A Rare and Difficult Diagnosis: A Case of Hepatoid Carcinoma of the Gallbladder

Extrahepatic metastasis of hepatocellular carcinoma is usually associated with extensive intrahepatic lesions. Hepatoid adenocarcinoma is a rare variant of extrahepatic malignant adenocarcinoma that exhibits remarkable histological and immunohistochemical similarity to hepatocellular carcinoma, which can result in an underestimated diagnosis. This case report describes a patient with a newly found gallbladder polyp. Following cholecystectomy, the initial histological and immunohistochemical evaluation suggested a metastasis of hepatocellular carcinoma. However, after multiple scans, no primary intrahepatic lesion was found. A subsequent review of the gallbladder specimens showed negative staining for CK7 and CK19, leading to a diagnosis of hepatoid carcinoma of the gallbladder.

Hepatoid prostatic carcinoma with adrenal metastasis and novel genetic alterations

Hepatoid carcinoma (HC) encompasses epithelial extrahepatic tumors exhibiting features of hepatocellular carcinoma (HCC) both by morphology and immunohistochemistry. Distinguishing metastatic HCC from HC may be challenging, particularly when limited material, such as a cytologic specimen, is available. HC from prostatic origin is unusual and has only rarely been characterized by cytology. Herein we present an 86-year-old male with history of castration-resistant prostate cancer developing a left adrenal gland nodule. Fine needle aspiration revealed a poorly differentiated malignant neoplasm diagnosed as metastatic hepatoid prostatic adenocarcinoma based on immunohistochemistry (positive for HepPar1, AFP, NKX3.1, PSMA, and Racemase; and negative for CK7, CK20, cytokeratin 34betaE12, p63, and Arg-1). Because prostatic carcinoma with hepatoid features is rare, and the patient had failed standard therapy, next generation sequencing was performed in an attempt to identify druggable molecular targets. Well-known prostate carcinoma-related alterations were found in three genes (CDK12, AR, and SPOP). In addition, three variants of uncertain significance (DDR2 R128C, SRC P428L, and HNRNPU K574Sfs*32) were identified, which to the best of our knowledge have not been previously reported. Our results support the power of an immunohistochemistry panel including Arg-1 and HepPar1 when HC is suspected, and highlight the value of cytology for comprehensive diagnostic evaluation.

Hepatoid carcinoma and related entities of the extrahepatic bile duct: A clinicopathological study of four cases

Hepatoid carcinoma or related entities (HPC/RTs) are extremely rare, especially in the extrahepatic bile duct (EHBD). Only a few case reports have been published. We analyzed the clinicopathological features of HPCs/RTs in EHBD. HPC/RT of extrahepatic cholangiocarcinoma (eCCA) cases were selected based on the histological characteristics and immunohistochemical detection of spalt-like transcription factor 4 (SALL4) and/or alpha-fetoprotein (AFP). Four HPC/RT cases arose in the distal but not in the perihilar EHBD. The four patients with HPC/RT included one female and three males with a median age of 77 years. There are various macroscopic types of HPC/RT. The predominant histological features were two solid-type carcinomas that mimicked hepatocellular carcinoma and two well-differentiated tubular adenocarcinomas. Immunohistochemically, SALL4 and glypican-3 were expressed in all cases, and AFP was expressed in one case. Cancer cell phenotypes included intestinal, pancreatobiliary, and mixed pancreatobiliary and intestinal types. Focal neuroendocrine differentiation and severe perineural and lymphovascular invasions were also observed. HPC/RT recurred in two patients within 2 years, and one patient died 13 months postoperatively. It is suggested that the HPC/RT of EHBD shares common characteristics with HPC/RT arising in various organs, and has some unique characteristics. HPC/RT of EHBD might be more aggressive than conventional eCCA.

High-grade serous carcinoma of fallopian tube with yolk sac tumor differentiation in a postmenopausal patient

Yolk sac tumors (YSTs) are the second most common germ cell malignancy of the ovaries, generally presenting in children and young women. However, they rarely occur in the fallopian tubes of postmenopausal patients. The current rare case is composed of yolk sac tumor differentiation within high-grade serous carcinoma (HGSC) arising in the fallopian tube of a 68-year-old woman. Serum α-fetoprotein was much higher than normal level. This case exhibited some areas of glandular architecture with positivity for SALL4, AFP, and Glypican-3 and negative staining for PAX8, supporting a germ cell tumor differentiation. By reviewing the published literature, we believe that YSTs, whether or not associated with an epithelial component detected histologically in older patients, constitute a single entity that is different from YSTs in younger patients. Above all, the pathologist must check carefully tissue stained with hematoxylin-eosin especially in postmenopausal women with ovarian, fallopian tube, or endometrial mass and an elevated serum α-fetoprotein level. Neoplasms of this type should be treated aggressively, and should respond to platinum-based chemothotherapy.

Primary hepatoid carcinoma of the ovary: A case report and review of the literature

INTRODUCTION

Hepatoid carcinoma of the ovary (HCO) is a rare disease that originates from the ovarian surface epithelium. It is histologically characterized as hepatocellular carcinoma (HCC) with a hepatocyte-rich granular cytoplasm.

PATIENT CONCERNS

A 65-year-old female patient was admitted with complaints of indigestion, abdominal bloating, and pain.

DIAGNOSIS

The patient showed an elevated level of serum alpha-fetoprotein (AFP) with abdominal bloating and pain. After surgery and histopathology analysis, she was finally diagnosed with HCO, Figo stage IC.

INTERVENTIONS

After cytoreductive surgery, she underwent adjuvant chemotherapy with carboplatin and paclitaxel. Although the disease was diagnosed at an early stage, it recurred 6 months after completion of adjuvant chemotherapy. Elevation of serum AFP level and removal of a mass from the lumbar vertebra confirmed the recurrence of this disease. Subsequently, the patient underwent radiation therapy and palliative chemotherapy.

OUTCOMES

She died 31 months after the diagnosis due to disease progression.

CONCLUSION

The aggressive nature of HCO was clearly observed in this case despite early diagnosis and treatment. Further studies are needed to understand the proper treatment and prognostic factors of HCO.

Morphology and Molecular Features of Rare Colorectal Carcinoma Histotypes

Several histopathological variants of colorectal carcinoma can be distinguished, some associated with specific molecular profiles. However, in routine practice, ninety/ninety-five percent of all large bowel tumors are diagnosed as conventional adenocarcinoma, even though they are a heterogeneous group including rare histotypes, which are often under-recognized. Indeed, colorectal cancer exhibits differences in incidence, location of tumor, pathogenesis, molecular pathways and outcome depending on histotype. The aim is therefore to review the morphological and molecular features of these rare variants of intestinal carcinomas which may hold the key to differences in prognosis and treatment.

Primary Hepatoid Carcinoma of the Pancreas: A Clinicopathological Study of 3 Cases With Review of Additional 31 Cases in the Literature

Primary pancreatic hepatoid carcinoma (PHC) is very rare. Here, we reported 3 such cases with review of additional 31 cases in the literature. Our 3 patients were male (83, 72, and 54 years old, respectively). Serum α-fetoprotein (AFP) was elevated in 1 patient (case 3, 8338 ng/mL) and not measured in the other two. The PHC in patient 1 (pathological stage pT2N0M0) and patient 2 (pT3N0M0) showed pure hepatocellular carcinoma (HCC)-like morphology, whereas in case 3 it was a PHC with true glandular differentiation (pT4N0M0). The diagnosis of PHC was confirmed with positive immunohistochemical staining in the tumor cells for AFP (2/3), Hep Par 1 (3/3), glypican-3 (2/3), arginase-1 (2/3), and Sal-like protein 4 (1/3). CD10 and polyclonal carcinoembryonic antigen stains show focal canalicular pattern in 2/3 tumors. Patient 1 did not receive further treatment after resection and was alive with no evidence of disease at 107 months. Patient 2 died of postoperative complications, whereas patient 3 received postsurgical chemoradiation and died of disease at 29 months. Our findings and literature review indicate that PHCs can be divided into 4 histological subtypes: with pure HCC-like morphology (n = 22), with neuroendocrine differentiation (n = 8), with true glandular differentiation (n = 3), and with acinar cell differentiation (n = 1). On univariate analysis, pure HCC-like morphology was associated with better disease-specific survival (DSS; P = .04), whereas lymph node and distant metastases were associated with worse DSS ( P = .002 for both). Age, gender, presenting symptoms, serum AFP level, and T stage were not associated with DSS. On multivariate analysis, none of these parameters was significantly associated with DSS.

AFP-negative mixed hepatoid adenocarcinoma of the colon: a case report with review of literature

AIM

To investigate the clinicopathologic profile of hepatoid adenocarcinoma (HAC) of the colon and to improve the diagnostic and treatment level.

MATERIALS AND METHODS

The clinical observations and histopathologic and immunohistochemical features of HAC were analyzed.

RESULTS

HAC is usually composed of well-differentiated common adenocarcinoma and hepatoid differentiation. The tumor cells in hepatoid differentiation area are arranged in trabecular or solid shape, with large polygonal tumor cells, and abundant cytoplasm. Immunohistochemical markers showed the HAC cells were positive for Glypican-3, HepPar1, CK19, and carcinoembryonic antigen (CEA), while alpha-fetoprotein (AFP) was negative.

CONCLUSION

HAC is a rare malignant tumor of the colon. Its diagnosis depends on histopathology and immunohistochemical staining. Surgical resection should be the treatment of choice if possible.

Fetal-type gastrointestinal adenocarcinoma: a morphologically distinct entity with unfavourable prognosis

AIMS

This multi-institutional study and a re-evaluation of the TCGA cohort explores the morphological spectrum, genetics and outcome of GI (gastrointestinal) hepatoid tumours, tumours expressing alpha-fetoprotein (AFP) and fetal-type (FT) GI adenocarcinomas.

METHODS

44 tumours with evidence of hepatocellular differentiation were evaluated for morphology as well as by immunohistochemistry for AFP, HepPar1, glypican-3 and arginase-1 and by in situ hybridisation for albumin. Three categories were defined: type I (hepatoid: morphological evidence of hepatocellular differentiation), type II (FT GI adenocarcinoma: tubular profiles and subnuclear vacuolisation, resembling fetal intestine) and type III: positive for at least two hepatocyte-specific markers but lacking morphological evidence of hepatocellular differentiation. GI adenocarcinomas in the TCGA cohort were also evaluated (n=829).

RESULTS

18 cases were classified as type I, 19 as FT GI adenocarcinomas and 7 as type III (resembling conventional gastrointestinal carcinomas). Serum AFP was elevated in 92% of cases. 93% of tumours were positive for glypican-3, 90% for albumin and 89% for AFP. Arginase-1 was restricted to 35% of type 1 tumours. TCGA gastric tumours with elevated AFP expression showed morphological features of FT GI adenocarcinoma (70%) and were exclusively MSI stable. TCGA gastric adenocarcinomas with high AFP expression showed inferior survival on univariate and multivariate analysis.

CONCLUSIONS

FT GI adenocarcinomas show a distinctive morphological and immunohistochemical profile. Gastric adenocarcinomas with elevated expression of AFP morphologically resemble FT GI adenocarcinomas, demonstrate aggressive behaviour, independent of grade and stage, and a distinct genetic profile.

Recurrent ovarian undifferentiated carcinoma resembling hepatoid morphology treated with pegylated liposomal doxorubicin and bevacizumab

Hepatoid carcinomas are undifferentiated epithelial carcinomas that are pathologically similar to hepatocellular carcinoma, but occur in a variety of organs. Hepatoid carcinomas, as strictly defined, typically produce α-fetoprotein. In addition, a standard effective chemotherapy regimen for hepatoid carcinoma has yet to be established. We present a case of advanced primary ovarian cancer that was pathologically similar to hepatoid carcinoma without staining for α-fetoprotein or hepatocyte paraffin 1. The primary ovarian, metastatic, and recurrent tumors shared similar pathological characteristics. Fourth-line chemotherapy with pegylated liposomal doxorubicin and bevacizumab was effective in treating the recurrent tumor, even though this disease had recurred three times.

Successful treatment of a case with pancreatic neuroendocrine carcinoma with focal hepatoid differentiation: a case report and literature review

A 33-year-old Chinese woman was admitted to our hospital because of an elevated serum alpha-fetoprotein (AFP) level (300 ng/mL) found in a regular medical checkup. Computed tomography imaging of the abdomen revealed a 1.6 × 2.2 cm low-attenuation mass in the head of the pancreas, with no enlarged lymph nodes and no metastatic liver nodules, and a pancreaticoduodenectomy was performed and the tumor was completely removed. The tumor was solid, unencapsulated and poorly demarcated, measuring 2 × 1.4 × 1.8 cm, and the cut surface was grey-yellowish. Histologically, most of the areas of the tumor were composed of small monotonous and round shaped neuroendocrine cells, and approximately 20% of the areas were cells with indistinct cytoplasmic borders, large oval nuclei, prominent nucleoli and abundant eosinophilic cytoplasm, resembling the appearance of HCC. Immunohistochemical stains revealed that the neuroendocrine areas were diffusely positive for chromogranin, and the hepatoid areas showed diffuse and strong positive reaction to AFP. After surgery the AFP level reduced to normal. She received six cycles of postoperative chemotherapy and three years after the surgery was found to have an elevated serum AFP level again which gave rise to the suspicion of tumor recurrence, and a positron emission tomography-computed tomography confirmed the speculation by showing a hypermetabolic lymph node behind the body of the pancreas. She then underwent radiotherapy and the AFP level reduced to normal. Up till now she has survived 46 months since the initial diagnosis. This case and previous cases suggest that the serum AFP could be a useful marker for early detection of the disease, but careful differential diagnosis should be performed, and AFP could also be a marker for evaluation of therapeutic response and recurrence of the AFP-producing hepatoid carcinomas of pancreas.