Fibrolamellar hepatocarcinoma: radiology, management, and pathology

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.

Hepatic incidentalomas

Recent advances in multidetector-row computed tomography, magnetic resonance imaging, and ultrasonography have led to the detection of incidental hepatic lesions in both the oncology and nononcology patient population that in the past remained undiscovered. These incidental hepatic lesions have created a management dilemma for both clinicians and radiologists. In this review, guidelines concerning the diagnosis and management of some of the more common hepatic incidentalomas are presented.

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.

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: imaging and pathologic findings in 31 recent cases

PURPOSE

To review characteristic findings of fibrolamellar hepatocellular carcinoma (HCC) at computed tomography (CT) and magnetic resonance (MR) imaging.

MATERIALS AND METHODS

The authors retrospectively reviewed the clinical, pathologic, and preoperative imaging findings in 31 patients with histologically proved fibrolamellar HCC. Dynamic contrast material-enhanced CT of the liver was performed in 31 patients, helical multiphase CT in 21, and MR imaging in 11. Complete resection was performed in 17 patients, and imaging-pathologic correlation was performed.

RESULTS

Large tumors (mean diameter, 13 cm) were depicted at CT and MR in all cases. At CT, the margins of the tumors were well defined in 24 (77%) of 31 cases calcifications were depicted in 21 (68%), a central scar in 22 (71%), and abdominal lymphadenopathy in 20 (65%). In 20 (80%) of 25 cases with hepatic arterial phase CT images, all tumors were heterogeneous and depicted areas of hypervascularity. At MR imaging, tumors were hypointense to liver on T1-weighted images (n = 11) and hyperintense to liver on T2-weighted images (n = 10). Calcification was not depicted on MR images, but a central scar was depicted as hypointense to surrounding tumor in nine cases.

CONCLUSION

CT and MR images demonstrate characteristic features that may allow confident diagnosis of fibrolamellar HCC.

Primary hepatic malignant neoplasms

Although metastatic disease is by far the most common form of neoplastic involvement of the liver, a variety of primary hepatic malignant neoplasms may develop from any of the cell types within the liver. Primary hepatic neoplasms include hepatocellular carcinoma, intrahepatic cholangiocarcinoma, biliary cystadenocarcinoma, and a variety of mesenchymal tumors. This article reviews the clinical presentation and pathology of these tumors and discusses their sonographic, CT scan, and MR imaging appearance.

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.

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.

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.

Fibrolamellar carcinoma of the liver in the Orient

We describe, in a 56-year-old man, the first case of fibrolamellar carcinoma of the liver (FCL) in the Orient. Contrary to patients seen in the Western world, our patient has many characteristics of ordinary hepatocellular carcinoma seen in the Orient, i.e., middle age, male, HBsAg carrier, elevated alpha-fetoprotein, presence of HBsAg in the hepatocytes, and chronic hepatitis. These clinicopathological findings suggest a possible relationship between exposure of HB virus and FCL.

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.

The fibrolamellar variant of hepatocellular carcinoma. Its association with focal nodular hyperplasia

A case of fibrolamellar hepatocellular carcinoma (FL-HCC) associated with adjacent focal nodular hyperplasia (FNH) is described. These two regions were adjacent but distinct, both on gross and microscopic examination. Currently, it is unclear whether FL-HCC rarely arises in preexisting FNH, or whether FNH is a typical response to this vascular variant of hepatocellular carcinoma (HCC). The FNH region, which is peripheral, may be biopsied to exclude the underlying carcinoma, and thus lead to inadequate therapy. Previous reports of this association are reviewed.

Primary liver cancer in a referral hospital in Hawaii

This is a retrospective review of 43 patients who had primary liver cancer diagnosed during 1974-1983. Patients' ages ranged from 27 to 84 years (median 52.5). Nine of 39 patients with hepatoma were females, while two of the four patients with cholangiocarcinoma were women. Hepatitis surface antigen was positive in 90% tested, and 62% had cirrhosis. Also, 60-65% were heavy users of alcohol and cigarettes. Alpha-fetoprotein was elevated in one of four white patients, and in six of eight patients of other races (75%). Tissue diagnosis was obtained by peritoneoscopy in 16, by percutaneous biopsy in 7, by laparotomy in 9, and at autopsy in 11. Only one of 11 patients who were explored has his lesion resected. About half of the cases diagnosed antemortem died 1 month or less after diagnosis. The median survival of hepatoma patients who had no specific treatment or systemic chemotherapy was 2 months. Two patients who received chemotherapy in conjunction with occlusion of the hepatic artery lived 16 to 19 months.

"Scar sign" on computed tomography and sonography in fibrolamellar hepatocellular carcinoma

Demonstration by computed tomography of a central linear or stellate low-attenuation region within a focal liver mass has been reported to be suggestive of focal nodular hyperplasia in appropriate clinical settings. We present a case of a focal liver mass with typical central scarring in which the ultimate diagnosis was fibrolamellar hepatocellular carcinoma.

The radiology of fibrolamellar hepatoma

Seven patients with fibrolamellar hepatoma were examined with computed tomography (CT), ultrasonography and angiography. On CT the tumours were large, of low attenuation, had a well-defined edge and some contained areas of calcification or necrosis. Ultrasonography revealed well-defined masses of mixed echogenicity, occasionally involving the portal vein. In one patient there was dilatation of the intrahepatic biliary tree. Arteriography showed vascular tumours with involvement of the portal vein in five cases and compression of the inferior vena cava in five cases. CT and ultrasonography are the most useful radiological investigations for suggesting the diagnosis of fibrolamellar hepatoma which should be considered in the case of any large solitary well-defined hepatic tumour in the noncirrhotic liver of a young person.

Fibrolamellar carcinoma of liver: a primary malignant oncocytic carcinoid?

Immunohistochemical and ultrastructural findings in two cases of fibrolamellar carcinoma of the liver and two cases of hepatocellular carcinoma of the common histologic type are described. Ultrastructural examination of both cases of fibrolamellar carcinoma revealed the presence of neurosecretory (NS) granules which were sparse in some cells and abundant in others. Many of the tumor cells had a distinct oncocytic appearance with abundant mitochondria. A portion of the glutaraldehyde-fixed neoplasm was processed for the uranaffin reaction (an ultrastructural cytochemical stain specific for the NS granules of neuroendocrine tissue). Abundant uranaffin-positive granules were found in the neoplastic cells of both cases of fibrolamellar carcinoma, whereas no uranaffin-positive granules were found in hepatocellular carcinoma of the common histologic type. There was no statistical difference in the mean diameter of the uranaffin-positive granules measured from both cases. Immunohistochemistry revealed the presence of neuron-specific enolase (NSE) and serotonin in one of the two cases of fibrolamellar carcinoma and no NSE staining in two cases of hepatocellular carcinoma of the common histologic type. These findings suggest that some liver tumors presenting histologically as fibrolamellar carcinoma may be neuroendocrine in nature.

Fibrolamellar hepatocarcinoma: clinical, radiologic, and pathologic features

Three new cases of an unusual subtype of hepatocellular carcinoma (HCC) referred to as fibrolamellar hepatocarcinoma (FLHC) recently seen at our institution are described. This report focuses on the clinical, radiologic, and pathologic features of this rare subset of HCC. All three patients were under 30 years of age with no previous history of hepatitis or cirrhosis. Each had had subacute symptoms for 5 months to 1 year before medical attention was sought and/or diagnosis of FLHC was established. There was no reliable correlation with oral contraceptive use in the 2 female patients. Serum alpha-1-fetoprotein levels were normal with only mild elevation of liver enzymes. The CT features, although not specific, were suggestive of an aggressive tumor with amorphous calcification in 2 of the 3 cases. Angiographically all tumors were hypervascular without any evidence of arterioportal shunting or venous invasion of major vessels. The clinical and radiologic recognition of these tumors is important since the surgical resectibility rate and 2- and 5-year survival rates are higher than those applicable to conventional HCC.

Hepatic perfusion abnormalities after liver transplantation

The angiographic and CT findings in a liver transplant patient with perioperative hepatic ischemia are reported. Extensive arterial collaterals and unusual portal-to-hepatic venous shunting in the transplanted liver were observed. Post-transplant clinical, laboratory, and CT findings were compatible with partial right lobe hepatic infarction that was confirmed at autopsy. The possible relationship between the ischemic damage and intrahepatic shunting is discussed. The need for caution during preoperative angiography in potential liver transplant recipients is emphasized.

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

This study demonstrates the unique clinical and histologic aspects of fibrolamellar hepatic carcinoma, a rare variant of hepatocellular carcinoma. Three cases are reviewed and an extensive study of immunologic and intracellular substances defining this tumor is presented. Length of survival was considerably longer than typical hepatoma. The cause of death generally is due to a lack of control of the primary tumor. Successful treatment appears to relate to the ability to perform a total excision of the primary hepatic tumor. Chemotherapy should be used only in the presence of metastatic disease. Surgical resection of metastatic disease, unlike the usual hepatocarcinoma, may have some beneficial use. Fibrinogen was found in all tumors. It is possible that this tumor produces fibrinogen to create its unique histologic appearance. Carcinoembryonic antigen is described for the first time in this tumor. Both deposits of alpha-1 antitrypsin and copper were found in most of the tissues studied. The presence and amounts of these substances differ markedly from the common type of hepatoma. This unique composition of intracellular components may both facilitate histologic diagnosis, particularly if the amount of tissue is limited, and give further insight into the etiology of this tumor.

Fibrolamellar hepatoma

We found the clinical features of fibrolamellar hepatoma similar to those of nonfibrolamellar hepatoma with the exception of patient age. Although the histopathologic findings of fibrolamellar hepatoma are distinct and easily recognizable, we found that fibrolamellar hepatomas may be histologically heterogeneous. The overall length of survival of patients with fibrolamellar hepatoma was greater than that of patients with nonfibrolamellar hepatoma, but the survival resection was similar, regardless of histologic characteristics. Differences in overall survival between histologic subtypes probably reflects differences in the rate of resectability between fibrolamellar and nonfibrolamellar hepatomas.