncology field. However, there are several case reports resulted in the regression of hepatocellular carcinoma (HCC) and the accumulation of clinical information and analyses of the mechanism can contribute to the development of a novel therapy. For this purpose, we have carefully reviewed 23 cases of spontaneously regressed HCC published in recent 5 years and our case. The information regarding the tumor size, tumor marker, treatments, etc., have been summarized. The mechanism of spontaneous regression has been discussed to date and presumed to be due to many factors, including hypoxia and immunological reactions. In this careful review of the 24 cases based on the clinical information, hypoxia, systemic inflammation, and both upon spontaneous regression were seen in 3, 8, and 4 cases, respectively among the 15 cases for which the information regarding the proposed mechanisms are available. Recent development of immunotherapeutic approaches in oncology shows promising results, therefore, accumulation of additional cases and analysis of mechanisms underlying the spontaneous regression of HCC are essential and could lead to the development of a new generation of immunotherapies including antibodies directed against immune reactions.

Complete spontaneous necrosis of hepatocellular carcinoma confirmed on resection: A case report

•

Spontaneous necrosis of hepatocellular carcinoma without any pretreatment or angiography is extremely rare.

•

Spontaneous necrosis of HCC was highly suspected given the history of alcoholic hepatitis, based on the elevation of AFP and the CT findings.

•

The mechanisms of spontaneous regression are still unclear.

•

Recurrence after regression or viable malignant cells in resected specimen are reported.

•

The ideal management strategy for this disease is surgical intervention if the liver function is acceptable.

Introduction

Complete spontaneous necrosis of hepatocellular carcinoma (HCC) without any pretreatment or angiography is rare. We present a rare case of spontaneous complete necrosis of HCC, as confirmed after hepatectomy.

Presentation of case

The patient, a 74-year-old man with a history of alcoholic hepatitis, was referred to our hospital for confirmation of suspected HCC. In March 2015, abdominal ultrasonography detected a low echoic mass in segment 8 (S8) of the liver. Contrast-enhanced computed tomography (CT) imaging revealed interval growth of this tumor and showed that the tumor was well enhanced in the arterial phase and washed out in the portal and delayed phases. The serum alpha-fetoprotein level was elevated at 30.8 ng/mL and the percentage of the L3 isoform was 25.5%. Two months later, CT imaging showed that the tumor was of low density and had decreased in size; no contrast enhancement of the tumor was seen. Spontaneous necrosis of the HCC was considered; however, as we could not exclude viable malignant cells in the tumor, we performed S8 segmentectomy of the liver. The resected tumor specimen had a thick fibrous capsule. Histopathological findings showed only granulation and necrotic tissue accompanied by bleeding and hemosiderosis. No viable tumor cells were observed. The serum alpha-fetoprotein level returned to the normal range one month after surgery.

Discussion

If spontaneous regression has occurred, there is a possibility of HCC recurrence and of remnant viable tumor cells.

Conclusion

We present a rare case of complete spontaneous necrosis of HCC and strongly recommended surgical intervention.