Hepatic carcinosarcoma: evidence of polyclonal origin based on microsatellite analysis

Rare primary hepatic carcinosarcoma composed of hepatocellular carcinoma, cholangiocarcinoma, and sarcoma: a case report

Primary hepatic carcinosarcoma (HCS) is an extremely rare malignant tumor of the liver that contains carcinomatous and sarcomatous components. The diagnosis, treatment, and prognosis of HCS pose great challenges to clinicians. Herein, we present a case of HCS in a 67-year-old man with unique pathological manifestation. Preoperative magnetic resonance imaging showed a malignant lesion in the right liver and a small sub-focus in the left liver. Radical treatment was performed, including excision of the right posterior lobe of the liver, thrombectomy of the right posterior portal vein, and radiofrequency ablation of lesions in the left liver. The specimens were confirmed to be HCS by pathological examinations, which revealed a combination of poorly differentiated hepatocellular carcinoma, moderately differentiated cholangiocellular carcinoma, and spindle cell sarcoma. Transhepatic arterial chemotherapy and embolization was performed after surgery. Unfortunately, pulmonary metastasis occurred 1.5 months later, which meant a poor prognosis. In this report, we discuss the clinicopathological characteristics of this case and factors that affected surgical outcomes, which may add some ideas for the future diagnosis and treatment of HCS patients.

Primary Liver Sarcomatoid Carcinoma: A Case Series and Literature Review

Background

Primary liver sarcomatoid carcinoma (PLSC) is rare. To improve the understanding of PLSC, cases were described and reviewing the literature.

Methods

A retrospective analysis was performed on 14 cases of PLSC diagnosed by pathology in Northeastern China from 2010 to 2020. An individual participant data analysis based on reported cases was conducted to determine epidemiological characteristics, clinical characteristics, and prognoses of PLSC.

Results

A total of 136 cases involved our 14 cases and 122 cases from previous reports. The percentages of sarcomatoid hepatocellular carcinoma, sarcomatoid cholangiolocellular carcinoma, and mixed and unclassified types were 36.8%, 41.9%, 5.9%, and 15.4%, respectively. A total of 95.6% PLSC was found in Asia. There was a lower percentage of hepatitis-infected patients in Japan, when compared with the Republic of Korea (38.5% vs 70.0%, P<0.05). Five cases were initially misdiagnosed as a hepatic abscess by imaging. A total of 36.7% cases had metastases when being diagnosed, and 68.9% cases relapsed during the follow-up. The median disease-free survival and overall survival (OS) were 3 months and 5 months, respectively. Only radical surgery (hazard ratio = 0.308, 95% confidence interval 0.186–0.512, P<0.001) indicated a better OS.

Conclusion

PLSC was more prevalent in Asia and there were possibilities of misdiagnoses. Surgery is still an effective treatment and can significantly prolong the OS. Only limited strategies for recurrent or advanced PLSC, immunotherapy may be possible treatment.

Case Report: Review of CT Findings and Histopathological Characteristics of Primary Liver Carcinosarcoma

Objectives: The aim of the present study was to describe the computed tomography (CT) characteristics of primary liver carcinosarcoma (PLCS) and to explore the pathological basis for the diagnosis of primary hepatocellular carcinoma sarcoma.

Methods: Three male patients with PLCS were included in the present retrospective research, and the age was ranged from 52 to 63 years. The plain CT scan and third-stage enhancement scan were performed on patients. The pathological characteristics were analyzed. Stomachache was the main clinical symptoms of the three patients. Cirrhosis background was confirmed in one patients, and chronic Hepatitis B background was confirmed in other two patients.

Results: According to the results of CT, the inner diameter of the tumors ranged from 8.6 to 27.0 cm. The fibrous pseudocapsule around the tumor tissues was observed in two patients. Tumor tissues from all three patients were composed of sarcomatous and carcinomatous components. For carcinomatous components, hepatocellular carcinoma was observed in one patient and cholangiocarcinoma was observed in the other two patients. For sarcomatous components, angiosarcoma was observed in two patients and malignant fibrous histiocytoma was observed in another one patient. The tumor tissues were visualized as heterogeneous low density with large sheets of necrotic cystic lesions or thick-walled areas of multilocular cystic lesions using the plain CT scan. Edge-to-center filling and strengthening lesions, mild to moderate enhanced parenchyma at the arterial phase, and isodensity between the tumor parenchyma and the surrounding liver parenchyma at the portal vein phase or delayed phase were observed using the third-stage enhancement scan.

Conclusions: CT characteristics observed in the present study were of great benefit for the diagnosis of PLCS.

The Clinicopathological and Imaging Characteristics of Primary Hepatic Carcinosarcoma and a Review of the Literature

Purpose

To improve the understanding of hepatic carcinosarcoma (HCS) by analyzing radiological imaging data and clinicopathological features.

Materials and Methods

A retrospective analysis was performed on four patients with HCS confirmed immunohistochemically. The analysis included three males and one female, aged 29 to 64 years. Four patients underwent computed tomography (CT) scans, and one underwent magnetic resonance imaging (MRI) scans simultaneously.

Results

Three patients had a history of hepatitis B, cirrhosis or fibrosis, and two patients had schistosomiasis. Two cases tested positive for elevated serum carbohydrate antigen (CA) 19–9. The maximum diameters of the lesions ranged from 7.8 to 9.0cm. Pathologically, the carcinomatous and sarcomatous elements in two patients could not be classified, one of the patients had cholangiocellular carcinoma (CCC) and undifferentiated sarcoma, the other had hepatocellular carcinoma (HCC) and undifferentiated pleomorphic sarcoma (UPS). All tumors showed heterogeneous density/intensity, accompanied by vast cystic changes and necrosis, with two cases having cystic septations. Capsule formation was not identified. The margins of the radiological images showed irregular ring enhancement. One case presented continuous progressive enhancement, one case with “fast in fast washout” and two cases with “fast in late washout”. Lymphonodus metastasis, satellite nodules, vascular embolism, and organ invasion (hepatic flexure of the colon) were identified.

Conclusion

HCS is a rare, high-grade malignancy with poor prognosis. The preoperative diagnosis is expected to improve by carefully analyzing the imaging features of the patients in combination with their clinical characteristics. Radical resection and postoperative chemoradiotherapy can improve the survival rate of patients.

Efficacy and safety of nivolumab plus apatinib in advanced liver carcinosarcoma: a case report

Liver carcinosarcoma is a rare malignancy usually seen in adults, majority of whom have a history of chronic hepatitis. Radical resection in early stages leads to better prognosis; however, the treatment regimen for patients at advanced stage is usually based on previously published case reports. At present, there is no report on programmed death-1 blockade and liver carcinosarcoma. Here, we report the case of a patient with advanced liver carcinosarcoma treated with nivolumab plus apatinib, which resulted in partial remission. However, grade 3 elevation of aminotransferase occurred during treatment, suggesting that the combination therapy should be recommended only after risk assessment. Nonetheless, programmed death-1 blockade plus apatinib might be a promising therapeutic approach for patients with advanced liver carcinosarcoma.

Molecular profiling of the biphasic components of hepatic carcinosarcoma by the use of targeted next-generation sequencing

AIMS

To better understand the tumourogenesis and molecular features of hepatic carcinosarcoma (HCS).

METHODS AND RESULTS

We selected 13 cases of HCS, including the clinicopathological and immunohistochemical features, and analysed the molecular alterations in separately microdissected carcinomatous and sarcomatous components in eight cases by using targeted next-generation sequencing with a panel of 329 cancer-related genes. As a result, transitional areas were observed between the two components of HCS in all cases. Concordance and overlap in genetic alterations were identified in the two histological components of the eight HCS patients, indicating the clonal relatedness of the two tumour components. The most common gene alterations found in both components were TP53 (75%, 6/8) and NF1/2 (38%, 3/8) mutations and VEGFA amplification (25%, 2/8), which may be strongly associated with HCS tumorigenesis. Unique mutations and amplifications found only in one component were also identified. Amplifications involving MET (38%, n = 3/8) and PDGFRA (25%, n = 2/8) were present only in the sarcomatous components, whereas mutation affecting ERBB4 (25%, n = 2/8) and amplifications of CCND1 and FGF3/4/19 (38%, n = 3/8) were present only in the carcinomatous components, indicating their involvement in the clonal evolution of HCS. Furthermore, multiple potential therapeutic targets were identified for HCS.

CONCLUSIONS

Our findings indicate that HCS could have been of monoclonal origin, and that the diverse clonal evolution might be driven by special molecular alterations in each tumour component. Our results also identify multiple therapeutic targets of HCS, which are valuable for the personalised treatment of HCS.

Multiclonal tumor origin: Evidence and implications

An accurate understanding of the clonal origins of tumors is critical for designing effective strategies to treat or prevent cancer and for guiding the field of cancer risk assessment. The intent of this review is to summarize evidence of multiclonal tumor origin and, thereby, contest the commonly held assumption of monoclonal tumor origin. This review describes relevant studies of X chromosome inactivation, analyses of tumor heterogeneity using other markers, single cell sequencing, and lineage tracing studies in aggregation chimeras and engineered rodent models. Methods for investigating tumor clonality have an inherent bias against detecting multiclonality. Despite this, multiclonality has been observed within all tumor stages and within 53 different types of tumors. For myeloid tumors, monoclonal tumor origin may be the predominant path to cancer and a monoclonal tumor origin cannot be ruled out for a fraction of other cancer types. Nevertheless, a large body of evidence supports the conclusion that most cancers are multiclonal in origin. Cooperation between different cell types and between clones of cells carrying different genetic and/or epigenetic lesions is discussed, along with how polyclonal tumor origin can be integrated with current perspectives on the genesis of tumors. In order to develop biologically sound and useful approaches to cancer risk assessment and precision medicine, mathematical models of carcinogenesis are needed, which incorporate multiclonal tumor origin and the contributions of spontaneous mutations in conjunction with the selective advantages conferred by particular mutations and combinations of mutations. Adherence to the idea that a growth must develop from a single progenitor cell to be considered neoplastic has outlived its usefulness. Moving forward, explicit examination of tumor clonality, using advanced tools, like lineage tracing models, will provide a strong foundation for future advances in clinical oncology and better training for the next generation of oncologists and pathologists.

Primary carcinosarcoma of the liver: imaging features and clinical findings in six cases and a review of the literature

Background

Carcinosarcoma of the liver is a very rare tumor composed of a mixture of carcinomatous and sarcomatous elements. Less than 25 adequately documented cases have been reported, with inadequate description of imaging features. In order to improve the awareness of this rare tumor, this study aimed to analyze the clinicopathologic and imaging features of six cases of hepatic carcinosarcoma (HCS) confirmed by surgical pathologic evaluation.

Methods

We retrospectively studied the clinicopathologic and imaging features of six cases of HCS (matching the World Health Organization definition) and discussed the differential diagnosis on the basis of imaging findings. The patients, including five men and one woman, were 38 to 69 years of age. Five patients underwent CT scans, one underwent MRI scans.

Results

While 3 patients were positive for hepatitis-B surface antigen, 2 had cirrhosis. The largest tumor diameter ranged from 5.0 to 21.0 cm. Satellite nodules, venous thrombi, and organ invasion (gastric wall, gallbladder, and right adrenal gland) were identified. Pathologically, the carcinomatous components corresponded to hepatocellular carcinoma in three cases, cholangiocellular carcinoma in one case, and adenocarcinoma in two cases. The sarcomatous components exhibited complex features, with undifferentiated spindle cells in five cases and a leiomyosarcoma in one. All tumors showed heterogeneous density/intensity with extensive cystic change and necrosis; spot calcification was observed in one case. Capsule was not identified. While four tumors showed heterogeneous hypervascular enhancement, two showed hypovascular enhancement. All patients underwent surgical resection. The follow-up period ranged from 2 to 18 months. Four patients died from recurrence and metastasis.

Conclusions

The clinical and imaging features of HCS are heterogeneous. Due to the heterogenous nature and very low morbidity of HCS, combination of careful analysis of imaging findings and clinical features might be useful for a more accurate diagnosis of HCS.