Primary mesenchymal liver tumors: radiological spectrum, differential diagnosis, and pathologic correlation

Clinical and imaging characteristics of primary hepatic sarcomatoid carcinoma and sarcoma: a comparative study

Background

Primary hepatic sarcomatous carcinoma (PHSC) and primary hepatic sarcoma (PHS) are rare malignancies with frequent overlap in both the clinic and radiology. No comparative study of these tumors for the restricted cases has previously been undertaken. The purpose of our study was to analyze the clinical and imaging features of PHSCs and PHSs, with an emphasis on particularities and similarities through a comparison of the two tumors.

Methods

We retrospectively analyzed the clinical and imaging features of 39 patients with pathologically proven PHSCs (n = 23) and PHSs (n = 16) from four university centers over a 9-year period from 2010 to 2019. Univariate analyses were performed to determine the consistent and distinctive features.

Results

The background of chronic hepatitis or cirrhosis was observed with a high frequency in both of PHSCs (73.7%) and PHSs (62.5%). Tumors with a diameter greater than 10 cm were significantly more common in PHSs than PHSCs (p = 0.043) and cystic masses were more detected in PHSs (P = 0.041). Both PHSCs and PHSs mainly presented hypovascularity (78.3% vs 81.3%). The ring hyper enhancement on the arterial phase (AP) and wash out were more frequently seen in PHSCs and the iso-hypo enhancement on the AP followed persistent or progressive enhancement was more commonly detected in PHSs (all, p < 0.05).

Conclusion

PHSC and PHS generally present as mass lesions with hypovascularity. The ring hyper enhancement on the AP and wash out favor the diagnosis of PHSC. The large size greater than 10 cm, cystic lesion, iso-hypo persistent or progressive enhancement pattern might suggest the possibility of PHSs.

[Mesenchymal abdominal tumors in children]

Mesenchymal tumors in childhood comprise benign and malign entities and differ regarding typical sites of manifestation, age peak and clinical symptoms. In some cases biopsy is mandatory. If nephroblastoma is a possible diagnosis, biopsy must be avoided by all means in order to avoid biopsy tract metastasis. Imaging is used to narrow the differential diagnosis, describe the exact extent of the lesion and deliver complete staging. In pediatric patients sonography and MRI are the most important imaging modalities. Low-dose CT of the thorax serves for assessment of possible pulmonary metastases.

CT- and ultrasound-characteristics of hepatic lesions in patients with multiple endocrine neoplasia syndrome. A retrospective image review of 25 cases

Introduction

Liver metastases from neuroendocrine tumors in multiple endocrine neoplasia syndrome are common (75%) and significantly impairs the prognosis. Characterisation of liver lesions in these patients is challenging, as liver metastases are difficult to differentiate from benign liver lesions such as haemangioma.

Methods

In this study we aimed to characterize the radiological findings of hepatic metastases in MEN patients. The findings of contrast-enhanced CT were considered for the main diagnosis. We retrospectively evaluated 25 patients with MEN-syndrome (10 MEN1/ 15 MEN2) including 11 men and 14 women between 28–62 years of age.

Results

Liver metastases (48%, 12/25) and hemangioma (40%, 10/25) were the most common liver lesions among our patients. The most common primary tumors in our MEN1 and MEN2 patients with liver metastases were of pancreatic neuroendocrine tumor (70%, 7/10) und medullary thyroid carcinoma (100%, 15/15) origin, respectively. CT-characteristics were grouped into three main categories, depending on contrast dynamics. The majority of hepatic metastases (75%, 14/25) are presented as multiple lesions with a slow growth in an average 5 years of follow-up-period. We were able to find a common CT pattern and categorise these for each MEN-syndrome. Hepatic metastases in MEN1 presented commonly a blurred arterial enhancement with a low portal venous enhancement and less frequently a prominent enhancement in the arterial phase, which mimics the classical haemangioma. In MEN2 the liver metastases exhibited disseminated mixed hyper- and hypo-enhanced lesions in CT-scans. Moreover, lesion calcifications are pathognomonic in MEN2. The main limitation of this study is the missing histopathological confirmation in the majority of cases.

Conclusions

In this retrospective imaging study, we were able to categorise and find a common CT pattern for hepatic lesions in patients with MEN-syndrome. In order to differentiate these lesions sufficiently, a combination of a 3-phasic CT-scan with US is required. Other liver specific imaging modalities (MRI, CEUS, SMS-PET/CT) should complement the diagnosis in individual cases.

Undifferentiated embryonal sarcoma of the liver in adult patient: A report of two cases

Primary sarcomas of the liver are unusual neoplasms developing in adults. They constitute a heterogeneous group of neoplasms including undifferentiated embryonal sarcoma. Patients usually present with an abdominal mass and abdominal pain. Case 1: A 53-year-old woman presented with abdominal pain. Computed tomography showed an occupying mass in the right lobule and an intra-auricular multi-lobulated mass suggestive of a secondary deposit. Biopsy of the hepatic lesion revealed undifferentiated embryonal sarcoma. Despite radiotherapy and supportive measures, her overall status progressively worsened until cardiac arrest. Case 2: A 41-year-old woman presented with hepatomegaly. Abdominal imaging showed cystic lesions in the right hepatic lobule with multiple septae. The patient underwent extended right hepatectomy and a histopathological study reported high-grade undifferentiated embryonal sarcoma. Two years after surgery, a new cystic lesion in the surgical site was recorded and chemotherapy was scheduled. The lesion remained stable for three years when disease progression was observed and second-line chemotherapy was initiated. Although undifferentiated embryonal sarcoma of the liver has poor prognosis, early diagnosis is essential to increase the chances of survival. Currently, surgical resection and chemotherapy are the primary treatment modalities.

Peritumoral Hyperplasia in Hepatic Sclerosed Hemangioma

Peritumoral hyperplasia (PTH) is a hyperplastic lesion located around hypervascular tumors. Hepatic sclerosed hemangioma is a very rare form of hemangioma with sclerotic changes and is distinct from sclerosing hemangioma. We present a patient with non-alcoholic steatohepatitis-induced cirrhosis who presented with a hypervascular tumor. The tumor showed atypical findings of hemangioma and was treated with surgical resection because hepatic malignancy could not be ruled out. Histopathologic examination revealed the tumor was a sclerosed hemangioma with PTH. Lesions with carcinogenic potential were found in the PTH lesion. Sclerosed hemangioma should be observed and managed carefully.

Adult Embryonal Sarcoma of the Liver: Management of a Massive Liver Tumor

Undifferentiated embryonal sarcomas of the liver are extremely rare cases in adults. We report the case of a 30-year-old male who presented with early satiety and abdominal pain due to a massive tumor originating from the left liver and occupying the entire epigastrium. The patient underwent bland embolization in an attempt to decrease the size of the tumor. He then underwent a formal left hepatectomy with resection of liver segments 2, 3, and 4. Extrahepatic inflow control of the portal vein and hepatic artery was performed prior to parenchymal transection. No Pringle maneuver was required. Pathology analysis showed a 45 cm tumor consistent with an undifferentiated embryonal sarcoma and negative microscopic margins. The epidemiology, treatment, and prognosis of this unusual cancer presentation are reviewed.

Mesenchymal Hamartoma of the Liver in an Infant With Beckwith-Wiedemann Syndrome: A Rare Condition Mimicking Hepatoblastoma

Patients with Beckwith-Wiedemann syndrome (BWS) are known to be at an increased risk for childhood malignancies, particularly Wilms tumor and hepatoblastoma. We report a case of genetically confirmed BWS in a 5-month-old girl who presented with a 9.5-cm abdominal mass associated with elevated α-fetoprotein levels. The clinical impression was strongly suggestive of hepatoblastoma. Histologic examination of the surgically excised mass revealed mesenchymal hamartoma of the liver (MHL), a benign hepatic neoplasm.