CASE 16572 Published on 13.11.2019

Sarcomatoid hepatocellular carcinoma

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

João Macedo, Ana Aguiar Ferreira, Nuno Pereira da Silva, Fernando Alves, Paulo Donato, Filipe Caseiro-Alves

Centro Hospitalar e Universitário de Coimbra
E-mail address: joao.ant.macedo@gmail.com

Patient

62 years, male

Categories

Area of Interest Abdomen, Liver ; Imaging Technique CT

No Procedure ; Special Focus Neoplasia ;

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Clinical History

A 62-year-old man was admitted to our hospital, sent from peripheral hospital for having large liver mass. Past medical history includes HBV-infection.
Abdominal CT scan showed the presence of a liver mass and pulmonary nodular lesions suggestive of metastasis. Laboratory tests showed elevation of tumour markers AFP and CYFRA 21-1.
The tumour was unresectable and patient died after two months.

Imaging Findings

An abdominal contrast-enhanced triphasic computed tomography (CT) scan demonstrated a large and predominantly hypodense mass, occupying segments V, VI and VII, with 8 x 6.5 cm, with lobulated contours, displaying progressive peripheral enhancement after intravenous contrast administration, and a central hypodense region suggestive of necrosis.

Discussion

Sarcomatoid hepatocellular carcinoma (SHC), is an extremely rare form of liver malignant neoplasm, characterised by features of epithelial and mesenchymal tumours. Sarcomatoid carcinoma in general was reported in diverse organs, including lung, breast, urinary tract, skin, head and neck, mucosal region, and small intestine. It may also still be coined as spindle cell carcinoma or carcinosarcoma. [1-2]
SHC is an aggressive variant of hepatocellular carcinoma (HCC) with an incidence of 1.8 - 2% of all surgically resected cases and in 3.9-9.4% of autopsied cases, with either a sarcomatous change in part of the HCC or coexistence of a sarcoma and HCC or cholangiocellular carcinoma (CCC). [3-5]
The precise pathogenesis of sarcomatoid transformation of liver tumours is still unclear, since there are only a few reports of such cases. Clinical studies have suggested that sarcomatoid elements in liver carcinomas result from a dedifferentiation of HCC or CCC. [2-4] Other studies have also suggested that interventional radiological therapies such as transcatheter arterial chemoembolisation (TACE), radiofrequency ablation (RFA), and percutaneous ethanol injection may potentially be a causes of sarcomatoid transformation of hepatocellular carcinoma (HCC). [1-2-3]
Sarcomatoid HCC has a very poor prognosis. Rapid growth, venous invasion, distant and lymph node metastasis and high incidence of recurrence, even after curative resection occur frequently. [2-3]
The diagnosis of SHC is based on immunohistochemical, histopathological and precise pathological techniques. They are positive for cytokeratin-8, desmin, vimentin, SMA, EMA (epithelial membrane antigen) and CD34. Unlike HCC, SHC have low alpha-fetoprotein levels and possess a higher incidence of extrahepatic disease (e.g. lymph nodes, lungs, bone). [1-3]
Surgery is the most effective treatment. Radiofrequency ablation, transarterial chemoembolisation (TACE) and transplantation are other accepted forms of treatment. [1-4]
Written informed patient consent for publication has been obtained.

Differential Diagnosis List

Sarcomatoid hepatocellular carcinoma

Liver angiosarcoma

Metastasis of mucinous adenocarcinoma

Combined hepatocellular cholangiocarcinoma

Hepatocellular carcinoma

Final Diagnosis

Sarcomatoid hepatocellular carcinoma

References

[1] Yu Y, Zhong Y, Wang J and Wu D; Sarcomatoid hepatocellular carcinoma (SHC): a case report; Yu et al. World Journal of Surgical Oncology (2017) 15:219 (PMID: 29233162)

[2] Leng Q, Xiang X, Tang Y, Yang Y and Qiu L; Primary hepatic sarcomatoid carcinoma: A case report; Experimental And Therapeutic Medicine 10: 1145-1148, 2015

[3] Yoshida N, Midorikawa Y, Kajiwara T, Yoshida N, Nakayama H, Sugitani M, Takayama T; Hepatocellular Carcinoma with Sarcomatoid Change without Anticancer Therapies; Case Rep Gastroenterol 2013;7:169–174 (PMID: 23626518)

[4] Hepatocellular Carcinoma Variants: Radiologic–Pathologic Correlation. Chung et al. AJR 2009; 193:W7–W13 (PMID: 19542386)

[5] Bilgin M, Toprak H, Bilgin S, Kondakci M, Balcid C; CT and MRI findings of sarcomatoid cholangiocarcinoma; Cancer Imaging. 2012; 12(3): 447–451 (PMID: 23092855)

Case information

URL:	https://www.eurorad.org/case/16572
DOI:	10.35100/eurorad/case.16572
ISSN:	1563-4086

License

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Figure 1

Abdominal computed tomography

Axial images without contrast show a large and lobulated hypodense mass on the right lobe.

In arterial phase demonstrate a peripheral enhancement with a central hypodense region suggestive of necrosis.

In arterial phase demonstrate a peripheral enhancement with a central hypodense region suggestive of necrosis.

Portal and late phase show a continued peripheral enhancement and a central area of necrosis.

Portal and late phase show a continued peripheral enhancement and a central area of necrosis.

Figure 2

Histopathology

a) H&E 100x – Neoplasia composed by a proliferation of spindle cells, entrapping hepatocytes, with marked fibrous reaction.

H&E 200x – the tumour cells exhibit marked nuclear pleomorphism and areas of necrosis (bottom).

Figure 3

Histopathology

CK7 100x – the tumoural cells express a diffuse manner, with posited control on entrapped biliary duct, confirming the epithelial nature of the tumour.