Cholangiocarcinoma associated with multiple bile-duct hamartomas of the liver

von Meyenburg complexes are more frequently associated with cholangiocarcinoma

AIM

There is some evidence that von Meyenburg complexes (VMCs) can progress to cholangiocarcinoma (CC). This study aimed to evaluate the prevalence of VMCs in CC cases.

METHODS

All hepatic resections and explants with intra-hepatic CC (I-CC) and hilar-CC (H-CC) from 1985 to 2020 were studied. Hepatic resections (n=68) for benign lesions or metastatic colonic carcinoma and 15 cases with cirrhosis without any cancer were used as controls.

RESULTS

A total of 118 cases of CC (88 I-CC, 30 H-CC) were identified. Of these, 61 (52%) patients had no known background liver disease, and 20 (17%) had cirrhosis. Associated liver disorders included metabolic dysfunction-associated steatohepatitis (23), chronic viral hepatitis B or C (13), biliary disease (primary or secondary sclerosing cholangitis) (8), polycystic kidney disease (6), cryptogenic cirrhosis (5) and others miscellaneous disorders (7). VMCs were present in 34 (39%) of 88 I-CC cases and 7 (23%) of 30 H-CC cases. VMCs were present within the tumour (20 cases), outside the cancer (21 cases) or at both locations (10 cases). VMCs with dysplasia/carcinoma in situ were seen in 19 of 41 (46%) cases with CC and VMCs. In addition, bile duct adenomas were identified in 6 (5%) of CC. 7% of controls showed the presence of VMCs compared with 35% of CC cases (p<0.05).

CONCLUSIONS

VMCs are seen far more frequently in patients with CC than in the control group. The findings support the hypothesis that VMCs could represent a precursor of CC or a marker for a higher risk of developing CC.

INTRAHEPATIC BILIARY PROLIFERATIONS: HISTOPATHOLOGY AND POTENTIAL IMMUNOHISTOCHEMICAL MARKERS

•Intrahepatic biliary proliferations represent a spectrum varying from reactive to malignant entities. •Clinical and imaging patterns may be similar, requiring histopathological and immunohistochemistry for precise diagnosis. Intrahepatic biliary proliferations represent a spectrum from reactive (ductular reaction, some with atypical architecture), hamartomatous (von Meyenburg complex), benign (bile duct adenoma) and precursor/borderline entities (biliary intraepithelial neoplasia, intraductal papillary neoplasm of the bile duct) to fully malignant (cholangiocarcinoma) neoplasms. Clinical pictures and even imaging patterns may be similar, requiring refined studies aiming at histopathological and immunohistochemistry for more precise diagnosis, essential for correct patient management. This article discusses updated concepts and definitions of most relevant entities aiming more specifically at the differential diagnosis in practice, focusing on morphology and immunohistochemistry, with a discussion of potential markers to help distinguishing between benign and malignant lesions.

Malignant Transformation in Von-Meyenburg Complexes: Histologic and Immunohistochemical Clues With Illustrative Cases

Benign developmental defects known as Von-Meyenburg complexes (VMCs) have been postulated to progress to cholangiocarcinoma (CC) in rare instances. Although a gradual, sequential histologic transition from VMCs to CC has been described in some of these cases, the underlying genetic mechanism is yet to be elucidated. Here, we review the literature to put together a report on the clinicopathologic features and immunohistochemical changes associated with such transformation. We also review the documented association between CC and p16 inactivation, and discuss a possible role for this mechanism to contribute in VMCs to CC progression. In addition, using 2 illustrative cases encountered at our institute, we provide morphologic and immunohistochemical clues that can be used to detect such progression from hamartoma to malignancy. These cases and the accompanying review of literature further solidify the association between VMCs and CC.

Living donor liver transplantation using grafts with hepatic cysts

Cystic lesions in the liver are often found through the evaluation of liver donors. Multiple cysts are worrisome, and donor candidates with multiple cysts may be unacceptable as liver donors, especially when their recipients have fibrocystic disease (FCD), which is an inherited disorder. This study reviewed 183 cases of living donor liver transplantation. We collected clinical and radiological data associated with donors with cystic lesions and with donors without cystic lesions, and we evaluated the outcomes of these donors and their recipients. As part of the preoperative radiological assessment of grafts, magnetic resonance cholangiography (MRC) was performed to evaluate the biliary anatomy of donor candidates with multiple cysts. Thirty-four donors (18.6%) had 1 or more cystic lesions in the liver, and 6 of these donors had multiple cysts (ie, >10). Donors with multiple cysts were older and heavier, and there was a significant relationship between these donors and recipients whose original disease was FCD. During the follow-up (median = 3.1 years), all donors with cystic lesions were found to be doing well without any major postoperative complications. Fifteen recipients who received grafts with cystic lesions (12 left-sided lobes and 3 right-sided lobes) had no complications related to the cystic lesions. In conclusion, donors with cystic lesions may be acceptable as liver donors, although our data are limited mostly to left-sided lobe donation with a short follow-up period. MRC should be preoperatively performed to rule out any biliary anomalies, especially in donor candidates whose recipients have FCD.

Molecular evidence for the neoplastic potential of hepatic Von-Meyenburg complexes

Von-Meyenburg complexes (VMCs) have been shown to progress to cholangiocarcinoma (CC) in some cases. Histologic examination in such cases reveals a gradual transition of VMCs to intermediate lesions and finally to CC. The goal of this study was to determine if this histologic progression was also accompanied by sequential genetic alterations. Two cases that showed many VMCs with a transition to cholangiocarcinoma through intermediate lesions were analyzed. Multiple VMCs (away from the tumor), intermediate lesions and areas of frank CC were microdissected under stereoscopic guidance and were analyzed for allelic imbalance [loss of heterozygosity (LOH)] using a panel of 20 polymorphic microsatellite markers by polymerase chain reaction/electrophoresis. The 2 cases of CCs revealed LOH at 5 and 7 different genomic loci specific for each patient, respectively. Coexisting VMCs also exhibited LOH ranging from 0 to 3 loci in each case. Intermediate lesions showed LOH at a single locus in case 1, whereas the assay could not be performed in case 2 due to inadequate DNA yield. In case 2, the earliest acquired mutations were present in the VMCs supporting a causal relationship for neoplastic progression. Discordant LOH mutations were also present in the VMCs and the adenomatous lesions providing support that LOH detected at these sites did not passively migrate or reflect contamination. The results of the present study show that the histologic progression observed through these stages is also accompanied by LOH at loci harboring key oncogenes. The findings also support that VMCs are preneoplastic lesions that could progress to CC with time.

Intrahepatic cholangiocarcinoma arising in multiple bile duct hamartomas: report of two cases and review of the literature

Multiple bile duct hamartomas (BDHs)/von Meyenburg complexes, are tumor-like lesions of the liver. Malignant transformation in BDHs has been previously reported in very rare instances, and the most common tumor arising in this clinical setting is cholangiocarcinoma. Herein, we report on clinicopathological findings in two cases of cholangiocarcinoma occurring in liver with multiple BDHs. Histopathologically, multiple BDHs showed morphologic transition from clearly benign to dysplasia or carcinoma in situ, then to invasive carcinoma sequence of the biliary epithelium. The neoplastic epithelium showed positivity for cytokeratin 19, CA 19-9, and epithelial membrane antigen. Staining for Hep Par 1, alpha-fetoprotein, cytokeratin 20, and alpha1-antitrypsin was negative. All sections from the non-neoplastic liver in each specimen showed multiple BDHs. Any other clinically detectable primary tumor was not found. These two neoplasms were interpreted as a cholangiocarcinoma arising in BDHs. This suggested BDHs might be a risk factor of development of cholangiocarcinoma.

Cholangiocarcinoma arising in von Meyenburg complexes: report of four cases

Although von Meyenburg complexes (VMC) are largely considered to be innocuous, neoplastic transformations have been described. The present report describes four cases of cholangiocarcinoma (CC) occurring on a background of VMC. The patients were all male and aged 69, 59, 68 and 75 years, respectively. While two patients were asymptomatic, the other two had a history of colon cancer. Radiologically the tumors measured 3, 4, 4.5 and 10 cm and were well enhanced from the arterial to delayed portal phase. Microscopically, the tumor consisted of multiple foci of characteristic VMC, and had a gradual transition from VMC to hyperplasia or dysplasia and well- to moderately differentiated adenocarcinomas. One patient had combined hepatocellular carcinoma (HCC) and CC, occurring in the high grade dysplastic nodule and VMC. On immunohistochemistry the epithelial cells of the VMC and CC were immunopositive for cytokeratin (CK) 7 in three patients, with another patient being focally positive only for CK19. The Ki-67 labeling indices increased from the VMC to the dysplastic areas and then to the carcinomas. As a potentially precancerous lesion, VMC should be carefully followed up in terms of any size increases. Thus, biopsies are essential to determine any proliferative epithelial changes including dysplasia and malignant transformation.

Multiple biliary hamartomas: magnetic resonance features with histopathologic correlation

The purpose of this study was to report the magnetic resonance imaging (MRI) features of multiple biliary hamartoma (MBH) and to correlate them with histopathology. MRI features of 11 patients with MBH proven by histology were retrospectively reviewed and correlated to histopathology. MBH presented as multiple, tiny, and uniformly distributed lesions in all cases. All were hypointense on T1-weighted images and hyperintense on T2-weighted images relative to the liver parenchyma. Mural nodules were identified in 10 of 11 (91%) cases. They were isosignal on T1-weighted images, intermediate signal on T2-weighted images. Gadolinium-enhanced images showed mural nodule enhancement in 9 of 10 patients (90%) or a peripheral rim-like enhancement of the whole lesion in one case (9%). MBH were present in all liver specimens. In the six patients examined at MR cholangiography, the lesions lacked communication with the biliary tree. At histopathology, the mural nodule corresponded to an endocystic polypoid projection made of conjunctive septa. Three (27%) patients had associated focal nodular hyperplasia, and 1 (9%) had concomitant cholangiocarcinoma. MRI features allowed diagnosis of MBH with accuracy. Their recognition, especially the mural nodule, may help avoid misdiagnosis.

Intraductal papillary cholangiocarcinoma associated with von Meyenberg complexes: a case report

Intraductal papillary cholangiocarcinoma (IPC) is a rare form of bile duct neoplasm with only 28 cases reported in the English literature to date. We report a rare case of an IPC arising in a liver containing many von Meyenberg complexes (VMC) in a 70-year-old woman. She presented with colicky right upper quadrant pain and nausea, mimicking biliary colic. Imaging studies showed a mass in the left lobe of the liver. A left hepatectomy, which included segments 2 and 3 was performed, and an ill-defined shiny polypoid nonhomogenous mass (8.2x2.9 cm) was identified within the lumen of a dilated bile duct without invading the liver parenchyma. Histologically, the tumor was composed of papillary fronds with fine fibrovascular cores lined by tall biliary columnar mucus secreting epithelium. Focally the cells were of the gastric foveolar type. The tumor extended into the peribiliary glands and merged with an adjacent large VMC. A possibility that the carcinoma may have originated in a VMC was considered. On follow-up after 12 months the patient is doing well and is without any disease or recurrence.

[Von Meyenburg disease found during laparoscopic surgery: report of two cases]

The authors report two cases of von Meyenburg complexes disease found during laparoscopic surgical procedures. The first patient (41 years old) had multiple gallbladder stones with recurrent hepatic colics. The second patient (45 years old) had gastroesophageal reflux with recurrent peptic esophagitis. In both cases, multiple millimetric and superficial hepatic lesions were found during the exploration of the abdominal cavity. Then, an hepatic biopsy was done because the macroscopic aspect should suspect secondary metastatic lesions. Histological result made the diagnosis of von Meyenburg complexes disease (biliary microhamartomas). It seems to be important to know this anomaly of the ductal plate development and to do a liver biopsy during laparoscopy to affirm the diagnosis and cancel the diagnosis of multiple hepatic metastasis. In fact, this congenital pathology could be associated with increased risk of cholangiocarcinoma of the liver. The modality of radiological monitoring still remains to be defined.

Cholangiocarcinoma occurring in a liver with multiple bile duct hamartomas (von Meyenburg complexes)

A 59-year-old woman presented with epigastric pain and weight loss. Ultrasound, computed tomography, and magnetic resonance imaging scans of the abdomen showed a tumor in segments 6 and 7 of the right liver lobe, measuring 8 cm in greatest diameter. The tumor was subsequently resected, and histopathology showed a poorly differentiated adenocarcinoma immunoreactive for CA 19-9 and cytokeratin 19. In the absence of any other clinically detectable primary tumor, the lesion was diagnosed as a peripheral intrahepatic cholangiocarcinoma. In addition, multiple bile duct hamartomas were found in the surrounding parenchyma. The tumor was unrelated to Caroli disease, primary sclerosing cholangitis, ulcerative colitis, or nonbiliary cirrhosis, as demonstrated by further clinical and histopathologic investigations, but probably was associated with the presence of multiple bile duct hamartomas. To our knowledge, this is the eighth reported case of a cholangiocarcinoma associated with multiple bile duct hamartomas.

Evidence for the neoplastic transformation of Von-Meyenburg complexes

Von-Meyenburg complexes (VMC) are seen frequently in the liver and are largely considered to be innocuous, with only 11 cases reported in the literature of neoplastic transformation of VMCs. The authors report three cases of cholangiocarcinoma, each occurring in a background of fibrosis and nodularity that was reported initially as micronodular cirrhosis. Although the livers showed cirrhosis, the central veins were often preserved, and regenerative activity was patchy and focal. Histologic examination revealed many VMCs, and a gradual transition from VMCs to hyperplastic or adenomatous lesions and cholangiocarcinoma. The adenomatous lesions consisted of extensive replacement of the parenchyma by tumor-like nodules of ductular proliferations without obvious features of malignancy. All three patients were older than 60 years of age and had portal hypertension. Computed tomographic scans showed multiple, small renal cysts in one patient. Immunohistochemical staining showed positivity for epithelial membrane antigen, carcinoembryonic antigen, and keratins (AE1/AE3 and CAM5.2) in tumor cells, consistent with cholangiocarcinoma. The pattern of fibrosis and nodularity in these cases is not typical of either congenital hepatic fibrosis or usual cirrhosis. The authors propose that these patients represent another aspect in the spectrum of ductal plate malformations that may be modified by other factors such as alcohol, drugs, or infection. To their knowledge, neoplastic transformation of VMCs in the background of such changes has never been reported before.

Adenocarcinoid of the liver arising within an area of hamartoma with predominant bile duct component

Malignant transformation in bile duct hamartomas has been previously reported in very rare instances. Here, we describe a unique case of a neuroendocrine tumor of the liver arising within an area of unusually large hamartoma with predominant bile duct component, hitherto unreported and distinct from the conventional von Meyenburg complex. The tumor was apparently secreting gastrin and chromogranin, with associated gastrinoma syndrome over several years. The histologic picture was reminiscent of a moderately differentiated adenocarcinoid, with positive mucin staining in a signet ring pattern. Tumor cells showed positive staining for neuron-specific enolase, chromogranin A, gastrin, and serotonin. Staining for pancreatic hormone peptides was negative. Resection of the tumor was apparently curative, with complete resolution of the patient's symptoms.

Cholangiocarcinoma arising in bile duct adenoma with focal area of bile duct hamartoma

A 59-year-old male with history of sigmoid colon cancer had a high serum-CEA level and was referred for the evaluation of metastatic liver disease. Ultrasonography and computerized tomography showed two tumours in the liver. Macroscopically, these were in segment 4 (S4) and 2 (S2). Histologically, the tumour in S4 showed a number of bile ductules with variable amounts of stroma, an appearance compatible with bile duct adenoma (BDA). There were markedly atypical ductules of various sizes, the epithelium of which had coarsely granular/hyperchromatic large nuclei, in some areas of the lesion. These atypical ductules showed invasive growth into the liver parenchyma. Some cystically dilated ductules with bile plugs resembling bile duct hamartoma (BDH) were also seen. The other tumour in S2, was a metastatic adenocarcinoma from sigmoid colon and showed strongly positive staining for CEA. Since the lesion in S4 of our case is solitary and most of histological features are similar to those of BDA with markedly atypical bile ductules, we consider that this may be the first case of cholangiocarcinoma associated with BDA with focal area of BDH. It is possible that the adenoma-carcinoma sequence occurs in biliary tumours.

Case report: imaging of bile duct hamartomas

A rare case of multiple bile duct hamartomas of the liver has been evaluated with ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI) and digital subtraction angiography (DSA). The CT and angiographic features of the hamartomas described here differ significantly from previously reported cases. In addition, the MR appearance of these tumours is reported for the first time.

Ampullary hamartoma: endoscopic diagnosis and treatment

This study shows a patient who presented with intermittent biliary tract obstruction caused by ampullary hamartoma. Endoscopic retrograde cholangiopancreatography showed a large ulcerated papilla and dilated biliary ducts. Tissue diagnosis was established by a large particle biopsy obtained with a snare. The patient underwent a successful endoscopic sphincterotomy and has remained symptom free for 4 years.

Pathological observations of intrahepatic peribiliary glands in 1,000 consecutive autopsy livers. II. A possible source of cholangiocarcinoma

It remains unclear whether atypical epithelial lesions, including carcinomas and precancerous lesions, develop in intraheptic peribiliary glands. This question was tested in this study. One thousand livers from consecutive autopsies were surveyed and 201 livers with bile duct carcinomas or metastatic malignant neoplasms were excluded because atypical epithelial lesions of the glands were difficult to distinguish from the primary or metastatic malignant cells. Consequently, 799 livers were examined for the atypical epithelial lesions by histological, mucin-histochemical and immunohistochemical methods. The atypical epithelial lesions were divisible into papillary hyperplasia, atypical hyperplasia and carcinomatous transformation. Of the 799 livers, papillary hyperplasia was only found in six livers (0.8%), papillary hyperplasia and atypical hyperplasia coexisted in four livers (0.5%) and carcinomatous transformation and atypical hyperplasia coexisted in one liver (0.1%). Mucin-histochemical study showed that the intracytoplasmic location of mucin was different between carcinomatous transformation and normal peribiliary glands. From an immunohistochemical standpoint, epithelial cells of the atypical epithelial lesions showed stronger immunoreactivities to carcinoembryonic antigen, carbohydrate antigen 19-9 and DU-PAN-2 than those of normal intrahepatic peribiliary glands. These findings suggest that intrahepatic cholangiocarcinomas arising from intrahepatic peribiliary glands actually exist, and that papillary and atypical hyperplasia of the peribiliary glands may precede this type of cholangiocarcinoma.