Fibrolamellar carcinoma of the liver. Review of three cases and the presentation of a characteristic set of tumor markers defining this tumor

Fibrinogen and tumors

Elevated plasma fibrinogen (Fg) levels consistently correlate with an unfavorable prognosis in various tumor patient cohorts. Within the tumor microenvironment, aberrant deposition and expression of Fg have been consistently observed, interacting with multiple cellular receptors and thereby accentuating its role as a regulator of inflammatory processes. Specifically, Fg serves to stimulate and recruit immune cells and pro-inflammatory cytokines, thereby contributing to the promotion of tumor progression. Additionally, Fg and its fragments exhibit dichotomous effects on tumor angiogenesis. Notably, Fg also facilitates tumor migration through both platelet-dependent and platelet-independent mechanisms. Recent studies have illuminated several tumor-related signaling pathways influenced by Fg. This review provides a comprehensive summary of the intricate involvement of Fg in tumor biology, elucidating its multifaceted role and the underlying mechanisms.

A Light Microscopic and Ultrastructural Study of Two Cases of Fibrolamellar Hepatocellular Carcinoma

We describe two cases of fibrolamellar hepatocellular carcinoma of the liver in two young women. Both patients presented with diffuse intra-abdominal metastases; nevertheless they had a survival of 28 and 32 months, respectively, which sustains the better prognosis of this neoplasm. Electron microscopy of one case confirmed the oncocytic features of the neoplastic cells and showed intra- and intercellular duct-like vacuoles with numerous microvilli containing a microfilament core that terminated in a terminal web, which represents an unusual aspect in the spectrum of differentiation of fibrolamellar hepatocellular carcinoma.

Fibrolamellar hepatocellular carcinoma: current clinical perspectives

Fibrolamellar carcinoma (FLC) is a variant of hepatocellular carcinoma (HCC), which comprises ∼1%–9% of all HCCs. Although FLC is a variant of HCC, it is distinct from HCC in that it most often affects younger patients (10–35 years of age) with no underlying liver disease. FLC often presents with vague abdominal pain, nausea, abdominal fullness, malaise, and weight loss. Surgery is the current mainstay of treatment for FLC and remains the only potentially curative option. While FLCs are considered less responsive to chemotherapy than their classic HCC counterparts, there have been suggestions that multimodality treatments may be effective, especially in advanced cases. Further research is necessary to determine effective systemic therapies as an adjunct to surgery for FLC.

Fibrolamellar carcinoma: 2012 update

Fibrolamellar carcinomas are a unique type of primary liver cancer. They occur most commonly in children and young adults. Their etiology remains a mystery, as they are not associated with chronic liver disease. Fibrolamellar carcinomas are not indolent tumors, but have an overall better prognosis than typical hepatocellular carcinomas, in part because of the younger age at presentation and the lack of cirrhosis. The most important prognostic feature is whether the tumor is resectable. Histologically, the tumor is made up of large cells that contain abundant mitochondria. The nuclei of the tumor cells have prominent nucleoli. The tumor cells induce the formation of extensive intratumoral fibrosis, which often grows in parallel, or lamellar bands. The tumor cells clearly show hepatocellular features but are also unique in showing both biliary and neuroendocrine differentiation. The uniqueness of fibrolamellar carcinoma extends to their molecular findings. While the genetic abnormalities that lead to fibrolamellar carcinomas are not yet known, studies have shown that they lack mutations in the genes most commonly mutated in typical hepatocellular carcinoma (TP53 and CTNNB1). In this paper, the clinical, pathological, and basic science literature on fibrolamellar carcinoma is comprehensively reviewed. Key areas of needed research are also discussed.

Mediastinal metastasis from a fibrolamellar hepatocellular carcinoma: Report of a case

Fibrolamellar hepatocellular carcinoma (FL-HCC) is an uncommon clinicopathological variant of hepatocellular carcinoma (HCC). The etiology of FL-HCC is unknown, but FL-HCC is not associated with hepatic viruses or alcohol. Hepatocellular carcinoma usually occurs in cases of chronic hepatitis or cirrhosis, whereas FL-HCC predominantly occurs in a normal liver and in younger adults. Fibrolamellar HCC shows relatively slow growth, and late recurrence is common. Repeated resections for recurrences should be considered not only because there is a lack of other effective treatment options but also because FL-HCC shows a relatively better prognosis after a resection in comparison to common HCC. This report presents a case of a rare mediastinal metastasis from FL-HCC in a patient who had undergone a previous resection for retroperitoneal metastasis after the initial hepatic operation. This is the second report of the same case. This patient also had a mediastinal neurogenic tumor, and these mediastinal tumors were concurrently resected.

Fibrolamellar hepatocellular carcinoma

Fibrolamellar hepatocellular carcinoma (FHLCC) generally occurs in young individuals lacking a background of chronic liver disease and other risk factors for hepatocellular carcinoma. The clinical presentations of FLHCC are generally nonspecific, and the alpha-fetoprotein level is typically within the normal range in most cases. Imaging studies have a major role in clinical diagnosis, but pathology is the gold standard in confirming diagnosis. Pathological characteristics of FLHCC include the presence of tumor cells with a deeply eosinophilic cytoplasm and macronucleoli surrounded by abundant fibrous bands. The most effective treatment for FLHCC is aggressive surgical resection. This comprehensive literature review gives a full account of the clinical, pathological, and molecular features of FLHCC.

Fibrolamellar carcinoma presenting as a pancreatic mass: case report and review of the literature

Fibrolamellar carcinoma is a subtype of hepatocellular carcinoma with distinct clinicopathologic features including presentation at a younger age. Although early studies suggested that fibrolamellar carcinoma had a better prognosis than conventional hepatocellular carcinoma, most later studies have found no difference. Patients often have lymph node metastases at presentation in addition to the hepatic primary. We describe an unusual case in a Thai boy who presented with a pancreatic mass that was clinically suspected to be a primary pancreatic tumor, but on biopsy was found to be metastatic fibrolamellar carcinoma. To our knowledge, this manner of presentation has not been previously reported for fibrolamellar carcinoma, nor has metastatic spread to the pancreas.

[Diagnosis and differential diagnosis of hepatocellular carcinoma]

The incidence of hepatocellular carcinoma (HCC) will continue to increase for the next decade due to a latency of about 30 years due to cirrhosis caused by chronic hepatitis C. The diagnosis of an underlying cirrhosis is of diagnostic importance. According to WHO guidelines, HCC encompasses the following: trabecular, pseudoglandular, acinar, compact, scirrhous and fibrolamellar subtypes. Cytological appearance includes hepatocellular pleomorphic, clear cell and sarcomatous subtypes. Tumor cells in hepatocellular carcinoma may display intracytoplasmic inclusions that are helpful for establishing the diagnosis. Differential diagnosis has to be considered for such hepatic tumors as adenoma and precancerous lesions such as dysplastic nodules or mesenchymal tumors. Metastases in the liver may be difficult to differentiate, especially for primary tumors from the gastrointestinal tract which may be similar to glandular or scirrhous type of HCC. The existence of underlying cirrhosis is helpful for the diagnosis and an ample spectrum of antibodies against liver antigens and adenocarcinomas are commercially available to confirm the correct diagnosis.

Clinical and pathologic factors associated with survival in young adult patients with fibrolamellar hepatocarcinoma

Background

Fibrolamellar Carcinoma (FLC), a subtype of hepatocellular carcinoma (HCC), is a rare primary hepatic malignancy. Several aspects of the clinic features and epidemiology of FLC remain unclear because most of the literature on FLC consists of case reports and small cases series with limited information on factors that affect survival.

Methods

We did a retrospective analysis of the clinical and histological characteristics of FLC. We also determined the rate of cellular proliferation in biopsies of these tumors. We assessed whether these variables were associated with survival.

Results

We found 15 patients with FLC out of 174 patients with HCC (8.6%). Between patients with these neoplasms, we found statistically significant survival, age at onset, level of alpha fetoprotein, and an earlier stage of the disease. The 1, 3 and 5 year survival in patients with FLC was of 66, 40 and 26% respectively. The factors associated with a higher survival in patients with FLC were age more than 23 years, feasibility of surgical resection, free surgical borders, absence of thrombosis or invasion to hepatic vessels and the absence of alterations in liver enzymes. The size of the tumor, gender, cellular proliferation and atypia did not affect the prognosis.

Conclusion

We concluded that FLC patients diagnosed before 23 years of age have worse prognosis than those diagnosed after age 23. Other factors associated with worse prognosis in this study are: lack of surgical treatment, presence of positive surgical margins, vascular invasion, and altered hepatic enzymes.

Fibrolamellar hepatocellular carcinoma. Case reports and a review of the literature

Fibrolamellar hepatocellular carcinoma is an uncommon malignancy seen in young adults without underlying liver disease. Physical signs are minimal and laboratory values are noncontributory. Diagnosis is suggested by clinical history, supported by radiographic studies, and confirmed by histologic examination. Individuals with fibrolamellar carcinoma generally have a greater survival than those with hepatocellular carcinoma. Although most patients with fibrolamellar carcinoma undergo curative surgery, two of the three patients we report had inoperable tumors.

[Fibrolamellar carcinoma]

Fibrolamellar carcinoma (FL-Ca) is a primary malignant liver tumor at unknown etiology, without cirrhosis and usually without an increase at tumor markers, which occurs mainly in young patients. As it can simulate malignant and benign tumors, particularly FNH, diagnosis is difficult. Ultrasound and angiography show mostly uncharacteristic features. The highest specificity has CT, if calcifications are present, because these calcifications in a tumor similar to FNH are pathognomonic for FL-Ca. In MRI the central scars of FL-Ca and FNH have a different signal intensity in T2-weighted images, so that MRI becomes more and more important in the differential diagnosis to FNH.

Hepatic neoformations

The aim of the paper is an accurate histologic description and illustration of those liver lesions that are usually summarized under the heading of "hepatic tumors and related subjects". For in some cases it may be unclear or at least controversial, whether the individual lesion is indeed an autonomous neoplasia or a malformation, regeneration or hyperplasia, the indifferent master term of neoformation is introduced, based on the fact that all of them are characterized by a cellular multiplication. According to common definitory practice the survey distinguishes between mesenchymal (angiomatous and non angiomatous) and epithelial neoformations. Among the latter hepatocellular and cholangiocellular types are distinguished, the criterium for differentiation being a phenomenological one, which is by no means identical with a histogenetical statement. The definition of subgroups mostly adheres to current nomenclatory usage; only occasionally--in the group of endothelial tumors--a novel term is employed, in view of brevity and coordination with the overall system of neoformations.

Resection of presumed benign liver tumours

The surgical treatment of benign liver tumours (focal nodular hyperplasia (FNH) and hepatic adenoma) remains controversial. From 1984 to 1990, all 51 women aged below 50 years who presented with presumed benign liver tumours and without chronic liver disease underwent tumour resection. Preoperative assessment included liver tests, ultrasonography and dynamic computed tomography in all patients, plus angiography (n = 20), magnetic resonance imaging (n = 22) and technetium-sulphur colloid liver scintigraphy (n = 19). The aims of this study were to compare preoperative and final pathological diagnosis and determine whether surgical treatment was justified. Preoperative assessment suggested FNH in 18 patients and hepatic adenoma in 11. In 22 patients, the distinction between FNH and adenoma could not be determined before operation. Operative procedures included resection of one segment or less in 22 patients, two segments in 14 and three or more segments in 15. There was no postoperative death and no serious complication. The final diagnosis after pathological examination of resected specimens was FNH in 36 patients (71 per cent), including the 18 presumed before operation to have FNH, hepatic adenoma in 12 (24 per cent) and malignant lesions in three (6 per cent): hepatocellular carcinoma (HCC) arising in normal liver, fibrolamellar carcinoma, and adenoma containing areas of HCC in one patient each.

IN CONCLUSION

(1) precise preoperative diagnosis of benign liver tumours remains difficult despite new imaging methods; (2) malignant liver tumours can go unrecognized; and (3) resection of all these lesions can be carried out safely. Resection of presumed benign liver tumours should be performed in young women when a preoperative diagnosis of FNH is not firmly established.

Fibrolamellar carcinoma of the liver--a case report

A 36-year-old woman was admitted to our hospital because of general fatigue. The physical and laboratory findings on admission revealed splenomegaly, pancytopenia, hypocoagulopathy, liver hypofunction with a hepaplastin test of 55% and ICG Rmax of 0.6 mg/kg/min. Diagnostic imaging showed a hypoechoic mass 1.5 in diameter a low density area on the CT scan and a faint tumor stain on the AAG in the posterior inferior area of the liver. On a diagnosis of hepatocellular carcinoma with liver cirrhosis and hypersplenism, partial hepatectomy and splenectomy were performed. The resected hepatic specimen revealed a small liver cancer of 1.9 x 1.5 x 1.3 cm with liver cirrhosis. The specimen consisted of a firm rubbery mass. Macroscopically, the tumor appeared oval and was lobulated with a thin capsule. A fibrous scar was observed in the central area. Microscopically, malignant hepatocytes showed various shapes, ranging from polygonal to spindle form, with eosinophilic granular cytoplasm and were surrounded by abundant fibrous stroma. Orcein stain, revealed that these malignant hepatocytes contained many black granules of copper-binding protein. Immunoperoxidase staining for alpha 1-antitrypsin was also positive in the malignant hepatocytes. However, within this lamellar fibrous regions, there were many cords of tumor cells in which nucleoli were absent and abortive biliary differentiation was suggested. Consequently this tumor was diagnosed as an atypical fibrolamellar hepatocellular carcinoma. We think that this case is the 3rd case reported in Japan and the 2nd case in a Japanese person.

Cytoreduction and sequential resection: a hope for unresectable primary liver cancer

For decades, unresectable primary liver cancer (PLC) determined by operation was incurable. However, a retrospective study of 24 years' materials with unresectable PLC indicated that 5-year survival of unresectable PLC has increased from 0% in 1966-1977 (n = 137) to 16.9% in 1978-1989 (n = 345). This encouraging improvement was mainly a result of cytoreduction therapy followed by sequential resection. Multimodality combination treatment with hepatic artery ligation, plus hepatic artery infusion with chemotherapy, plus radioimmunotherapy (or radiotherapy) yielded the highest sequential resection rate (30.6%) and 5-year survival (28.0%) as compared with double combination and single modality treatment. The 5-year survival of 33 patients receiving sequential resection after cytoreduction therapy was 63.2%. It is suggested that cytoreduction and sequential resection might offer a hope for surgically verified unresectable PLC.

Some histological remarks on the fibrolamellar carcinoma of the liver

Investigations on five fibrolamellar carcinomas of the liver suggest that this tumor originates from purely epithelial proliferations, while the ensuing fibrous growth leading to lamellar formations is but a secondary event. Nevertheless, progressing fibrosis has a considerable influence on cell shape as the surrounded cell complexes are quasi immured, and their supply and transport procedures impaired. Its influence further evokes a compensatory increase of mitochondria so that, in advanced cases, these cells may be mistaken for genuine oncocytes, although the appraisal of an oncocytic tumor is not confirmed. At this point only, increased amount of fibrinogen-containing (endoplasmic) vacuoles and PAS positive globuli are interpreted as phenomena of cellular retention, and so is the accumulation of unexcretable copper. Ultimately, this fibrous incarceration will cause cell death, destruction and depletion resulting in abundant scarring especially in the center of the focus, without, however, signalling any close relationship with focal nodular hyperplasia. Excess fiber formation exerts a proliferation-inhibiting effect resulting in slower growth and consequently, in the more favorable prognosis of this tumor of distinctive and well-characterized morphology.

Radioimmunotherapy in the multimodality treatment of hepatocellular carcinoma with reference to second-look resection

Experimental study using nude mice human hepatocellular carcinoma (HCC) xenograft indicated that the combination treatment with iodine 131 (131I)-anti-human HCC isoferritin (131I-isoFtAb), cisplatin, and mixed bacterial vaccine (MBV) yielded better inhibition rate as compared with double combination or 131I-isoFtAb alone. Based on these findings, 25 patients with surgically proven nonresectable and pathologically proven HCC have been treated by radioimmunotherapy using 131I-isoFtAb intrahepatic arterial infusion as a part of multimodality treatment. Of the 25 patients, seven (28.0%) received second-look resection after marked shrinkage of tumor. The 1-year survival was 52.5% (12/23) and 2-year survival 27.7% (five of 18) in the entire series. Of the five patients with 2-year survival, four were in the second-look resection group. Patients with tumor less than or equal to 8 cm showed higher second-look resection rate (62.5% versus 11.8%) and 1-year survival (85.7% versus 37.5%) as compared with tumor greater than 8 cm. Mixed bacterial vaccine as adjuvant immunotherapy seemed effective to prolong survival. The 2-year survival was higher in patients with second-look resection as compared with those without (75.0% versus 14.3%). Thus, radioimmunotherapy using 131I-isoFtAb might be one of the modalities of choice, particularly in the conversion of nonresectable to resectable HCC in a well-designed multimodality treatment regimen.

Stress bleeding prophylaxis with sucralfate. Pathophysiologic basis and clinical use

The development of acute stress bleeding in intensive-care patients occurs on a multifactorial basis. The basic mechanism lies in the imbalance between aggressive and protective factors. Most intensive care patients show a reduced acid secretion, a reduction of the gastric mucosal blood flow, and a decreased mucus and bicarbonate secretion. Sucralfate enhances most of the defensive mechanisms. These actions are the pathophysiologic basis of the efficacy of sucralfate in the prevention of stress bleeding. Because sucralfate has only a minor influence on the gastric pH and at the same time has proven bactericidal effects, gastric and gut bacterial overgrowth is significantly reduced. These effects explain the observed differences in mortality between sucralfate and alkalinizing drugs like antacids or H2-antagonists. The indications and limits of sucralfate in stress bleeding prophylaxis are pointed out.

Histologic markers in primary and metastatic tumors of the liver

To investigate the value of different tissue markers in the histologic diagnosis of hepatic tumors, we performed immunoperoxidase stains for alpha-fetoprotein (AFP), alpha-1-antitrypsin (AAT), carcinoembryonic antigen (CEA), and an erythropoiesis-associated antigen (ERY-1) on formalin-fixed, paraffin-embedded samples from 107 primary and metastatic tumors of the liver. AFP was present in 17% of the hepatocellular carcinomas, in 7% of the metastatic carcinomas, and in none of the cholangiocarcinomas. AAT was present in 41% of the hepatocellular carcinomas, in 37% of the cholangiocarcinomas, and in 50% to 70% of the metastatic carcinomas of the liver. Intracytoplasmic CEA was found in 75% of the cholangiocarcinomas, in 92% to 100% of the metastatic carcinomas, and in only one of the mixed hepatocellular-cholangiocarcinomas. ERY-1 was present in 89% of the hepatocellular carcinomas, whereas none of the cholangiocarcinomas or metastatic carcinomas stained for this marker. We conclude that immunohistochemical assays for AFP and AAT are of limited value in the differential diagnosis of hepatic tumors. However, immunohistochemical stains for ERY-1 and CEA can be valuable in differentiating hepatocellular carcinomas from metastatic tumors.

Fibrolamellar carcinoma as a cause of bile duct obstruction

Obstructive jaundice due to growth within bile ducts of hepatocellular carcinoma is uncommon and usually a manifestation of advanced, lethal tumour. We report a case of fibrolamellar carcinoma of the liver presenting with obstructive jaundice, caused by tumorous permeation of the left hepatic duct with migration of tumour fragments into the common bile duct. Immunocytochemical and ultrastructural features are described. Two and a half years after complete surgical resection the patient is free of tumour. The importance of accurate diagnosis of such tumours is emphasized.

Fibrolamellar carcinoma of the liver: an immunohistochemical study of nineteen cases and a review of the literature

Hepatocellular carcinoma (HCC) is a rapidly fatal neoplasm of high worldwide prevalence. Fibromellar carcinoma (FLC), a variant of HCC, lacks the dismal prognosis of "ordinary" HCC (O-HCC) and is characterized by a diagnostic histologic appearance. The current study analyzes the clinical characteristics, immunohistochemistry, and treatment of nineteen cases of FLC. These data, together with a detailed review of the literature, further characterize this unique variant. FLC affects younger patients and lacks the male predominance of O-HCC. Also, FLC lacks specific association with cirrhosis, hepatitis B virus infection, use of oral contraceptives, and alcohol abuse, all of which are implicated in other hepatic tumors. This, along with differences in serum tumor marker prevalence (AFP, B12 binding protein) suggests that its pathogenesis differs from that of O-HCC. Despite these differences, FLC shares a common differentiation with O-HCC. The increased amounts in FLC of stainable alpha-1-antitrypsin, fibrinogen, and C-reactive protein, all of which are acute phase reactants and normal hepatocyte products, implies better differentiation of FLC cells. Finally, the better prognosis of FLC is supported by this study, since only two of the 19 patients died because of tumor. This contrasts with the reported survival of patients with O-HCC, usually measured in weeks. Hepatic transplantation may hold promise for future patients with "surgically unresectable" FLC as procedure-related complications are overcome.

Hepatocellular carcinoma: importance of histologic classification as a prognostic factor

The characteristics and clinical courses of 15 patients with fibrolamellar carcinoma have been compared to 62 patients with hepatocellular carcinoma treated over the same time period. Marked differences were found in patient, tumor, and treatment characteristics. Survival rates in these two groups of patients have been compared by univariate analysis of the subsets of those patient, tumor, and treatment characteristics. The longer survival of the group of patients with fibrolamellar carcinoma could not be accounted for by the prevalence or absence of any of these characteristics. Comparison of subsets of patients with documented noncirrhotic livers or those having complete resection of their tumors revealed a significantly prolonged survival in patients with the fibrolamellar variant. The 5 year survival rate of the patients with fibrolamellar carcinoma who had complete tumor resection was 45 percent, with a median survival time of 50 months. The 5 year survival of patients with hepatocellular carcinoma who had complete tumor resection was 0 percent, with a median survival time of 22 months.

Copper and copper-binding protein in liver tumors

The presence of copper and copper-binding protein was histochemically investigated in 39 hepatocellular carcinomas, 24 metastatic tumors of the liver, and eight benign hepatic tumors. None of the hepatocellular carcinomas was fibrolamellar. The presence of copper (demonstrated by rhodanine) and of copper-binding protein (demonstrated by modified orcein) was simultaneously observed in 11 of the 39 hepatocellular carcinomas (28%). Deposition was mild in three cases, moderate in two cases, and marked in six cases, and it was significantly related to the presence of bile within the tumor. Copper and copper-binding protein granules were not found in metastatic tumors of the liver, and were observed in two of the eight cases of benign hepatic tumors. These results suggest that the presence of copper and copper-binding protein in tumor cells may be found in all variants of hepatocellular carcinomas and not only in fibrolamellar carcinomas as previously suggested, and might be helpful in differentiating primary from secondary liver tumors.