Imaging features predict prognosis of patients with combined hepatocellular-cholangiocarcinoma

Current advances and future directions in combined hepatocellular and cholangiocarcinoma

The low incidence of combined hepatocellular cholangiocarcinoma (cHCC-CCA) is an important factor limiting research progression. Our study extensively included nearly three decades of relevant literature and assembled the most comprehensive database comprising 5,742 patients with cHCC-CCA. We summarized the characteristics, tumor markers, and clinical features of these patients. Additionally, we present the evolution of cHCC-CCA classification and explain the underlying rationale for these classification standards. We reviewed cHCC-CCA diagnostic advances using imaging features, tumor markers, and postoperative pathology, as well as treatment options such as surgical, adjuvant, and immune-targeted therapies. In addition, recent advances in more effective chemotherapeutic regimens and immune-targeted therapies were explored. Furthermore, we described the molecular mutation features and potential specific markers of cHCC-CCA. The prognostic value of Nestin has been proven, and we speculate that Nestin will also play a role in classification and diagnosis. However, further research is needed. Moreover, we believe that the possibility of using machine learning liquid biopsy for preoperative diagnosis and establishing a scoring system are directions for future research.

The significance of the predominant component in combined hepatocellular-cholangiocarcinoma: MRI manifestation and prognostic value

PURPOSE

To investigate the significance of the predominant component of combined hepatocellular-cholangiocarcinoma (cHCC-CC) in terms of MRI manifestation and its potential prognostic value compared to hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC).

MATERIALS AND METHODS

A total of 300 patients with chronic liver disease from two centers were retrospectively enrolled, including 100 surgically proven cases of cHCC-CC, HCC, and ICC each. Univariate and multivariate regression analyses were performed to identify independent predictors for distinguishing HCC-predominant cHCC-CC and ICC-predominant cHCC-CC from HCC and ICC, respectively. Diagnostic models were constructed based on the independent features. Recurrence-free survival (RFS) was estimated and compared between groups.

RESULTS

The predominant component was an independent predictor for RFS in cHCC-CC (hazard ratio = 1.957, P = 0.044). The presence of targetoid appearance (odds ratio(OR) = 10.907, P = 0.001), lack of enhancing capsule (OR = 0.072, P = 0.001) and arterial peritumoral enhancement (OR = 0.091, P = 0.003) were independent predictors suggestive of HCC-predominant cHCC-CC over HCC; their combination yielded an area under the curve of 0.756. No significant differences were observed in RFS between HCC-predominant cHCC-CC and HCC (P = 0.864). Male gender (OR = 4.049, P = 0.015), higher alpha fetoprotein (OR = 16.789, P < 0.001) and normal carbohydrate antigen 19-9 (OR = 0.343, P = 0.036) levels, presence of enhancing capsule (OR = 7.819, P < 0.001) and hemorrhage (OR = 23.526, P = 0.004), and lack of targetoid appearance (OR = 0.129, P = 0.005) and liver surface retraction (OR = 0.190, P = 0.021) were independent predictors suggestive of ICC-predominant cHCC-CC over ICC; their combination yielded an area under the curve value of 0.898. ICC-predominant cHCC-CC exhibited poorer survival with shorter RFS than ICC (P = 0.009).

CONCLUSION

The predominant histopathological component is closely related to the imaging manifestation of cHCC-CC; and more importantly, it plays a significant prognostic role, which may alter the RFS prognosis of cHCC-CC.

Combined hepatocellular carcinoma-cholangiocarcinoma with a predominant HCC component: better survival and MRI-based prediction

OBJECTIVES

To determine the optimal cutoff value of HCC% for predicting the outcome of patients with combined hepatocellular carcinoma-cholangiocarcinoma (cHCC-CCA) and to investigate how preoperative MR features based on the Liver Imaging Reporting and Data System (LI-RADS ver. 2018) are related to the HCC% in cHCC-CCA.

METHODS

The study enrolled 107 patients pathologically confirmed to have single cHCC-CCA according to the 2019 WHO classification. A receiver operating characteristic (ROC) curve was used to find the optimal cutoff value of HCC% based on overall survival (OS). The preoperative MR imaging features and clinicopathological findings were retrospectively evaluated and compared between the high HCC% and low HCC% groups.

RESULTS

In total, 107 patients (mean age, males vs. females: 56.6 ± 10.7 years vs. 54.2 ± 12.8 years) were evaluated. Analysis of the relationship between HCC% and OS by ROC curve suggested that the optimal cutoff value was 65%, by which 51 (47.7%) patients were assigned to the high HCC% group. LI-RADS categorization (OR = 3.657, p = 0.006 vs. OR = 4.075, p = 0.004) and serum carcinoembryonic antigen (CEA) >5 ng/mL (OR = 0.348, p = 0.089 vs. OR = 0.298, p = 0.040) were significant predictors for HCC% in cHCC-CCA in both univariate and multivariate analysis.

CONCLUSIONS

cHCC-CCA patients with HCC components higher than 65% tend to exhibit better overall survival, and MRI-based LI-RADS categorization and serum CEA level are valuable for identifying HCC% in cHCC-CCA preoperatively.

KEY POINTS

• cHCC-CCA patients with HCC components higher than 65% tend to exhibit better overall survival. • MRI-based LI-RADS categorization and serum CEA level were significant predictors for HCC% in cHCC-CCA in both univariate and multivariate analyses and valuable for identifying HCC% in cHCC-CCA preoperatively.

Rare histotypes of epithelial biliary tract tumors: A literature review

Adenocarcinoma represents the most frequent biliary tract cancer. However, other rare histotypes can be found in the biliary tract, such as cholangiolocellular carcinoma, cholangiocarcinoma with ductal plate malformation pattern, adenosquamous carcinoma, mucinous carcinoma, signet ring cell carcinoma, clear cell carcinoma, mucoepidermoid carcinoma, lymphoepithelioma-like carcinoma, and sarcomatous cholangiocarcinoma. These cancer types account for less than 10 % of all the already rare biliary tract tumors. Yet, they represent a relevant issue in everyday clinical practice, given the lack of therapeutic recommendations and the overall scarcity of data, mainly deriving from isolated small center-specific cohorts of patients.The shifts of such histotypes from the most common ones reflect genetic and molecular differences, determine changes in clinical aggressiveness, and suggest a possible variability in sensitivity to the standard treatments of biliary adenocarcinomas. The consistency and degree of these variables are still to be solidly demonstrated and investigated. Therefore, this paper aims to review the current literature concerning very infrequent and rare epithelial biliary tract cancers, focusing our attention on the clinical, molecular, and immunohistochemical features of these tumors.

Clinicopathologic and MRI features of combined hepatocellular-cholangiocarcinoma in patients with or without cirrhosis

BACKGROUND AND AIMS

Differences in combined hepatocellular-cholangiocarcinomas (cHCC-CCAs) arising in high-risk patients with or without liver cirrhosis have not been elucidated. This study aimed to compare the clinicopathologic and imaging characteristics of cHCC-CCAs in patients with or without cirrhosis and to determine the prognostic factors for recurrence-free survival (RFS) after curative resections of single cHCC-CCAs.

METHODS

This retrospective study included 113 patients with surgically resected single cHCC-CCAs who underwent preoperative magnetic resonance imaging from January 2008 to December 2019 at two tertiary referral centres. Clinical, pathologic and imaging features of tumours were compared in high-risk patients with or without cirrhosis. Imaging features were assessed using the Liver Imaging Reporting and Data System (LI-RADS) version 2018. RFS and associated factors were evaluated using Cox proportional hazards regression analysis, Kaplan-Meier analysis and log-rank test.

RESULTS

cHCC-CCAs arising from cirrhotic livers had a smaller mean tumour size (2.9 cm vs. 4.5 cm; P < .001) and were more frequently categorized as LR-5 or 4 (41.2% vs. 20.0%; P = .024) than those arising from non-cirrhotic livers. In multivariable analysis, a tumour size of > 3 cm (hazard ratio [HR], 2.081; 95% confidence interval [CI], 1.180-3.668; P = .011) and the LR-M category (HR, 2.302; 95% CI, 1.198-4.424; P = .012) were independent predictors associated with worse RFS.

CONCLUSIONS

The tumour size and distribution of LI-RADS categories of cHCC-CCAs differed in high-risk patients with or without cirrhosis. And LR-M category was a worse prognosis predictor after curative resections than LR-5 or 4 category.

Histological Heterogeneity of Primary Liver Cancers: Clinical Relevance, Diagnostic Pitfalls and the Pathologist's Role

Simple Summary

Primary liver cancers (PLCs) mainly comprise hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (iCCA), and combined (c)HCC-CCA. Both small duct types iCCA (a subtype pf iCCA) and cHCC-CCA are known to be tumors with histological heterogeneity. Understanding key tumor heterogeneity is crucial as it reflects tumor aggressiveness, patient outcome, treatment choice, and is predictive of treatment efficacy. In addition, PLCs often present with multiple liver tumors, which can be a combination of different types of PLCs or HCCs (intrahepatic metastasis or multicentric occurrence), and the pathological interpretation plays an important role in these cases. The aim of this review is to clarify the pathological features of HCC, iCCA, and cHCC-CCA, including their diagnostic pitfalls, molecular profiles, and the correlation between tumor subtypes and treatment choice.

Abstract

Primary liver cancers (PLCs) mainly comprise hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (iCCA), and cHCC-CCA. Combined HCC-CCA and small duct type iCCA show similar clinical presentations, and their histological features are more complex than seen in HCC. Therefore, while their treatment strategy differs, it is difficult to properly diagnose these tumors. Currently, HCC is the only tumor that can be treated by liver transplantation. In addition, small duct type iCCA harbors IDH1/2 mutations and FGFR2 fusions, which can be used for targeted therapy. Thus, improving diagnostic accuracy is crucial. A further point to note is that PLCs often present as multiple liver tumors, and they can be a combination of different types of PLCs or HCCs. In the case of HCCs, two different scenarios are possible, namely intrahepatic metastasis, or multicentric occurrence. Therefore, it is essential to characterize the type of multiple liver tumors. This review aims to clarify the pathological features of HCC, iCCA and cHCC-CCA, including their diagnostic pitfalls and clinical relevance. It is designed to be of use to clinicians who are dealing with PLCs, to provide a better understanding of the pathology of these tumors, and to enable a more accurate diagnosis and optimal treatment choice.

Update on Pathologic and Radiologic Diagnosis of Combined Hepatocellular-Cholangiocarcinoma

Combined hepatocellular-cholangiocarcinoma (cHCC-CCA) is a malignant primary liver carcinoma characterized by the unequivocal presence of both hepatocytic and cholangiocytic differentiation within the same tumor. Recent research has highlighted that cHCC-CCAs are more heterogeneous than previously expected. In the updated consensus terminology and WHO 2019 classification, "classical type" and "subtypes with stem-cell features" of the WHO 2010 classification are no longer recommended. Instead, it is recommended that the presence and percentages of various histopathologic components and stem-cell features be mentioned in the pathologic report. The new terminology and classification enable the exchange of clearer and more objective information about cHCC-CCAs, facilitating multi-center and multi-national research. However, there are limitations to the diagnosis of cHCC-CCA by imaging and biopsy. cHCC-CCAs showing typical imaging findings of HCC could be misdiagnosed as HCC and subjected to inappropriate treatment, if other clinical findings are not sufficiently considered. cHCC-CCAs showing at least one of the CCA-like imaging features or unusual clinical features should be subjected to biopsy. There may be a sampling error for the biopsy diagnosis of cHCC-CCA. An optimized diagnostic algorithm integrating clinical, radiological, and histopathologic information of biopsy is required to resolve these diagnostic pitfalls.

Combined hepatocellular-cholangiocarcinoma: An update on epidemiology, classification, diagnosis and management

BACKGROUND

Combined hepatocellular-cholangiocarcinoma (CHC) is a rare subtype of primary hepatic malignancies, with variably reported incidence between 0.4%-14.2% of primary liver cancer cases. This study aimed to systematically review the epidemiological, clinicopathological, diagnostic and therapeutic data for this rare entity.

DATA SOURCES

We reviewed the literature of diagnostic approach of CHC with special reference to its clinical, molecular and histopathological characteristics. Additional analysis of the recent literature in order to evaluate the results of surgical and systemic treatment of this entity has been accomplished.

RESULTS

The median age at CHC's diagnosis appears to be between 50 and 75 years. Evaluation of tumor markers [alpha fetoprotein (AFP), carbohydrate antigen 19-9 (CA19-9) and carcinoembryonic antigen (CEA)] along with imaging patterns provides better opportunities for CHC's preoperative diagnosis. Reported clinicopathologic prognostic parameters possibly correlated with increased tumor recurrence and grimmer survival odds include advanced age, tumor size, nodal and distal metastases, vascular and regional organ invasion, multifocality, decreased capsule formation, stem-cell features verification and increased GGT as well as CA19-9 and CEA levels. In case of inoperable or recurrent disease, combinations of cholangiocarcinoma-directed systemic agents display superior results over sorafenib. Liver-directed methods, such as transarterial chemoembolization (TACE), percutaneous ethanol injection (PEI), hepatic arterial infusion chemotherapy (HAIC), radioembolization and ablative therapies, demonstrate inferior efficacy than in cases of hepatocellular carcinoma (HCC) due to CHC's common hypovascularity.

CONCLUSIONS

CHC demonstrates an overlapping clinical and biological pattern between its malignant ingredients. Natural history of the disease seems to be determined by the predominant tumor element. Gold standard for diagnosis is histology of surgical specimens. Regarding therapeutic interventions, major hepatectomy is acknowledged as the cornerstone of treatment whereas minor hepatectomy and liver transplantation may be applied in patients with advanced cirrhosis. Despite all therapeutic attempts, prognosis of CHC remains dismal.

Diagnostic performance of the LR-M criteria and spectrum of LI-RADS imaging features among primary hepatic carcinomas

PURPOSE

To evaluate the diagnostic performance of LR-M criteria for differentiating hepatocellular carcinoma, intrahepatic mass-forming cholangiocarcinoma, and combined hepatocellular-cholangiocarcinoma and to compare the imaging features of each type.

METHODS

In this retrospective study, 110 patients were surgically diagnosed with cholangiocarcinoma (n = 67) and combined hepatocellular-cholangiocarcinoma (n = 43) at a single tertiary hospital between 2013 and 2018. Among them, those with risk factors were enrolled (16 cholangiocarcinomas and 33 combined hepatocellular-cholangiocarcinomas). Forty-nine other patients with size-matched hepatocellular carcinoma were selected as a control group. Two independent readers evaluated the imaging findings of the preoperative MRIs based on LI-RADS version 2018 and assigned an LI-RADS category. The diagnostic performance of the LR-M criteria for diagnosing cholangiocarcinoma or combined hepatocellular-cholangiocarcinoma was evaluated, and the imaging features were compared. The imaging findings of the tumors in patients without risk factors (51 cholangiocarcinomas and 10 combined hepatocellular-cholangiocarcinomas) were evaluated for subgroup analysis.

RESULTS

In the non-hepatocellular carcinoma group, 33 patients were categorized into LR-M and 14 patients into LR-5 (67.3% and 28.6%, respectively), while 5 patients with hepatocellular carcinoma were categorized into LR-M and 38 patients into LR-5 (10.2% and 77.6%, respectively). Sensitivity and specificity of the LR-M criteria were 67.3% and 89.8%, respectively. When more than two LR-M features were present, cholangiocarcinoma or combined hepatocellular-cholangiocarcinoma were suggested with a specificity of 95.9%.

CONCLUSION

The diagnostic performance of the LR-M criteria is acceptable with moderate sensitivity and high specificity for both cholangiocarcinoma and combined hepatocellular-cholangiocarcinoma. Imaging findings of primary hepatic carcinomas should be understood as a spectrum.

Combined Hepatocellular-Cholangiocarcinoma: Changes in the 2019 World Health Organization Histological Classification System and Potential Impact on Imaging-Based Diagnosis

Combined hepatocellular-cholangiocarcinoma (cHCC-CCA) is a primary liver cancer (PLC) with both hepatocytic and cholangiocytic phenotypes. Recently, the World Health Organization (WHO) updated its histological classification system for cHCC-CCA. Compared to the previous WHO histological classification system, the new version no longer recognizes subtypes of cHCC-CCA with stem cell features. Furthermore, some of these cHCC-CCA subtypes with stem cell features have been recategorized as either hepatocellular carcinomas (HCCs) or intrahepatic cholangiocarcinomas (ICCs). Additionally, distinctive diagnostic terms for intermediate cell carcinomas and cholangiolocarcinomas (previous cholangiolocellular carcinoma subtype) are now recommended. It is important for radiologists to understand these changes because of its potential impact on the imaging-based diagnosis of HCC, particularly because cHCC-CCAs frequently manifest as HCC mimickers, ICC mimickers, or as indeterminate on imaging studies. Therefore, in this review, we introduce the 2019 WHO classification system for cHCC-CCA, illustrate important imaging features characteristic of its subtypes, discuss the impact on imaging-based diagnosis of HCC, and address other important considerations.

Intrahepatic cholangiocellular carcinoma with radiological enhancement patterns mimicking hepatocellular carcinoma

Non-invasive diagnosis of hepatocellular carcinoma (HCC) in cirrhotic patients requires demonstration of wash-in and wash-out on contrast-enhanced imaging. Recent studies have reported misclassification of mass-forming intrahepatic cholangiocarcinoma (MFCCC) as HCC. We aimed to analyze the contrast enhancement patterns of MFCCC, focusing especially on lesions mimicking HCC. We retrospectively evaluated all consecutive patients with MFCCC who underwent surgery between 2007 and 2017. Patients with mixed HCC-MFCCC were excluded. Two expert radiologists reviewed preoperative CT and MRI. Full-nodule hyperenhancement in the arterial phase in conjunction with hypoenhancement in the portal/late phase was classified as an "HCC-like pattern". Imaging of MFCCCs with an HCC-like pattern was reviewed by an additional radiologist blinded to clinical data. Ninety-two patients were analyzed. All patients were investigated with multiphase CT and 85 with MRI. Twelve tumors (13%) showed full-nodule arterial hyperenhancement. Of these, four were hypoenhancing in the portal/late phase. Overall, 4/92 (4%) MFCCCs (4/45 in patients with cirrhosis/hepatitis, 9%) showed an HCC-like pattern accounting for misclassification as HCC on imaging review. HCC-like MFCCCs accounted for 9% of single tumors ≤ 50 mm. All HCC-like MFCCCs occurred in patients with cirrhosis or hepatitis, whereas only 47% of non-HCC-like MFCCCs did so (p = 0.053). After a median follow-up of 29 months, all patients with HCC-like MFCCCs are alive and disease free (median 64 months). In conclusion, MFCCC was misdiagnosed as typical HCC in 4% of all cases and in 9% of patients with single tumors ≤ 50 mm or with cirrhosis/hepatitis. The risk of misdiagnosis should be considered prior to treatment planning.

Imaging features of combined hepatocellular and cholangiocarcinoma compared with those of hepatocellular carcinoma and intrahepatic cholangiocellular carcinoma in a Chinese population

AIM

To determine the enhanced computed tomography (CT) and magnetic resonance imaging (MRI) characteristics of combined hepatocellular carcinoma and cholangiocarcinoma (cHCC-CC) in Chinese patients.

MATERIALS AND METHODS

Patients with histopathologically proven cHCC-CC (n=54) were compared with hepatocellular carcinoma (HCC; n=41) and cholangiocellular carcinoma (CCC; n=41) patients. Clinical information was measured in all patients. Tumour size, tumour margins, signs of cirrhosis, pseudocapsule, capsular retraction, rim enhancement, intrahepatic biliary dilatation, portal vein thrombosis, upper abdominal lymphadenopathy, were assessed on CT and/or MRI. The dynamic pattern of enhancement was also assessed.

RESULTS

The majority (81.5%) of cHCC-CC patients had positive hepatitis B serology. The presence of cirrhosis and tumour blood vessels was comparable in cHCC-CC and HCC, but significantly lower in CCC (p>0.05). The presence of ill-defined margin and regional lymphadenopathy was comparable in cHCC-CC and CCC, but significantly lower in HCC (p>0.05). The pseudocapsule, capsular retraction, biliary dilatation, rim enhancement, and abnormal perfusion were significantly different between the three types of lesions, with cHCC-CC being intermediate between HCC and CCC. Nearly half of the cHCC-CC tumours (25; 46.3%) showed the wash-in and wash-out enhancement pattern; the gradual, persistent, and mixed patterns were seen in 12 (22.2%), 5 (9.3%), and 12 (22.2%) tumours, respectively.

CONCLUSION

The majority of cHCC-CC tumours occur against a background of positive hepatitis B serology and cirrhosis. Imaging findings vary widely between cHCC-CC tumours. In the present series, the enhancement pattern of cHCC-CC tumours was HCC-like in most cases.

How to utilize LR-M features of the LI-RADS to improve the diagnosis of combined hepatocellular-cholangiocarcinoma on gadoxetate-enhanced MRI?

OBJECTIVES

To investigate the diagnostic accuracy of each LR-M feature defined in version 2017 of the Liver Imaging Reporting and Data System (LI-RADS) and determine the optimal LR-M feature for differentiating combined hepatocellular-cholangiocarcinoma (cHCC-CCA) and hepatocellular carcinoma (HCC) on gadoxetate-enhanced magnetic resonance imaging (MRI).

METHODS

Ninety-nine patients with pathologically proven cHCC-CCA (n = 33) or HCC (n = 66) after surgery were identified. Two radiologists retrospectively assessed preoperative gadoxetate-enhanced MRI for features favoring non-HCC malignancies (LR-M features) according to LI-RADS version 2017. Multivariate logistic regression analysis was performed to determine the independent differential features. The sensitivity and specificity for diagnosing cHCC-CCA were calculated for each LR-M feature.

RESULTS

Targetoid appearance showed the highest sensitivity (75.8%, 95% confidence interval [CI] 60.6%, 87.3%) to correctly identify cHCC-CCA as LR-M. At least one LR-M feature was observed in 31 (93.9%) patients with cHCC-CCA and 34 (51.5%) patients with HCC. The sensitivity and specificity for diagnosing cHCC-CCA using the presence of any one of the LR-M features were 93.9% (95% CI 80.7, 98.9) and 48.5% (95% CI 41.9, 51.0), respectively. The presence of three LR-M features yielded the highest diagnostic accuracy of 80.8% (95% CI 72.1, 86.1) with a reduced sensitivity of 54.5% (95% CI 41.4, 62.5).

CONCLUSION

The majority of cHCC-CCA cases can be properly categorized as LR-M when any one of the LR-M features defined in the LI-RADS version 2017 is used as a determiner. However, approximately half of HCC cases also show at least one LR-M feature.

KEY POINTS

• Targetoid appearance, including rim APHE, peripheral "washout" appearance, and delayed central enhancement, was the LR-M feature that identified cHCC-CCA as a non-HCC malignancy with the highest sensitivity. • Most cHCC-CCA cases can be properly categorized as LR-M when the presence of any one of the LR-M features was used as the determiner. • Approximately half of HCC cases also showed at least one LR-M feature.

LI-RADS Classification and Prognosis of Primary Liver Cancers at Gadoxetic Acid-enhanced MRI

Purpose To (a) evaluate the postsurgical prognostic implication of the Liver Imaging Reporting and Data System (LI-RADS) categories of primary liver cancers and (b) determine the performance of LI-RADS version 2017 in differentiating hepatocellular carcinoma (HCC) from intrahepatic cholangiocarcinoma (IHCC) and combined hepatocellular-cholangiocarcinoma (cHCC-CC) at gadoxetic acid-enhanced MRI. Materials and Methods In this retrospective study, 194 patients with cirrhosis and surgically proven single primary liver cancer (53 with cHCC-CC, 44 with IHCC, and 97 with HCC) were evaluated with gadoxetic acid-enhanced MRI between 2009 and 2014. The mean patient age was 57 years (age range, 30-83 years). There were 155 men with a mean age of 56 years (range, 30-81 years) and 39 women with a mean age of 58 years (range, 38-83 years). Two independent readers assigned an LI-RADS category for each nodule. Overall survival (OS), recurrence-free survival (RFS), and their associated factors were evaluated by using the Kaplan-Meier method, log-rank test, and Cox proportional hazard model. Results In the multivariable analysis, the LI-RADS category was an independent factor for OS (hazard ratio, 4.2; P < .001) and RFS (hazard ratio, 2.6; P = .01). The LR-M category showed more correlation with poorer OS and RFS than did the LR-4 or LR-5 category for all primary liver cancers (P < .001 for both), HCCs (P = .01 and P < .001, respectively), and cHCC-CCs (P = .01 and P = .03, respectively). The LR-5 category had a sensitivity of 69% (67 of 97) and a specificity of 87% (84 of 97) in the diagnosis of HCC; most false-positive diagnoses (85%, 11 of 13) were the result of misclassification of cHCC-CCs. Conclusion The Liver Imaging Reporting and Data System (LI-RADS) category was associated with postsurgical prognosis of primary liver cancers, independent of pathologic diagnosis. The LI-RADS enabled the correct classification of most hepatocellular carcinomas (HCCs) and intrahepatic cholangiocarcinomas, whereas differentiation of combined hepatocellular-cholangiocarcinoma from HCC was unreliable. © RSNA, 2018 Online supplemental material is available for this article. See also the editorial by Bashir and Chernyak in this issue.

Response to Loco-Regional Therapy Predicts Outcomes After Liver Transplantation for Combined Hepatocellular-Cholangiocarcinoma

INTRODUCTION AND AIM

Combined hepatocellular-cholangiocarcinoma (HCC-CCA) is a rare liver malignancy distinct from either hepatocellular carcinoma (HCC) or cholangiocarcinoma. Liver transplantation (LT) is not recommended for HCC-CCA because of suboptimal outcomes. Non-invasive diagnosis of HCC-CCA is extremely challenging; thus, some HCC-CCAs are presumed as HCC on imaging and listed for LT with the correct diagnosis ultimately made on explant pathology. We compared HCC-CCA with HCC to determine the utility of response to pre-transplant loco-regional therapy (LRT) in predicting outcomes for HCC-CCA after LT as a potential means of identifying appropriate HCC-CCA patients for LT.

MATERIAL AND METHODS

Retrospective review of 19 patients with pathologically confirmed HCC-CCA were individually matched to 38 HCC patients (1:2) based on age, sex, and Milan criteria at listing was performed. The modified response evaluation criteria in solid tumors was used to categorize patients as responders or non-responders to pre-transplant LRT based on imaging performed before and after LRT. Overall survival (OS) and recurrence-free survival (RFS) were examined.

RESULTS

OS at 3 years post-transplant was 74% for HCC-CCA and 87% for HCC. RFS at 3 years was 74% for HCC-CCA, and 87% for HCC. Among responders to LRT, the 3-year OS was 92% for HCC-CCA and 88% for HCC; among non-responders, 3-year OS was 43% for HCC-CCA and 83% for HCC. Higher 3-year OS was observed among HCC-CCA responders (77%) compared with HCC-CCA non-responders (23%).

CONCLUSIONS

OS was similarly high among.

The Predictive Value of Staging Systems and Inflammation Scores for Patients with Combined Hepatocellular Cholangiocarcinoma After Surgical Resection: a Retrospective Study

BACKGROUND

Combined hepatocellular cholangiocarcinoma (cHCC-CC) is a rare form of primary liver tumor. A specific staging system for predicting survival in patients with cHCC-CC is not available. The aim of the present study was to evaluate the ability of staging systems and inflammation-based scores to predict overall survival (OS) and progression-free survival (PFS) of patients with cHCC-CC after surgical resection.

METHODS

The data from 99 patients with cHCC-CC after surgical resection from June 2000 and January 2017 were retrospectively collected. Patients were allocated into HCC (hepatocellular carcinoma)-dominant (IHD) group and ICC (intrahepatic cholangiocarcinoma)-dominant (IID) group based on radiological characteristics. Similarly, patients were also divided into HCC-dominant (PHD) group and ICC-dominant (PID) group based on pathological characteristics. Univariate and multivariate analyses were performed to identify variables associated with OS and PFS. The prognostic value of staging systems and inflammation-based scores were analyzed and compared using receiver operating characteristic (ROC) curves.

RESULTS

The 1-, 2-, and 3-year OS rates were 82.6, 66.3, and 59.6%, respectively. The 1-, 2-, and 3-year PFS rates were 52.2, 38.1, and 31.5%, respectively. Independent prognostic factors identified by multivariate analyses included HCC-TNM staging system and tumor diameter both for OS and PFS analyses. HCC-TNM staging system displayed higher area under ROC curve (AUC) values than the other staging systems or inflammation-based scores.

CONCLUSIONS

HCC-TNM staging system was able to adequately predict prognosis of patients with cHCC-CC after surgical resection, especially for patients with HCC-dominant characteristics in clinical practice.

The effectiveness of transarterial chemoembolization in recurrent hepatocellular-cholangiocarcinoma after resection

Background

Combined hepatocellular-cholangiocarcinoma (cHCC-CC) can present as a hypervascular or peripherally enhancing tumor in dynamic imaging. We evaluated the effect of transarterial chemoembolization (TACE) on prognosis according to post-operative recurrence imaging patterns.

Methods

We retrospectively analyzed 42 cHCC-CC and 59 hepatocellular carcinoma (HCC-control) patients at the Asan Medical Center. We classified recurrent cHCC-CC according to enhancement pattern (globally enhancing: GE cHCC-CC, peripherally enhancing: PE cHCC-CC) and evaluated tumor response, time-to-local progression (TTP_local), and overall survival (OS).

Results

The GE cHCC-CC group had a significantly higher best objective response rate (complete remission + partial response) than the PE cHCC-CC group (36% vs 0%, P = 0.005), and it was comparable to that of the HCC-control group (35.6%, P = 0.97). TTP_local in the GE cHCC-CC group was significantly shorter than in the HCC-control group (6.6 vs 27.1 months, P < 0.001), and was not significantly different from that in the PE cHCC-CC group (5.3 months, P = 0.12). OS was 12.4 months, 52.8 months, and 67.5 months in the PE cHCC-CC, GE cHCC-CC, and HCC-control groups, respectively (Ps < 0.05). The adjusted hazard ratios (HRs) for TTP_local and OS revealed an independent association with enhancement pattern of recurrent cHCC-CC (TTP_local: HR 2.46; 95% CI 1.10–5.46; P = 0.03; OS: HR 5.97; 95% CI 2.38–14.96; P < 0.001).

Conclusions

The GE cHCC-CC group showed better response and prognosis after TACE than the PE cHCC-CC group, but poorer response and prognosis than the HCC-control group. Enhancement patterns at recurrence were crucially associated with tumor response and overall survival.

Recurrent infectious subcapsular renal hematoma accompanied by microaneurysm

An 80-year-old woman was admitted to the hospital complaining of loss of appetite. 10 days earlier, her oral intake gradually decreased with no other specific symptoms, such as abdominal pain, nausea, vomiting, headache, or low back pain. Abdominal computed tomography (CT) scan revealed a left subcapsular renal hematoma. We suspected infective subcapsular renal hematoma, so percutaneous needle aspiration and drainage were performed. Intravenous sulbactam-ampicillin was started immediately. On day 9 after admission, repeat CT scan revealed the subcapsular hematoma had reduced in size. The drain was removed, and intravenous antibiotics were discontinued. Follow-up CT scan on day 21 revealed increased subcapsular renal hematoma size. The patient also had high fever. Suspecting recurrence of infective subcapsular renal hematoma, we repeated the drainage of the hematoma and restarted intravenous antibiotics. Renal arteriography showed a renal artery microaneurysm and her condition improved with renal artery embolization. Renal arteriography was useful for detecting renal artery microaneurysm in infective subcapsular renal hematoma that did not resolve after antibiotic treatment and drainage.

Imaging features of combined hepatocellular-cholangiocarcinoma on contrast-enhanced ultrasound: correlation with clinicopathological findings

AIM

To evaluate the relationship between the imaging features of combined hepatocellular-cholangiocarcinoma (CHC) on contrast-enhanced ultrasound (CEUS) and clinicopathological findings.

MATERIALS AND METHODS

From August 2004 to August 2016, 40 patients (29 males, 11 females; mean age 52.8±11.2 years) with histopathologically proven CHC were investigated. The CEUS imaging features and clinicopathological findings of CHC were analysed and compared retrospectively.

RESULTS

On CEUS, peripheral irregular rim-like enhancement, diffuse heterogeneous enhancement, and diffuse homogeneous enhancement was illustrated in 13 (32.5%), 21 (52.5%), and six (15%) lesions, respectively. Histopathological findings showed hepatocellular carcinoma (HCC) predominance and cholangiocarcinoma (CC) predominance throughout the tumour were illustrated in 21 (52.5%) and 19 (47.5%) cases, respectively. HCC-predominant CHCs displayed diffuse heterogeneous enhancement more frequently than peripheral irregular rim-like enhancement (p=0.005), whereas CC-predominant CHCs displayed peripheral irregular rim-like enhancement more frequently than diffuse heterogeneous enhancement and homogeneous enhancement (p=0.005 and p=0.01, respectively). CHCs >5 cm displayed diffuse heterogeneous enhancement more frequently than diffuse homogeneous enhancement, whereas CHCs ≤5 cm displayed diffuse homogeneous enhancement more frequently than diffuse heterogeneous enhancement (p=0.004).

CONCLUSION

The enhancement pattern of CHC on CEUS depended on the relative proportions of the HCC and CC components and showed size-dependent characteristics.