Lymphoepithelioma-like hepatocellular carcinoma: A case report and a review of the literature

A unique case of lymphoepithelioma-like HCC with osteoclast-like giant cells: CT imaging features with pathologic correlations

Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver, with several histological variants being reported in literature. Hereby, we describe a case of a 77-year-old man with chronic liver disease referred to our department for performing a computed tomography (CT) due to a liver mass discovered at an abdominal ultrasound follow-up. At CT, a large, ill-defined lesion in the third hepatic segment was detected, characterized by progressive and delayed enhancement with minimal retraction of the hepatic capsule, associated with perihepatic adipose tissue inhomogeneity, mimicking a cholangiocarcinoma. At histopathological evaluation, the lesion turned out to be an HCC with lymphoepithelioma-like component and osteoclastic-like giant cells. This report focuses on the clinicopathological and radiological features of this unique case.

CK5/6-positive, P63-positive lymphoepithelioma-like hepatocellular carcinoma: A case report and literature review

BACKGROUND

Lymphoepithelioma-like carcinoma (LELC), a rare and unique variant of liver cancer, can be divided into lymphoepithelioma-like hepatocellular carcinoma and lymphoepithelioma-like intrahepatic cholangiocarcinoma. Dense lymphocytic infiltration is its characteristic pathological feature. In recent years, the number of reported cases of this type has increased each year. Studies have shown that lymphoepithelioma-like cholangiocarcinoma occurs more frequently in Asian women; LELC is associated with Epstein–Barr virus infection of liver cells of epithelial origin. Existing research shows that the prognosis of this tumour is good.

CASE SUMMARY

A 38-year-old female patient was hospitalized after 3 mo of abdominal pain and nausea. She had been infected with hepatitis B virus more than 10 years prior. The patient was hospitalized on January 21, 2022. Magnetic resonance imaging showed a 36 mm × 28 mm mass under the envelope of the left inner lobe of the liver. No metastasis of lymph nodes or other organs was observed. After left hemihepatectomy, biopsy and immunohistochemistry yielded a final diagnosis of lymphoepithelial hepatocellular carcinoma. After 12 mo of outpatient follow-up and chemotherapy, no tumour metastases were found on the latest computed tomography examination.

CONCLUSION

Herein, the patient was treated surgically and then followed up as an outpatient for 12 mo. This case will further expand our overall knowledge of the diagnosis and treatment of this rare tumor.

Lymphoepithelioma-like Hepatocellular Carcinoma: a Case Report and Review of Literature

We report a case of hepatic lymphoepithelioma-like carcinoma-hepatocellular carcinoma subtype (LEL-HCC) in a 41-year-old man with chronic hepatitis C virus (HCV) infection. The patient presented with abdominal pain and further assessment revealed a hypoechoic mass on ultrasonography. Serum alpha-fetoprotein (AFP) was 13·6 ng/dl. The patient was diagnosed as hepatocellular carcinoma based on the established triphasic computed tomography (TCT) diagnostic criteria and he underwent a surgical resection of the mass. Microscopic examination showed sheets and cords of malignant epithelial cells intermixed with heavy lymphoid infiltrate, with more than 100 tumor-infiltrating lymphocytes (TILs) per 10 high-power-field (HPF). Based on immunohistochemical studies, the malignant cells were positive for Hep Par 1 and glypican 3, focally positive for cytokeratin 7 (CK7), and negative for cytokeratin 20 (CK20). TILs were diffusely positive for cluster of differentiation 3 CD3 with an approximately equal CD4/CD8 ratio. The patient was recurrence free at 25 months after surgery, as evident by CT and serum alpha-fetoprotein level. LEL-HCC is a rare variant of HCC with a relatively better prognosis. Exploring the potential for immune modulator-based therapy in this subset of tumors is highly recommended.

Programmed cell death ligand 1 expression in a case of poorly differentiated lymphocyte-rich hepatocellular carcinoma

Our pathological study of a case of poorly differentiated lymphocyte-rich hepatocellular carcinoma suggested that immune checkpoint inhibitor may be an effective therapy. The histological type is an important factor in determining treatment choices.

Surgical treatment of Epstein-Barr virus-associated lymphoepithelioma-like carcinoma occurring in both the posterior mediastinum and liver: Case report

RATIONALE

Lymphoepithelioma-like carcinoma (LELC) is a rare malignant tumor that can occur in many areas of the body. The pathogenesis of LELC remains unknown, but Epstein-Barr virus (EBV) has been shown to be strongly correlated with LELC at several anatomic sites, including the lungs and thymus. To the best of our knowledge, EBV-associated LELC has never been reported in both the posterior mediastinum and liver. Herein, we report the case of a 41-year-old female diagnosed with LELC in both the posterior mediastinum and liver and discuss whether it is beneficial to perform surgery on advanced LELC when resectable metastases are found.

PATIENT CONCERNS

The patient was a 41-year-old woman who had been suffering from intermittent pain in the upper right quadrant for 3 months without obvious cause and was admitted to our hospital with occasional nausea without vomiting.

DIAGNOSIS

Her cancer antigen 125 and cytokeratin 19 fragment levels were elevated, whereas alpha-fetoprotein and alanine aminotransferase were normal. Computed tomography (CT) and magnetic resonance imaging revealed a mass in the S6 segment of the liver. Whole-body positron emission tomography/computed tomography (PET/CT) revealed a 3.2-cm mass in the posterior mediastinum and a 6.7-cm mass on the right side of the liver. We made a diagnosis of LELC based on the histological and immunohistochemical findings of specimens obtained by operation. However, it was difficult to determine the primary origin of the tumor.

INTERVENTIONS

The patient underwent mediastinal tumor resection, hepatectomy, and diaphragmatic repair. Thereafter, she was administered paclitaxel and cisplatin as adjuvant chemotherapy.

OUTCOMES

The postoperative course was uneventful, and the patient was discharged 10 days later. Although she was administered paclitaxel and cisplatin as adjuvant chemotherapy, we noted recurrence during the 4-month follow-up examination. Then, the patient passed away 5 months after surgery.

LESSONS

We present the first case of LELC found in both the posterior mediastinum and liver and describe the functionality of PET/CT for finding occult carcinomas and identifying their primary tumor origin. Additional studies are urgently needed to discover whether it is beneficial to perform surgery on advanced LELC when resectable metastases are revealed by PET/CT.

Lymphoepithelioma-like carcinoma in liver not associated with Epstein-Barr virus: a report of 3 cases and literature review

Background

Lymphoepithelioma-like carcinoma is a rare distinctive variant of liver cancer with unique epidemiological and pathological characteristics, characterized by dense lymphocyte infiltration. It can be divided into lymphoepithelioma-like hepatocellular carcinoma and lymphoepithelioma-like intrahepatic cholangiocarcinoma. Existing research shows that the prognosis of this tumor is good. To date, only 101 cases have been reported.

Case presentation

The first patient was a 62-year-old Chinese man with hepatitis B virus infection who presented with a single lesion in the liver. The patient underwent surgical treatment and was discharged on the 4th day. The patient was diagnosed with combined lymphoepithelioma-like hepatocellular carcinoma and cholangiocarcinoma; he has been alive for 15 months. The second patient was a 63-year-old Chinese woman with right upper abdominal pain and hepatitis B virus infection. The imaging examination revealed a single lesion in the liver. The patient underwent surgical treatment and was discharged 1 week later. The patient was diagnosed with lymphoepithelioma-like hepatocellular carcinoma and was considered to have recurrence in the lymph nodes approximately 2 years after the operation. The patient underwent local radiotherapy; she has been alive for 60 months. The third patient was a 50-year-old Chinese man with hepatitis B virus infection who presented with a single lesion in the liver and two enlarged lymph nodes. The patient received liver puncture before surgery to indicate lymph node metastasis and experienced local recurrence after liver resection. The patient underwent chemotherapy and radiotherapy. The patient was diagnosed with lymphoepithelioma-like hepatocellular carcinoma. The patient was deceased at 24-month follow-up.

Conclusions

This article reports 3 cases without Epstein-Barr virus and reviews the current literature, which suggests even mixed pathological type or locally advanced cases of LELC with lymph node metastasis and postoperative recurrence should be actively treated for a longer survival period.

Glypican-3 Expression in Patients with Oral Squamous Cell Carcinoma

STATEMENT OF THE PROBLEM

Oral squamous cell carcinoma (OSCC) is a malignant neoplasm that affects the structures or tissues of mouth. Early diagnosis of these tumors is important to improve the outcome of treatment. Therefore, using pathological techniques based on molecular markers may be useful for optimal diagnosis and treatment. Glypican-3 (GPC3) is involved in regulation of cell proliferation and morphogenesis and is abundant during embryogenesis and organogenesis but is limited in most of adult tissues. GPC3 overexpression has a role in carcinogenesis.

PURPOSE

The aim of the present study was to investigate GPC3 expression in the non-neoplastic oral epithelium and oral squamous cell carcinoma.

MATERIALS AND METHOD

In this cross-sectional study, 45 patients with OSCC (30 males and 15 females) with a mean age of 52.3 selected from Oral Pathology Department of Shiraz Dental School were enrolled. The control group was consisted of 15 cases of normal oral epithelium. Glypican-3 expression was assessed by using immunohistochemical methods.

RESULTS

Non neoplastic tissues were GPC3 negative. Frequency of GPC3 positivity in tumoral tissues was recorded as 73.3% (33 cases) which was significantly higher than non-neoplastic tissues (p< 0.001).The clinicopathologic features of GPC3 expression demonstrated no association with clinicopathologic parameters except tumor size.

CONCLUSION

GPC3 was over expressed at protein level in oral squamous cell carcinoma, but its potential use for diagnostic and therapeutic purposes requires further investigation.

A case of small well-differentiated hepatocellular carcinoma with marked lymphocytic infiltrate

We herein report a case of well-differentiated small hepatocellular carcinoma (HCC) with severe lymphocytic infiltrate (SLI) in a 55-year-old male patient with HCV-related cirrhosis. The patient had been followed-up because of HCV-related cirrhosis. He was found to have two small nodules in S8 by imaging techniques, and he underwent S8 segmentectomy. The resected liver showed two small nodules. Both were encapsulated, well-defined, solid, reddish and expansive nodules with fibrous septa. They measured 8 × 8 mm and 15 × 10 mm, respectively. Histologically, both tumours were pure HCC; the smaller showed SLI with lymphocytes/HCC cells ratio over 20, while the larger showed mild lymphocytic infiltration with lymphocytes/HCC cells ratio of 0.8. The smaller HCC was well-differentiated (trabecular thickness <3) HCC-SLI with Edmondson II = I cytologic atypia, while the larger was moderately-differentiated (trabeculae >3) HCC (Edmondson II>III>I). Extremely well-differentiated Edmondson I HCC or adenomatous hyperplasia areas were seen in the periphery of both HCCs. The patterns of SLI could be classified into the following three: sinusoids (S) type, portal tract (PT) type, lymph follicle (LF) type. In S-type, lymphocytes were infiltrated between the trabeculae. In PT-type, SLI was found to arise from extension from already inflamed PT within HCC or neighboring PT. The HCC cells frequently exhibited moth-eaten or piece meal necrosis in PT-type. In LF-type, lymphocytes were activated, and nuclear dusts were noted. It appeared that LF-type has arisen from preexisting S-type and/or PT-type. We speculated that the entry of SLI was from S in S-type, from incorporated inflamed PT in PT-type, and from both in LF-type. The approximate overall positive ratios of lymphoid cells among inflammatory cells were as follows: CD20 50%, CD3 70%, CD4 50%, CD8 30%, CD138 3%, CD163 40%, granzyme B 2%, smooth muscle actin (SMA) 30%, CD31 30%, CD21 2%, S100 3%, bcl-2 10%, CK19 1%, CD10 1%, CD30 0%, CD56 0% and Ki67 labeling index = 5%. EBV-ISH and HPV IHC were negative. Interestingly, Kupffer cells had myofibroblastic antigen in addition to macrophage antigens, and stellate cells expressed macrophage antigens aside from myofibroblastic antigens. These data suggest that, in the present case, pan-B-cells, pan-T-cells, helper T-cells, cytotoxic T-cells, plasma cells, macrophages, Kupffer cells, stellate cells, myofibroblasts, fibroblasts, endothelial cells, dendritic cells, Langerhans cells, and toxic molecules may play roles in tumour immunology.

Inflammatory Stroma of Lymphoepithelioma-like Carcinoma of the Cervix: Immunohistochemical Study of 3 Cases and Review of the Literature

The aim of this study was to characterize the inflammatory infiltrate of the lymphoepithelioma-like carcinoma, a variant of squamous cell carcinoma clinically associated with a good prognosis. Immunohistochemistry was used to characterize 3 cases of lymphoepithelioma-like carcinoma in the uterine cervix, diagnosed over a period of 3 yr. The patients were between 30 and 50 yr old. Their cervical smears had shown atypical squamous cells of unknown significance or high-grade squamous intraepithelial lesions, and the initial cervical biopsy showed high-grade cervical intraepithelial neoplasia (CIN3) or squamous cell carcinoma. All patients underwent a Wertheim operation, 2 of which were preceded by a cervicectomy. Microscopically, all tumors were characterized by poorly defined sheets of undifferentiated squamous cells with a syncytial pattern and a dense background of infiltrating lymphocytes. Immunohistochemical analysis revealed that the lymphocytes were predominantly CD3 and CD8 T cells. The tumor lobules contained isolated CD8 T cells, whereas CD4 T cells and CD20 B cells surrounded the tumor lobules. CD56 NK cells and CD79 B cells were scattered in the tumor tissue. An in situ hybridization staining for Epstein-Barr encoding region was negative but all cases were immunohistochemically positive for P16. Follow-up varied between 2 mo and 2.7 yr. All 3 patients were disease free. Lymphoepithelioma-like carcinoma of the uterine cervix is a variant of squamous cell carcinoma, known for its better prognosis. The good prognosis of this tumor is potentially explained by the high levels of infiltrating CD8 T cells.

EBV-associated lymphoepithelioma-like thyroid carcinoma with favorable outcome: case report with cytopathologic and histopathologic study

Background

Lymphoepithelioma-like carcinoma (LELC) is a rare entity among thyroid tumors. Based on the limited number of case reports that exist, the association of Epstein–Barr virus (EBV) with primary thyroid LELCs seems inconsistent.

Case presentation

We present a confusing cytological case of lymphoepithelioma-like thyroid carcinoma with expression of EBV. The patient presented with a central neck mass and bilateral lymphadenopathy. Fine-needle aspiration cytology revealed three-dimensional and syncytial fragments of epithelioid cells accompanied by small lymphocytes. The surgical specimen of resected thyroid tumor disclosed typical histopathological features of LELC. Metastatic papillary carcinoma was also discovered in the metastatic lymph nodes. In situ hybridization for EBV-encoded RNA (EBER-ISH) was positive in the tumor cells. Negative immunoreactivity for TTF-1, Pax-8, and CD5 was observed. The patient is currently undergoing regular follow-up and is 1 year and 10 months postresection with no evidence of recurrence.

Conclusions

Long-term survival is discussed in relation to this variant of thyroid carcinoma, which might differ in behavior from anaplastic carcinoma. Further investigation is required to elucidate the clinical significance of EBV expression and progression of this unique variant of thyroid carcinoma.

Lymphoepithelioma-like hepatocellular carcinoma: A case report and brief review of literature

RATIONAL

Lymphoepithelioma-like hepatocellular carcinoma (LEL-HCC) is a rare variant of hepatocellular carcinoma (HCC). To date, few cases have been reported in the literature, and almost no report in analyzing the different features of LEL-HCC.

PATIENT CONCERNS

We describe a 37-year-old female patient with a 32 × 30 mm mass in the right liver.

INTERVENTIONS

Complete surgical resection of the lesion was performed.

DIAGNOSES

Histopathological examination of the resected tumor revealed undifferentiated HCC cells with significant lymphocytes infiltration. Immunohistochemically, the tumor cells were positive for AFP (alpha fetoprotein), hepatocyte, CK8, and glypican-3. The patient was diagnosed with LEL-HCC.

OUTCOMES

The patient had a favorable clinical outcome, and was free from tumor recurrence after a 52-months follow-up.

LESSONS

Our case was the youngest patient of all the reported cases, and the third case who was infected with both hepatitis B virus (HBV) and hepatitis C virus (HCV). LEL-HCC is a rare variant of HCC, with a relatively favorable prognosis. Further research recruiting more patients is required to determine the accurate causes and mechanism of LEL-HCC.

[Tumor grading of the hepatobiliary system]

Tumors of the liver, intrahepatic and extrahepatic bile ducts as well as the gallbladder are very heterogeneous and show different biological behavior. The 4‑stage (i.e. well, moderately, poorly and undifferentiated) grading system for hepatocellular carcinoma proposed by the WHO takes tumor size and architecture as well as the extent of cell and nuclear pleomorphism into account. In addition, the WHO defines some special forms of hepatocellular carcinoma. For carcinomas of intrahepatic bile ducts the WHO provides a 3‑stage (well, moderately and poorly differentiated) grading system, which is based on architectural and cytological changes. At this localization there are also additional special histological forms that have to be dealt with outside the grading system described. The WHO proposes a 3‑stage (well, moderately and poorly differentiated) grading system for carcinomas of the extrahepatic bile ducts and the gallbladder, which considers the proportion of glands contained within the adenocarcinoma. Similar to cancers of the liver and intrahepatic bile ducts there are also numerous special histological forms, which are explained in this article.

Morphologic Subtypes of Hepatocellular Carcinoma

Hepatocellular carcinomas can be further divided into distinct subtypes that provide important clinical information and biological insights. These subtypes are distinct from growth patterns and are on based on morphologic and molecular findings. There are 12 reasonably well-defined subtypes as well as 6 provisional subtypes, together making up 35% of all hepatocellular carcinomas. These subtypes are discussed, with an emphasis on their definitions and the key morphologic findings.

Lymphoepithelioma-Like Carcinoma in Liver

Liver cancer, primarily encompassing hepatocellular carcinoma and intrahepatic cholangiocarcinoma, has become the second leading cause of worldwide cancer-related death during the past two decades. Lymphoepithelioma-like carcinomas (LELCs) are defined as tumors composed of undifferentiated epithelial cells with a prominent lymphoid infiltrate, and can arise in the liver as hepatocellular or cholangiocarcinoma forms. Patients with liver LELC display distinctive demographics and tumor characteristics. LELCs also appear to be associated with strikingly better outcomes compared to typical liver cancers, with 5-year survival rates of 57% to 100% versus 12% to 68%, respectively. Liver LELCs represent a unique model of immune response in liver cancer. Data on LELCs of the liver remain limited, and future comprehensive studies are needed to further elucidate this disease, which could ultimately offer precious insights for immunotherapeutic strategies in liver cancer.

Intrahepatic Cholangiocarcinoma With Lymphoepithelioma-like Carcinoma Components Not Associated With Epstein-Barr Virus: Report of a Case

A carcinoma displaying undifferentiated features with dense lymphoplasmacytic infiltration is defined as lymphoepithelioma-like carcinoma (LELC). Intrahepatic cholangiocarcinoma (ICC) with LELC components is rare, and most LELCs are associated with Epstein-Barr virus (EBV). We report here on a case of ICC with LELC components not associated with EBV. A 65-year-old woman was incidentally found to have a hepatic tumor in the caudate lobe. An extended right hepatectomy with lymphadenectomy was performed. Histologically, the tumor was mainly composed of large undifferentiated epithelial cells with vesicular nuclei, prominent nucleoli, indistinct cell borders, and heavy small lymphocytic infiltration, which are the characteristic features of LELC. Immunohistochemical studies revealed that the tumor cells were positive for cytokeratin 19 but were negative for glypican 3. In situ hybridization using EBV-encoded RNA was negative. Therefore, a diagnosis of ICC with LELC components not associated with EBV was made. Because there is limited information available regarding the prognosis and treatment of ICC with LELC components because of the limited number of reported cases, additional studies will be needed to clarify the clinicopathologic features of this disease.

Hepatocellular Carcinoma: Histologic Subtypes

This review discusses the various histologic subtypes of hepatocellular carcinoma (HCC), focusing on their clinical features, pathologic features, immunohistochemical profiles, differential diagnosis, prognosis, and clinical relevance of diagnosis. The WHO recognized variants of scirrhous HCC, fibrolamellar carcinoma, combined HCC-cholangiocarcinoma (HCC-CC), sarcomatoid HCC, undifferentiated carcinoma, and lymphoepithelioma-like HCC are discussed in detail. Other subtypes including clear cell HCC, diffuse cirrhosis-like HCC, steatohepatitic HCC, transitional liver cell tumor, and CAP carcinoma are also reviewed.

Lymphoepithelioma-like hepatocellular carcinoma: an uncommon variant of hepatocellular carcinoma with favorable outcome

Lymphoepithelioma-like hepatocellular carcinoma (LEL-HCC) is an uncommon variant of HCC with only 22 cases reported in the literature. To better determine the incidence, clinicopathologic features, prognostic significance, and molecular pathogenesis of LEL-HCC, we presented the largest series of LEL-HCC from a 9-year retrospective cohort of patients with HCC undergoing surgical resection. LEL-HCC was identified in 20 patients (4.9%). Compared with patients having HCC without significant tumor-infiltrating lymphocyte (TIL), patients with LEL-HCC had a relatively lower frequency of male sex (P=0.022), tended to present at early-stage disease (80.0% vs. 56.3% as AJCC stage I, P=0.037; 100% vs. 77.3% as BCLC stage 0/A, P=0.010), and all harbored a solitary tumor only (P=0.006). There was no significant difference in the age at presentation, underlying chronic liver disease, cirrhotic background, serum α-fetoprotein level, tumor size, histologic grade, and frequencies of vascular invasion. Most of the TILs in LEL-HCC were cytotoxic T lymphocytes. None of the LEL-HCCs was associated with Epstein-Barr virus. LEL-HCC was associated with better overall (5-y survival: 94.1% vs. 63.9%; P=0.007) and progression-free (5-y survival: 87.8% vs. 46.6%; P=0.002) survivals compared with HCC without significant TIL. The multivariate analysis revealed that LEL-HCC was an independent prognostic factor for overall and progression-free survivals. The adjusted hazard ratio of cancer death and tumor progression for LEL-HCC was 0.12 (P=0.037) and 0.14 (P=0.002), respectively. LEL-HCC did not differ in frequencies of microsatellite instability, BRAF mutation, and DNA hypermethylation. In brief, LEL-HCC is a distinct uncommon variant of HCC characterized by dense cytotoxic T-cell infiltration and favorable prognosis.

Lessons from rare tumors: Hepatic lymphoepithelioma-like carcinomas

In this review we focus on lymphoepithelioma-like hepatocellular carcinomas (LEL-HCC) and lymphoepithelioma-like cholangiocarcinomas (LEL-ICC). Despite their rarity, these tumors are of general interest because of their epidemiological and clinical features, and because they represent a distinct model of interaction between the immune system and neoplastic cells. Approximately half of LEL-HCC arise in the context of chronic hepatitis C virus (HCV) infection and have been described both in Eastern and Western patients. By contrast, LEL-ICC is associated in almost all cases with Epstein-Barr virus (EBV) infection and exhibits the same epidemiological features of EBV related malignancies. Compared with classical hepatocellular carcinoma and intrahepatic cholangiocarcinoma of corresponding stage, both LEL-HCC and LEL-ICC are characterized by lower rates of recurrence after surgery and better overall survival. How this behavior is related to distinct genetic alterations and tumor microenvironment is unclear. The pathophysiological mechanisms of lymphoid infiltrations seem to be different among the two groups of tumors. In fact, LEL-HCC frequently arises in the context of inflammatory changes driven by HCV infection, and has been recognized as a variant of classical hepatocellular carcinoma. At variance, lymphocyte recruitment of LEL-ICC is similar to that described in nasopharyngeal carcinoma and gastric LEL, and possibly depends on the expression pattern of latent EBV infection.

Primary lymphoepithelioma-like hepatocellular carcinoma: report of a locally advanced case and review of literature

Lymphoepithelioma-like hepatocellular carcinoma is rare, which has been recognized as a variant of hepatocellular carcinoma. Here we report a locally advanced case of lymphoepithelioma-like hepatocellular carcinoma. A 50-year-old man with chronic hepatitis B virus infection presented with a single mass in the liver and two enlarged lymph nodes in retroperitoneum suspected to be hepatocellular carcinoma with lymph node metastasis. After discussion by multidisciplinary team, the patient underwent hepatectomy of VIII segment and dissection of two enlarged lymph nodes. One month after the operation, pre-chemotherapy abdominal computed tomography (CT) showed retroperitoneal enlarged lymph nodes, considered as local recurrence. Therefore, 3 cycles of oxaliplatin and tegafur gimeracil oteracil potassium capsule and 3 cycles of paclitaxel and cisplatin were offered, and post-chemotherapy abdominal CT revealed disease remained stable. The patient has been alive for 6 months since performance of surgery. Our report suggests that even locally advanced lymphoepithelioma-like hepatocellular carcinoma may have a good prognosis and operation and postoperative chemotherapy may benefit the patient.

Characterization of inflammatory (lymphoepithelioma-like) hepatocellular carcinoma: a study of 8 cases

CONTEXT

The World Health Organization has recently recognized lymphoepithelioma-like carcinoma, or inflammatory hepatocellular carcinoma, as a variant of hepatocellular carcinoma.

OBJECTIVE

To identify and characterize the inflammatory hepatocellular carcinomas in our institution from 1988 to the present.

DESIGN

All cases of hepatocellular carcinoma in our institution from 1988 to the present were reviewed and reclassified as lymphoepithelioma-like carcinoma and were studied in comparison to appropriately matched controls.

RESULTS

Among the 8 cases of lymphoepithelioma-like carcinoma identified, the male to female ratio was 1:3, the mean age was 68.5 years (range, 57-78 years), and all of the cases were seen in noncirrhotic livers. The average numbers of lymphocytes were significantly higher in the cases than in the controls. T cells were predominant, with a uniform distribution of CD4 and CD8 positive cells. Cholangiolar differentiation was seen by K19 positivity as focal in 1 case and diffuse in 2 cases. In situ hybridization for Epstein-Barr virus was negative in all of the cases. Diffuse overexpression of p16 (>75% of cells) was seen in 2 cases, both of which were negative for the presence of transcriptionally active human papilloma virus by in situ hybridization. In our series, 3 of 8 cases (37.5%) showed local recurrence, which was similar to the controls (6 of 18; 33%), P > .99. Although the rate of distant metastases was lower among the cases (12.5%) than the controls (22.2%), the difference was not statistically significant (P > .99).

CONCLUSION

We present the first series of 8 cases of lymphoepithelioma-like carcinoma of the liver occurring in patients without cirrhosis and with a female preponderance and the absence of Epstein-Barr virus. Although clinical outcomes were similar to those of controls in our small series, additional data may be required for confirmation.

Epstein-Barr virus-associated lymphoepithelioma-like cholangiocarcinoma: a rare variant of intrahepatic cholangiocarcinoma with favourable outcome

AIMS

Lymphoepithelioma-like cholangiocarcinoma (LELCC) is a rare variant of intrahepatic cholangiocarcinoma (IHCC). Only 16 cases have reported previously in the literature, and about 62.5% of these cases were associated with Epstein-Barr virus (EBV).

METHODS AND RESULTS

We present the largest series (seven cases) of LELCC with descriptions of clinical and pathological characteristics, investigations of aberrant DNA methylation and mutation analyses of EGFR and KRAS. The evaluation also included 11 cases of stage-matched conventional IHCC for comparison.

RESULTS

All seven patients of LELCC were female and had stage I disease. LELCC had significantly better 2- and 5-year overall survival than IHCC (100% versus 52.8%, and 100% versus 13.2%, respectively, P = 0.003). All seven LELCCs were EBV-associated and composed exclusively of adenocarcinoma with varied glandular differentiation, dense lymphoplasmacytic infiltrate, and variable expression of biliary-type cytokeratins (CK7 and CK19) and stemness markers (CD133 and EpCAM). Gene hypermethylation was more frequent in LELCC than IHCC. CRBPI (85.7% versus 9.1%, P < 0.003) and CRBPIV (85.7% versus 0%, P < 0.001) showed statistically higher methylation frequencies in LELCC than IHCC. No LELCC harboured any EGFR or KRAS mutation.

CONCLUSION

Epstein-Barr virus-associated LELCC is a variant of IHCC, characterized by marked female predominance, favourable overall survival and distinctively frequent DNA hypermethylation.

Pulmonary adenocarcinoma with massive lymphocytic infiltration: a case report with review of the literature of a rare histological entity with a peculiar biological behaviour

Background

Tumors with a massive inflammatory infiltration are described in several organs. There is agreement about considering the inflammatory infiltration as the host’s immune response to neoplastic cells; such neoplasms indeed have a better prognostic outcome than non-inflammatory counterparts. Only seventeen cases of pulmonary adenocarcinoma with massive lymphocytic infiltration (AMLI) have been reported in literature so far.

Case presentation

We present a case of pulmonary adenocarcinoma with massive lymphocytic infiltration occurring in a 71 years old male smoker. He came under our attention because of dyspnea, and underwent a left lower lobectomy. Histological examination showed a moderately differentiated (G2) acinar adenocarcinoma associated with a stromal desmoplastic reaction and a massive inflammatory infiltration, made up mostly of CD3+ lymphocytes. pTNM stage was pT2a, N0 (clinical stage: Ib).

Molecular testing of EGFR gene showed no mutations and immunohistochemistry for ALK resulted negative.

EBV infection was ruled out by EBV in situ hybridization.

Conclusions

Literature review showed seventeen similar cases, with a 16/1 male/female ratio and a mean age of 70,2 years. In eight out of seventeen cases EBV-infection was demonstrated with immunohistochemical or molecular biology techniques.

Similarly to the cases previously reported in literature our patient is a male smoker, without lymph node metastasis and he is still alive after a follow-up period of six months without recurrent or residual disease.

Because of histological, biological and clinical peculiarity, we propose to take into account pulmonary adenocarcinomas with massive inflammatory infiltration for a separate pathological classification.

Hepatocellular carcinoma: histologic considerations: pure, mixed, and motley

Hepatocellular carcinoma (HCC) is the most common primary malignant liver tumor seen in adults. The histopathologic diagnosis of classic or conventional differentiated HCC is seldom challenging, however, HCC is a particularly heterogeneous tumor. HCC often has a medley of morphologic features that are either challenging to recognize as hepatocellular, or represents components that are of complex histogenesis. This review focuses on the heterogeneous nature of HCC, with discussion of the histologic variants, some of which the clinical significance is unknown. In some cases, a lack of numbers precludes elucidating the clinical significance of these variants. Ultimately, larger studies are needed to determine the diagnostic and prognostic relevance of the phantasmagoria within HCC.

Lymphoepithelioma-like hepatocellular carcinoma: a case report and a review of the literature

We report a rare case of lymphoepithelioma-like hepatocellular carcinoma. A 79-year-old Japanese man had undergone curative resection of extrahepatic bile ducts because of bile duct cancer 9 years prior. The bile duct cancer was diagnosed as mucosal adenocarcinoma, and the patient had been followed up every 6 months for the last 9 years. A recent computed tomography examination revealed a tumor, 4.2 cm in size, in the lateral segment of the liver. Based on the imaging findings, the tumor was diagnosed as hepatocellular carcinoma. Serology tests were negative for hepatitis B and C viruses. Chest and abdominal image analyses showed no evidence of metastasis, but a swollen lymph node was noted around the abdominal aorta. The patient subsequently underwent extended lateral segmentectomy and resection of the swollen lymph node. Microscopically, the tumor had the characteristic appearance of poorly differentiated hepatocellular carcinoma. Moreover, an abundant infiltration of inflammatory cells was observed in the tumor. Therefore, we diagnosed the tumor as lymphoepithelioma-like hepatocellular carcinoma. The resected para-aortic lymph node also had a carcinoma with features similar to those of the main tumor. The patient has been alive for 20 months since performance of the surgery. Since the first report of lymphoepithelioma-like hepatocellular carcinoma in 2000, only nine cases have been reported in the medical literature, and the clinicopathological features of the disease have not been well documented. Herein, we describe the clinicopathological features of this case for further understanding of the disease and review past cases in the literature.

Glypican-3 expression in gastrointestinal and pancreatic epithelial neoplasms

Glypican-3 (GPC3) is a plasma membrane-bound proteoglycan that can be overexpressed in certain malignancies but has been particularly linked to hepatocellular carcinoma (HCC). GPC3 is currently used as an immunohistochemical marker for HCC, but its expression in epithelial neoplasms of the gastrointestinal (GI) tract and pancreas, a common source of liver metastasis, has not been studied in detail. In this study, we examined GPC3 immunoreactivity in 98 neoplasms of the GI tract including 30 adenocarcinomas (ADCA), 29 squamous cell carcinomas (esophageal and anal), and 39 neuroendocrine carcinomas, and 60 neoplasms of the pancreas including 22 ADCA, 26 pancreatic neuroendocrine neoplasms, and 12 pancreatic acinar cell carcinomas. Two control groups of 32 HCCs and 16 intrahepatic cholangiocarcinomas were also stained with GPC3. Although most (7/12, 58.5%) acinar cell carcinomas were GPC3 positive, pancreatic ADCA and neuroendocrine neoplasms were GPC3 negative. In addition, 27.5%, (8/29) of squamous cell carcinomas, 20% (6/30) of ADCA, and 2.5% (1/39) of neuroendocrine carcinomas of the GI tract were immunoreactive for GPC3. HCC was positive for GPC3 in 75% (24/32) of cases but cholangiocarcinoma was negative. While significant correlation between GPC3 positivity and poor differentiation was observed in HCC only, GPC3 expression did not correlate with tumor size. In conclusion, 14% of GI tract and pancreatic carcinomas/neoplasms (particularly pancreatic acinar cell carcinoma) can express GPC3 by immunohistochemistry. As these tumors commonly metastasize to the liver, this offers a potential pitfall in differentiating between HCC and metastatic carcinoma when evaluating tumors involving the liver.

Lymphoepithelioma-like carcinoma of the breast: a diagnostic and therapeutic challenge

We present a patient with lymphoepithelioma-like carcinoma (LELC) of the breast whose diagnosis is illustrative of the pathology nuances that must be taken into account to successfully reach correct identification of the disease. We also present an overview of our patient's proposed treatment in the context of 16 other reported LELC cases. Although LELC cases are rare, a sufficient number have been reported to discern the natural history of this pathologic entity and to undertake a review of those cases and of the application of oncologic first principles in their management. Given the potential for locoregional spread and distant metastases in LELC, adjuvant therapy has a role in the treatment of this entity.

Non-Epstein-Barr virus associated lymphoepithelioma-like carcinoma of the inferior common bile duct

A carcinoma displaying undifferentiated features with dense lymphoplasmacytic infiltration is defined as a lymphoepithelioma-like carcinoma (LEC), and some of LEC is associated with Epstein-Barr virus (EBV). All of the 13 previously reported cases of LEC of the biliary system were intrahepatic in location. Herein, we describe the first case of LEC of the inferior common bile duct. A 68-year-old Japanese man, who had been previously treated for hepatocellular carcinoma using microwave coagulation therapy, was found to have tumors of the common bile duct and pancreas head. Histopathological study of the resected tumor showed solid or cohesive nests of large undifferentiated cells with irregular large vesicular nuclei and nucleoli. Around the tumor cell nests, dense lymphoplasmacytic infiltration was observed. Focal glandular differentiation (approximately 5%) was also present. These histopathological features corresponded morphologically to LEC. Immunohistochemically, the tumor cells were positive for cytokeratin (CK) 7, CK 19 and CA19-9, but negative for CK 20 and Hep Par 1. In situ hybridization for Epstein Barr virus early small RNAs disclosed no nuclear signal in tumor cells. Therefore, a diagnosis of non-EBV-associated LEC of the inferior common bile duct was made. Although the prognosis of the biliary LEC is thought to be better than that of conventional cholangiocarcinoma, the differences in prognosis between EBV-positive and -negative cases have not yet been established. Therefore, additional case studies will be needed to clarify the clinicopathological features of LEC of the biliary tract.