Clinicopathological features and differential diagnosis of hepatocellular carcinoma in extrahepatic metastases

Chest wall mass as a sign of ignored hepatocellular carcinoma in an alcoholic cirrhotic patient: a case report

Bone metastasis of hepatocellular carcinoma (HCC) is usually seen in the course of advanced intrahepatic HCC. Isolated bone metastasis as an initial manifestation of HCC is uncommon.

CASE PRESENTATION

The authors report a case of a 68-year-old male with a history of chronic alcohol consumption who presented with epigastric pain, abdominal distension, and a hard, tender lump on the right posterolateral aspect of his back. Investigation revealed HCC with isolated metastasis to the posterior thoracic wall.

CLINICAL DISCUSSION

HCC usually develops secondary to chronic hepatitis B and C infection in the background of chronic liver disease. Common presenting symptoms of bone metastasis include local pain, neurological manifestations, palpable subcutaneous masses, and pathological fractures. An immunohistochemistry analysis is important to differentiate HCC from non-HCC metastasis in patients without known underlying HCC. Treatment is often directed towards palliative care as the prognosis is poor.

CONCLUSION

An isolated rib mass can be an initial presentation of metastatic HCC. Thus, HCC with bone metastasis should be considered in the differential diagnosis in patients presenting with painful swelling in the thoracic region.

Potential biomarkers for the early detection of bone metastases

The clinical manifestations of bone metastases are diversified while many sites remain asymptomatic at early stage. As the early diagnosis method is not perfect and the early symptoms of tumor bone metastasis are not typical, bone metastasis is not easy to be detected. Therefore, the search for bone metastasis-related markers is effective for timely detection of tumor bone metastases and the development of drugs to inhibit bone metastases. As a result, bone metastases can only be diagnosed when symptoms are found, increasing the risk of developing skeletal-related event (SREs), which significantly impairs the patient's quality of life. Therefore, the early diagnosis of bone metastases is of great importance for the treatment and prognosis of cancer patients. Changes of bone metabolism indexes appear earlier in bone metastases, but the traditional biochemical indexes of bone metabolism lack of specificity and could be interfered by many factors, which limits their application in the study of bone metastases. Some new biomarkers of bone metastases have good diagnostic value, such as proteins, ncRNAs, circulating tumor cells (CTCs). Therefore, this study mainly reviewed the initial diagnostic biomarkers of bone metastases which were expected to provide references for the early detection of bone metastases.

Sonographic features of thoracoabdominal wall metastases of liver cancer after liver transplantation

Objective

Sonographic features are not well-defined in thoracoabdominal wall metastases (TAWM) of liver cancer after liver transplantation (LT), which is one of the most important reasons affecting the long-term survival of transplant recipients. The purpose of this study was to analyze the sonographic features of TAWM from liver cancer after LT and to identify the role of ultrasound (US) in the differential diagnosis between TAWM and benign lesions of the thoracoabdominal wall after LT.

Methods

This retrospective study included 1,999 LT recipients between January 2008 and July 2021. Clinical characteristics and sonographic features of 32 patients with thoracoabdominal wall lesions were analyzed. The types of thoracoabdominal wall lesions were studied, and the US findings of benign and malignant lesions were compared. Whether TAWM from liver cancer after LT exhibited any distinctive sonographic appearance was evaluated.

Results

All seven malignant cases were metastases from liver cancer. The benign group included 13 cases of thoracoabdominal wallencapsulated effusion/hematoma, nine of abdominal incisional hernia, and three of thoracoabdominal wall inflammatory mass. Sonographic features were significantly different between two groups. Compared with the benign group, metastases lesions were frequently located in the parietal peritoneum/pleura (4/7 vs 1/25, p = 0.009), fewer lesions were located at abdominal incisions (3/7 vs 23/25, p = 0.012), all metastatic lesions were hypoechoic (7/7 vs 5/25, p = 0.001), and most lesions had blood flow signals (4/7 vs 3/25, p = 0.026). Additionally, most metastatic cases had intrahepatic lesions (4/7 vs 1/25, p = 0.004) and multiple extrahepatic solid lesions in the abdomen (6/7 vs 0/25, p = 0.000).

Conclusions

Compared with benign lesions, TAWM of liver cancer after LT exhibited unique sonographic features.

Development and validation of an ensemble machine-learning model for predicting early mortality among patients with bone metastases of hepatocellular carcinoma

Purpose

Using an ensemble machine learning technique that incorporates the results of multiple machine learning algorithms, the study's objective is to build a reliable model to predict the early mortality among hepatocellular carcinoma (HCC) patients with bone metastases.

Methods

We extracted a cohort of 124,770 patients with a diagnosis of hepatocellular carcinoma from the Surveillance, Epidemiology, and End Results (SEER) program and enrolled a cohort of 1897 patients who were diagnosed as having bone metastases. Patients with a survival time of 3 months or less were considered to have had early death. To compare patients with and without early mortality, subgroup analysis was used. Patients were randomly divided into two groups: a training cohort (n = 1509, 80%) and an internal testing cohort (n = 388, 20%). In the training cohort, five machine learning techniques were employed to train and optimize models for predicting early mortality, and an ensemble machine learning technique was used to generate risk probability in a way of soft voting, and it was able to combine the results from the multiply machine learning algorithms. The study employed both internal and external validations, and the key performance indicators included the area under the receiver operating characteristic curve (AUROC), Brier score, and calibration curve. Patients from two tertiary hospitals were chosen as the external testing cohorts (n = 98). Feature importance and reclassification were both operated in the study.

Results

The early mortality was 55.5% (1052/1897). Eleven clinical characteristics were included as input features of machine learning models: sex (p = 0.019), marital status (p = 0.004), tumor stage (p = 0.025), node stage (p = 0.001), fibrosis score (p = 0.040), AFP level (p = 0.032), tumor size (p = 0.001), lung metastases (p < 0.001), cancer-directed surgery (p < 0.001), radiation (p < 0.001), and chemotherapy (p < 0.001). Application of the ensemble model in the internal testing population yielded an AUROC of 0.779 (95% confidence interval [CI]: 0.727-0.820), which was the largest AUROC among all models. Additionally, the ensemble model (0.191) outperformed the other five machine learning models in terms of Brier score. In terms of decision curves, the ensemble model also showed favorable clinical usefulness. External validation showed similar results; with an AUROC of 0.764 and Brier score of 0.195, the prediction performance was further improved after revision of the model. Feature importance demonstrated that the top three most crucial features were chemotherapy, radiation, and lung metastases based on the ensemble model. Reclassification of patients revealed a substantial difference in the two risk groups' actual probabilities of early mortality (74.38% vs. 31.35%, p < 0.001). Patients in the high-risk group had significantly shorter survival time than patients in the low-risk group (p < 0.001), according to the Kaplan-Meier survival curve.

Conclusions

The ensemble machine learning model exhibits promising prediction performance for early mortality among HCC patients with bone metastases. With the aid of routinely accessible clinical characteristics, this model can be a trustworthy prognostic tool to predict the early death of those patients and facilitate clinical decision-making.

Occurrence–regression–recurrence of hepatocellular carcinoma without any intervention: A case report

Background

Spontaneous regression of primary liver cancer is a rare event, and currently the exact pathogenesis of spontaneous tumor regression remains unclear.

Case description

Clinical information was collected from a patient with spontaneous regression of liver cancer at our center. The patient was a 41-year-old male. He was admitted to the hospital on 3 May 2019, due to aversion to fatty or greasy food, anorexia, loss of appetite, and abdominal distension. Laboratory examination results included hepatitis B surface antigen positivity, hepatitis B e antigen positivity, and hepatitis B core antibody positivity and tumor marker levels of alpha-fetoprotein 142,938.20 µg/L, abnormal prothrombin 4,599.91 mAU/ml, and carbohydrate antigen 19–9 82.05 U/ml. Upper abdominal enhanced computed tomography indicated right hepatocellular carcinoma with portal vein tumor thrombus formation. The patient declined any treatment. The tumor in the right lobe of the liver completely regressed after 1 year, and the patient is still undergoing follow-up.

Conclusions

We encountered a hepatocellular carcinoma patient who underwent spontaneous regression, but the exact pathogenesis remains unknown. Understanding the pathogenesis of spontaneous regression of hepatocellular carcinoma has the potential to contribute to the development of an effective treatment for hepatocellular carcinoma.

Common variants in AGR1 genes contributed to the risk and traits of cirrhotic cardiomyopathy in Han Chinese population

Aim: This study aimed to determine the association between polymorphisms of the ARG1 gene and the risk and traits of cirrhotic cardiomyopathy (CCM). Methods: A total of 468 CCM and 1012 cirrhosis patients were enrolled, and 12 single-nucleotide polymorphisms (SNPs) in the ARG1 gene were genotyped. Differences in genotype, allele and haplotype frequencies of the SNPs between the CCM and cirrhosis groups were analyzed by chi-square test. Correlations of the genotypes of SNPs and representative traits of liver and heart function were performed using linear regression analysis. Results: SNPs rs2781666 and rs2781667 were associated with the risk of CCM in both dominant and additive inheritance models. The GG genotype frequency of rs2781666 and CC genotype frequency of rs2781667 were lower in the CCM group than in the cirrhosis group. The G-C haplotype frequency of the block consisting of rs2781666 and rs2781667 was higher and the T-T haplotype frequency was lower in CCM patients than in cirrhosis patients. SNP rs2781666 was associated with the alanine transaminase level, and rs2781667 was associated with the ARG1 level and left atrial diameter. Conclusion: SNPs rs2781666 and rs2781667 in the ARG1 gene were associated with susceptibility to and traits of CCM in the Han Chinese population.

Hemorrhagic Brain Metastasis as an Initial Presentation of Hepatocellular Carcinoma in a Patient With Alcohol-Related Liver Cirrhosis: A Case Report and Review of Literature

Hepatocellular carcinoma (HCC) is the most common primary hepatic cancer. Although it usually presents as a liver mass, rarely HCC can have an initial presentation at an extrahepatic site before the diagnosis of the primary lesion in the liver. Even rarely was that brain metastasis as initial extrahepatic presentations. Furthermore, the initial presentation of HCC as brain metastases has been with most cases being secondary to hepatitis-related hepatoma. In this case report, we are presenting a rare and unusual case of hemorrhagic cerebral metastasis as an initial extrahepatic presentation of an alcohol-related hepatoma. Our case is the second case in the English literature that has been presented in such a way. Due to the uncommonness of presentation, there can be diagnostic dilemmas and delay in treatment. Therefore, a high level of suspicion is needed in the high-risk patients of HCC who present with unexplained or new neurological signs and symptoms. More exploration is warranted for clinical research and treatment guidelines for brain metastases of HCC to help improve survival and quality of life.

Update on Hepatocellular Carcinoma: a Brief Review from Pathologist Standpoint

Hepatocellular carcinoma is one of the most common cancers and an important health problem all over the world. Its prognosis is poor. For better patient care, early diagnosis is essential. Although new imaging techniques have a big impact on hepatocellular carcinoma diagnosis, histopathological examination is still the gold standard for precise diagnosis. Histopathological evaluation gives exact diagnosis in the meaning of tumor size, histological subtypes, grading, and differential diagnosis from metastasis and other tumors. Immunohistochemistry as a part of diagnostic histopathological technique plays an important role in routine practice. Immunohistochemistry is useful for confirming of hepatocytic origin, supporting hepatocellular malignancy, and differential diagnosis. It also gives prognostic information. There are growing attempts to classify tumors by their molecular genetic signatures. This is also actual for hepatocellular carcinoma. This mini review focuses on the histopathology of hepatocellular carcinoma including subtypes; differential diagnosis and immunohistochemistry as an ancillary diagnostic tool, updated or added entities, i.e., combined hepatocellular-cholangiocarcinoma; small hepatocellular carcinoma; correlation with molecular studies; and future perspectives.

A Rare Case of Metastatic Hepatocellular Carcinoma Masquerading as a Forehead Hematoma

Hepatocellular carcinoma (HCC) is the most common primary liver cancer and can arise from any form of chronic liver disease or cirrhosis. With increasing rates of metabolic syndrome and obesity, it is not surprising that NASH is quickly becoming a leading cause of chronic liver disease and HCC in the western hemisphere (Wang and Malhi, 2018). Metastasis is usually found in advanced stages of the disease, owing to its poor prognosis. The lung, bone, and lymph nodes are the most frequent sites of metastasis (Balogh et al., 2016, and Becker et al., 2014). On the other hand, metastasis to the skin and cranium is relatively rare. Literature review reveals less than 10 reported cases in the last 10 years. Herein, we report an unusual case of a “forehead hematoma” leading to the formal diagnosis of metastatic HCC.

High-throughput sequencing-based analysis of gene expression of hepatitis B virus infection-associated human hepatocellular carcinoma

Hepatitis B virus (HBV) infection is a critical factor for the initiation and progression of hepatocellular carcinoma (HCC). Gene expression profiles for HBV-associated HCC may provide valuable insight for the diagnosis and treatment of this type of HCC. The present study aimed to screen the differential genes in human HCC tissues based on high-throughput sequencing and to predict the potential therapeutic targets. Total mRNA was extracted from human HCC tissues and paracancerous tissues and sequenced using the Hiseq4000 sequencing platform. Differential gene expressions were screened and further analyzed using quantitative PCR and immunohistochemistry. A total of 2,386 differentially expressed genes were screened. Of these, 1119 were upregulated and 1,267 were downregulated in paracancerous tissues compared with tumor tissues. Gene Ontology term analysis demonstrated that differentially expressed genes were involved in carboxylic acid catabolism, monocarboxylic acid metabolic processes and α-amino acid metabolic processes. Molecular functional analysis revealed that the differentially expressed genes functioned in oxidoreductase activity, for example acting on CH-OH group of donors and permitting identical protein binding, anion binding, coenzyme binding and monocarxylic acid transporter activity. The Kyoto Encyclopedia of Genes and Genomes analysis reported that the differentially expressed genes were primarily concentrated in 20 signaling pathways, such as valine, leucine and leucine degradation, retinol metabolism and the cell cycle. Differential expression of proteins regulating the cell cycle, including stratifin, cyclin B1 and cyclin-dependent kinase 1, were significantly higher in tumor tissue compared with those in paracancerous tissue at both the mRNA and protein levels. These results were consistent with those obtained from high-throughput sequencing, indicating the reliability of the high-throughput sequencing. Together, these results identified differentially expressed genes and predicted the subsequent signaling pathways, which may be involved in the occurrence and development of HCC. Therefore, the present study may provide novel implications in the therapeutic and diagnosis of HCC.

Diagnostic value of glypican-3, arginase-1 and hepatocyte paraffin antigen -1 in differentiating hepatocellular carcinoma from intrahepatic cholangiocarcinoma

BACKGROUND

The aim of the present study was to investigate the diagnostic value of glypican-3 (GPC3), arginase-1 (Arg-1), and hepatocyte paraffin antigen 1 (HepPar-1) in differentiating hepatocellular carcinoma (HCC) from intrahepatic cholangiocarcinoma (ICC).

METHODS

The expression of GPC3, HepPar-1 and Arg-1 were measured by immunohistochemistry in 47 cases of HCC, 29 cases of ICC and their paracancerous tissues.

RESULTS

A high expression of GPC3, Arg-1 and HepPar-1 was observed in HCC tissues (68.09%, 76.60% and 78.72%, respectively; P>0.0125) while it was lower in ICC tissues (6.90%, 6.90% and 13.79%, respectively; P>0.0125). With regard to specificity, GPC3 performed better than Arg-1 and HepPar-1 (97.37% vs. 1.32% and 2.63%, respectively; P<0.05). The positive rate in poorly differentiated HCC for either GPC3, Arg-1 or HepPar-1 was lower than that in well- and moderately differentiated HCC. The majority of positive samples for GPC3 and Arg-1 were grade 2+ in well-, moderately- or poorly-differentiated HCC. Combined detection of GPC3, Arg-1 and HepPar-1 could increase the sensitivity up to 89.36% and the specificity to 100.00%, comparing with any single biomarker (P<0.05).

CONCLUSIONS

GPC3, Arg-1 and HepPar-1 were all useful biomarkers in differentiating HCC from ICC. The combination models could improve the diagnosis value of HCC and help differentiating HCC from ICC.