Double cancer consisting of adenosquamous and hepatocellular carcinomas of the liver

A very rare case of a double cancer consisting of adenosquamous and hepatocellular carcinomas of the liver in a 65-year-old-man is discussed. The patient was hospitalized with epigastralgia in May 1997. Abdominal computed axial tomography revealed a tumor located in the left lobe of the liver and a left hepatic lobectomy was performed. The tumor recurred several months after surgery and the patient died on 4 June 1999. At autopsy, both a major tumor mass with extensive involvement, located in the surgical margin, and a small mass located in S7 were discovered. Microscopically, the major tumor was diagnosed as adenosquamous carcinoma and the small one in S7 as hepatocellular carcinoma. To our knowledge, this is the first case of a double cancer consisting of adenosquamous and hepatocellular carcinomas of the liver. The pathological findings support the hypothesis that this tumor developed as a squamous transformation of adenocarcinoma.     

原发性肝细胞性肝癌中dysadherin的表达及意义

目的探讨抗黏附素（dysadherin）在原发性肝细胞性肝癌（hepatocellular carcinama,HCC）中表达的临床病理学意义。方法应用免疫组化SP方法,检测90例肝癌组织中dysadherin的表达,分析其与HCC各临床病理学参数之间的关系。结果原发性HCC组织中dysadherin的表达和和患者的HBsAg阳性率、2年生存率、HCC的Edmondson分级、TNM分期、有无肿瘤包膜及肝内转移等因素有显著关系,和E-cad蛋白的表达呈负相关关系。结论dysadherin可能是判断HCC的恶性程度和患者预后信息的重要指征。     

Endocrine liver tumour differential diagnosis from hepatocellular carcinoma

A liver tumour, initially diagnosed by light microscopy as a hepatocellular carcinoma, was later shown to be endocrine by argyrophilia and electron microscopy. It was tested by immunohistochemistry for insulin, glucagon, gastrin, VIP, pancreatic polypeptide, glicentin, C-peptide and somatostatin. A few cells were shown to contain somatostatin, but the secretion product in most of the cells was not identified. The patient is well, without any sign of endocrine disturbances, 18 months after the operation.     

Rare variants of primary liver cancer: Fibrolamellar,combined, and sarcomatoid hepatocellular carcinomas

Hepatocellular carcinoma (HCC) constitutes 80% of all primary liver cancers. Based on key developments in the understanding of its carcinogenesis and the advancement of treatment options, detailed algorithms and practice guidelines have been published to guide the clinical management of HCC. Furthermore, several subclasses of HCC have been described based on molecular profiles and linked to pathological characteristics, clinical features, and disease aggressiveness. Most recently, the combination of the checkpoint inhibitor atezolizumab plus bevacizumab has significantly increased treatment response in the first line systemic treatment of HCC. Unfortunately, rare HCC variants, in particular fibrolamellar liver cancer (FLC), combined hepatocellular carcinoma and cholangiocarcinoma (cHCC-CCA), and sarcomatoid hepatocellular carcinoma (sHCC), were excluded from phase III studies. Therefore, data for decision-making and treatment allocation for these distinct entities, representing 1–5% of all primary liver cancers, is scarce. Moreover, most of the knowledge available for these rare HCC variants is based on registry data and retrospective studies. In this position paper, we briefly summarize the current clinical knowledge regarding FLC, cHCC-CCA, and sHCC. Based on our summary, we propose future clinical research activities within the framework of the European Reference Network on Hepatological Diseases (ERN RARE-LIVER).     

肝细胞癌及癌旁肝组织中bcl-2和p53蛋白表达与端粒酶活性的相关性研究

目的：探讨ｂｃｌ２ 和ｐ５３ 蛋白的表达与端粒酶活性的相关性及其与 Ｈ Ｃ Ｃ 发生的关系。方法：利用端粒酶原位标记法显示端粒酶活性,采用 Ｓ Ｐ 法免疫组化技术检测ｂｃｌ２ 和ｐ５３ 蛋白。结果：端粒酶在 Ｈ Ｃ Ｃ 中的阳性率（９１７ ％ ） 显著高于癌旁肝组织（５８３ ％ ）（ Ｐ＜ ００５） ,端粒酶活性强度与 Ｈ Ｃ Ｃ 分化程度无关（ Ｐ＞ ００５） ;癌组织中ｂｃｌ２ 和ｐ５３ 蛋白的阳性率均高于癌旁组织（ Ｐ＜ ００１） ; Ｈ Ｃ Ｃ 和癌旁组织中端粒酶活性程度随ｂｃｌ２ 蛋白表达增强而升高,并呈明显正相关,但与ｐ５３ 蛋白表达强度无明显相关性。结论：ｂｃｌ２ 蛋白的过度表达可能是端粒酶激活的重要途径之一,ｂｃｌ２ 蛋白过度表达可能通过激活端粒酶使肝细胞恶性转化导致 Ｈ Ｃ Ｃ 发生,而ｐ５３ 基因突变可能对端粒酶的激活无直接影响。     

Arterial elements and perisinusoidal cells in borderline hepatocellular nodules and small hepatocellular carcinomas

Borderline hepatocellular nodule in the human cirrhotic liver is considered a preneoplastic lesion of hepatocellular carcinoma (HCC). However, the angiogenetic process and changes in perisinusoidal cells (fat-storing cells or Ito cells) during the borderline nodule-HCC sequence have not been investigated. We have investigated intraparenchymal arterial elements and perisinusoidal cells in normal livers, chronic hepatitis, borderline nodules and small HCC, using an immunohistochemical staining for α-smooth muscle actin. In normal livers, chronic hepatitis, cirrhotic nodules and large regenerative nodules, no or few arterial elements were present in the parenchyma, and α-smooth muscle actin-positive perisinusoidal cells were not increased. In borderline nodules, however, there were many intranodular arterial elements, and perisinusoidal cells were significantly increased. In small HCC, there were much more arterial elements, and perisinusoidal cells were increased further. These data suggest that angiogenesis first occurs in borderline hepatocellular nodules and it gradually proceeds during the nodule to HCC sequence along with an increase in perisinusoidal cells. The demonstration of arterial elements and perisinusoidal cells may be useful for the differential diagnosis of large regenerative nodule, borderline hepatocellular nodule and small HCC.     

Immunohistochemistry and angiography in adenomatous hyperplasia and small hepatocellular carcinomas

The sinusoidal structure and blood supply of 38 liver nodules less than 2 cm In diameter were Investigated. There were 18 cases of adenomatous hyperplasia (AH) and 20 cases of hepatocetlular carcinoma (HCC). Growth pattern, encapsulation and vascularity were examined, and Immunohistochemistry performed for factor VIII related antigen (factor VIII), type IV collagen (collagen IV), lamlnln and CD68. There were significant differences between AH and small HCC, except for the expression of CD68. There were differences In tumor size, vasculartty and the components of the basement membrane between AH and small, well differentiated HCC. The cases of AH were supplied by the portal system and maintained the sinusoidal structure, but small well-differentiated HCC were supplied by a mixture of portal and arterial vessels. In spite of their small size, moderately and poorly differentiated HCC had capillary and were supplied by branches of the hepatic artery.     

Immunohistochemical detection of bcl-2 protein in liver lesions: bcl-2 protein is expressed in hepatocellular carcinomas but not in liver cell dysplasia

A proto-oncogene, bcl-2, encodes a protein that inhibits programmed cell death (apoptosis) and may play a role in cell and tissue differentiation. As bcl-2 appears to be involved in the turn-over of stem or precursor cells, it is thought to be operational in carcinogenesis pathways. However, apart from certain lymphomas, only limited data are available on the frequency of its expression in solid tumors. Immunohistochemical analysis with an antibody specific for bcl-2 protein was used to detect the protein in hepatocellular carcinomas and in one of the putative precursor lesions, liver cell dysplasia. We detected bcl-2 protein in 5 of 37 hepatocellular carcinomas. Immunoreactivity was not related to type, grade, or extent of PCNA staining of the tumours. No bcl-2 protein staining was observed in three types of liver cell dysplasia. Thus, bcl-2 is abnormally expressed in some hepatocellular carcinomas but not in potential tumour precursor cells.     

Identification of hepatitis B virus X gene variants between hepatocellular carcinoma tissues and pericarcinoma liver tissues in Eastern China

Hepatocellular carcinoma (HCC) is one of the most malignant tumors worldwide, especially in Eastern China where HBV infection confirmed as the most important pathological element. HBV X gene, extremely easy to mutate and integrate into hepatocytes, plays a significant role in HBV infection and HCC development. We deduced that mutations of integrated HBx gene make transformation more malignant. The aim of the study was to investigate whether there were different mutation patterns between the HCC tissues and the pericarcinoma liver tissues (PCLT) from patients with HCC in Eastern China. Methods: HBx genes extracted from 287 HCC tissue samples and 195 PCLT tissue samples were analyzed by sequence alignment and stratified analysis with the matched medical records. Results: Mutations occurred complicated and changeable in both HCC and PCLT. COOH-terminal truncation is more frequently found in HCC than PCLT (P < 0.05). There is no single site mutation of nucleic acid or amino acid makes distribution discrepancy between HCC and PCLT. Hydrophobic/hydrophilic character of amino acid of site 43, 47, 127, 131, 132 make distribution discrepancy between HCC and PCLT in men when stratified for gender (P < 0.05). Hydrophobic/hydrophilic character of amino acid of site 40 makes distribution discrepancy between HCC and PCLT in both male and female (P < 0.05). Hydrophobic/hydrophilic character of amino acid of site 47 and 127 make significant discrepancy among clinical stage I, II, III (P < 0.05). Conclusions: During the infection and replication of HBV, HBx mutates to adjust itself to the hepatocyte and increase the carcinogenesis. COOH-terminal truncated HBX may play a stimulative role in HBV-related HCC carcinogenesis as well as hydrophobic/hydrophilic character changes in some specific amino acid sites.     

Metastatic malignant melanoma in liver aspirate: cytomorphologic distinction from hepatocellular carcinoma

Hepatic metastases of malignant melanoma are not unusual and frequently occur with a clinically long latent period following resection of a cutaneous or ocular primary. Due to its overlapping cytomorphology with a primary hepatocellular carcinoma, diagnostic difficulties may arise on fine-needle aspiration of these lesions if the clinical history of melanoma is not known. Thirty-two cases of metastatic melanoma in the liver and primary hepatocellular carcinoma were studied. Aspiration was performed under ultrasound guidance using 22-gauge spinal needle. Slides were stained with Diff-Quik and Papanicolaou stain; cell blocks were stained with H&E. A panel of immunostains was performed using conventional methodology. Of the 12 cytologic parameters assessed, the most helpful in making a metastatic melanoma diagnosis were the presence of sheet-like architecture, plasmacytoid and/or biphasic (epithelioid/spindled cell) morphology, cytoplasmic tails, necrosis, and cytoplasmic melanin-like pigment. For hepatocellular carcinoma, the presence of trabeculae, perivascular cellular clustering, endothelial wrapping, and centrally located nuclei with granular cytoplasm were helpful features. In selected cases, IPOX studies were critical in arriving at the correct diagnosis.     

Differentiation of liver cell adenomas from well-differentiated hepatocellular carcinomas by comparative genomic hybridization

Liver cell adenomas (LCAs) are rare tumours which may be difficult to differentiate from low-grade hepatocellular carcinomas (HCCs). This study used comparative genomic hybridization (CGH) to look for cytogenetic aberrations which would serve to distinguish between these tumours. For this purpose, ten LCAs and six well-differentiated HCCs were analysed and the results were compared with those reported previously for 15 well-differentiated HCCs. Aberrations were seen in 2/10 LCAs: a gain of chromosome 7p was observed in one and gains of 17q and 20 in a second case. In 6/6 well-differentiated HCCs, up to 13 aberrations were detectable, with a mean of 7.2 aberrations per case in chromosome sites 1q, 4p, 4q, 5p, 5q, 6p, 6q, 7p, 7q, 8p, 8q, 10q, 11p, 13q, 14q, 16p, 16q, 17p, 17q, 20p, 20q, and 21q. Aberrations focused on gains or losses of six chromosome sites, 1q, 4q, 8p, 8q, 16p, and 17p; in all HCC samples, at least two of these sites were affected. None of these aberrations occurred in any of the LCAs analysed. CGH is therefore helpful in distinguishing between LCA and well-differentiated HCC. Detection of one or more of the six most frequent aberrations in HCC supports the diagnosis of carcinoma and makes LCA unlikely.     

可溶性细胞间黏附分子-1在原发性肝癌患者血清中的表达及其与肝纤维化的关系

目的:探讨可溶性细胞间黏附分子-1(sICAM-1)在原发性肝癌(PHC)患者血清中的水平及其与肝纤维化的关系。方法:采用ELISA方法测定45例PHC患者、30例良性肿瘤患者和35例健康查体者血清sICAM-1和肝纤维化四项(PCⅢ、Ⅳ-C、LN、HA)水平,并分析sICAM-1与肝纤维化之间的关系。结果:PHC组血清sICAM-1和肝纤维化四项(PCⅢ、Ⅳ-C、LN、HA)水平均显著高于良性肿瘤组和正常对照组,相比较有显著性差异(P<0.05);而良性肿瘤组和正常对照组各指标比较差异无统计学意义(P>0.05);血清sICAM-1含量与PCⅢ、Ⅳ-C、LN、HA含量呈显著正相关性(r=0.683、0.575、0.573、0.539,P<0.05)。结论:检测血清sICAM-1的水平对判定PHC患者的病情、为肝癌的早期诊断和治疗有着重要的临床意义。     

‘Atypical adenomatous hyperplasia’ in liver cirrhosis: low-grade hepatocellular carcinoma or borderline lesion?

Adenomatous hyperplasia, defined as a sizable parenchymal nodule in cirrhosis, was examined morphologically. Ninety-seven nodules of adenomatous hyperplasia were obtained from 47 cirrhotic livers and were divided into 'ordinary' (44 nodules) and 'atypical' (53 nodules) types. The former consisted of hepatocytes similar to those of the surrounding liver, and showed regularly distributed portal tracts. The latter type was composed of hepatocytes showing nuclear atypia, relative to the surrounding liver, and showed irregular or sparse portal tracts. Atypical nodules were histologically heterogeneous, possessing areas of normo-trabecular, compact, pseudoglandular and/or scirrhous patterns. Several cytological changes, such as clear cell change, small or large cell change and fatty change, were intermingled variably within a given nodule. Atypical nodules showed expansive and/or replacing growth into the surrounding liver. Atypical hepatocytes also infiltrated into the fibrous septa and portal tracts. Foci of overt hepatocellular carcinoma were found in 11 of the 53 atypical nodules. These findings suggest that ordinary adenomatous hyperplasia may be a large-sized regenerative nodule, while atypical adenomatous hyperplasia may be a hepatocellular neoplasm, a peculiar form of low-grade hepatocellular carcinoma or borderline lesion, in which overt hepatocellular carcinoma is likely to evolve through multiple steps.     

Greater age and hepatocellular aging are independent risk factors for hepatocellular carcinoma arising from non-B non-C non-alcoholic chronic liver disease

We previously reported that hepatocellular aging can be assessed by measuring the nuclear size of hepatocytes. We attempted to elucidate whether this method is useful to identify the high risk group of hepatocellular carcinoma (HCC) in the patients with non-B non-C non-alcoholic liver injury. Fourteen patients with HCC and 78 without HCC, both of whom presented with non-B non-C non-alcoholic chronic liver injury and underwent liver biopsy, were selected. Twelve histologically normal liver tissues were selected as controls. The relative nuclear size (RNS) was calculated as the average nuclear size of the hepatocytes divided by that of lymphocytes. Multiple clinicopathological parameters were studied. The RNS values of normal livers ranged from 1.32 to 2.10, showing a gradual increase in an age-dependent manner. The RNS values of the injured livers without HCC increased after middle age. Univariate analysis identified greater age, existence of diabetes and RNS, as significantly positive contributors and ALT value and the degree of steatosis as negative contributors for the occurrence of HCC. Only age and RNS retained significance in multivariate analysis. All of the HCC patients were older than 50 and showed RNS values higher than 2.00. Therefore, such patients are classified as a high risk group of HCC.     

Analysis of genetic alterations,classified according to their DNA ploidy pattern,in the progression of colorectal adenomas and early colorectal carcinomas

DNA aneuploidy is a biological marker of the oncogenic potential of colorectal adenomas. The accumulation of genetic alterations of cancer-related genes is also essential for colorectal carcinogenesis. However, it is unclear whether there is any relationship between these genetic alterations and the DNA ploidy of colon tumour cells in the progression of colorectal adenomas and early colorectal carcinomas. Here we have studied the DNA ploidy state and genetic alterations occurring in colorectal tumours using the crypt isolation technique. Crypts isolated from a total of 106 colorectal tumors (adenoma, 93; early carcinoma, 13) were examined using a combination of flow cytometric analysis of DNA content, polymerase chain reaction-microsatellite assay, and single-strand conformation polymorphism assay for evidence of chromosomal allelic imbalance (AI; 17p; 5q; 18q) or p53 gene mutation. In addition, we examined microsatellite instability (MSI) with BAT 26 primer sets. DNA multiploidy was infrequently detected in colorectal adenomas (15.1%), in contrast to early carcinomas (46.2%). There was a significant difference in the incidence of AI of chromosome 18q between diploid adenomas and aneuploid populations of multiploid adenomas (18.1% vs 57.1%, p = 0.0043). Mutation of p53 was also found more frequently in aneuploid populations of early multiploid colorectal carcinomas than in early diploid colorectal carcinomas (66.7% vs 0%, p = 0.021). MSI was found in only 2 of 93 adenomas, with no MSI detected in early colorectal cancers. The two MSI-positive adenomas were diploid. We subdivided multiploid adenomas into two groups: those with a low or a high DNA index (DI). The incidence of genetic alterations of high-DI adenomas did not differ from those of low-DI adenomas. Allelic imbalance involving loci on chromosome 18q and mutations of p53 seems to be associated with the progression of diploidy to multiploidy in colorectal tumours. On the other hand, MSI may be associated with the development of some diploid tumours. In addition, the incidence of genetic alterations in the colorectal adenomas that we examined appears to be independent of the tumour's DNA index.     

Clinicopathological characteristics of PIK3CA and HBx mutations in Korean patients with hepatocellular carcinomas

Hepatocellular carcinoma (HCC) is the fourth most common form of cancer in the Korean population, caused primarily by infection with either the Hepatitis B or C virus. Progression of this disease is frequently associated with mutations in either phosphoinositide‐3‐kinase, catalytic, alpha (PIK3CA) or hepatitis B virus X (HBx) gene. Previous studies have examined the frequency of PIK3CA mutations in HCC, although the clinical significance of these mutations has not been studied in a Korean population. In addition, HBx appears to play a key role in modulating a wide range of cellular functions, leading to HCC. In this study, we examined microdissected tumor samples from 50 HCC patients who underwent hepatectomy at Keimyung University Dongsan Medical Center. These patients were screened for mutations in PIK3CA and HBx to identify the clinical outcomes associated with these mutations. Exons 9 and 20 of PIK3CA and the entirety of HBx were screened for mutations by polymerase chain reaction and direct DNA sequencing. PIK3CA mutations were detected in 7 of 50 patients (14%). Among the 42 patients who were seropositive for hepatitis B, 17 (40.5%) had HBx mutations and 4 (9.52%) had mutations in PIK3CA. PIK3CA mutations were strongly correlated with tumor size. Patients harboring HBx mutations exhibited a longer time to recurrence; this difference was statistically significant not only in comparison with the PIK3CA mutation but also compared with those without any mutations. This result suggests a role for PIK3CA and HBx mutations as prognostic markers in HCC.     

Reactive lymphoid hyperplasia of the liver mimicking hepatocellular carcinoma: incidental finding of two cases

Reactive lymphoid hyperplasia is a rare disease that forms a mass-like lesion and is characterized by the proliferation of non-neoplastic, polyclonal lymphocytes forming follicles. We recently encountered 2 cases of reactive lymphoid hyperplasia of liver, both of which were asymptomatic and mimicked hepatocellular carcinoma by various imaging modalities. Based on the clinical impression of hepatocellular carcinoma, surgical resections were performed. Microscopic findings revealed that both lesions consisted of an aggregation of lymphocytes consisting of predominantly B-cells, with multiple lymphoid follicles positive for CD10 and negative for bcl-2, consistent with the diagnosis of reactive lymphoid hyperplasia. Polyclonality of both lesions was further confirmed by B cell receptor gene rearrangement study. The incidence of reactive lymphoid hyperplasia in the liver is exceedingly rare, and it is difficult to differentiate such lesions from hepatic malignancies based upon clinical grounds. The clinicopathological findings and literature review of this report may be helpful to improve the clinical decision-making.     

Procuration and identification of bacteria in paraffin-embedded liver tissues of hepatocellular carcinoma by laser-assisted microdissection technique

This study was aimed at procuring directly and identifying the bacteria which had been found in paraffin-embedded liver tissues of hepatocellular carcinoma (HCC) patients. In our previous studies, Helicobacter spp. had been detected by polymerase chain reaction (PCR) and observed by histology in the liver tissues of HCC patients but had never been cultured successfully. To obtain and identify the uncultured bacteria, laser microdissection and pressure catapulting (LMPC) techniques were applied. Following microdissection from the liver tissue sections, these bacteria were examined by PCR using Helicobacter genus-specific 16S rRNA primers and sequence analysis. Amplified products of 16S rRNA were positive in all six microdissected samples with bacteria, and showed 99%-100% similarity with Helicobacter pylori by sequence analysis. Another H. pylori-specific 26 kDa gene (encoding one 26 kDa protein as H. pylori-specific antigen) was also tested by PCR. Four of six samples were positive. Therefore, Helicobacter spp. detected by PCR in the liver tissues of HCC patients in our previous studies are actually the bacteria observed by histology and identified as H. pylori by further sequence analysis. The laser-assisted microdissection technique can be extensively applied for identification of bacteria in tissue samples in bacteriology research.     

Predictive value of liver cell dysplasia for development of hepatocellular carcinoma in patients with non-cirrhotic and cirrhotic chronic viral hepatitis

AIMS: Hepatocellular carcinoma (HCC) frequently develops in patients with chronic viral hepatitis, especially in the cirrhotic stage. We retrospectively studied whether the presence of the putative preneoplastic lesions large liver cell dysplasia (LLCD) and/or small liver cell dysplasia (SLCD) in a needle liver biopsy of these patients are a risk factor for the development of HCC. Methods and results: The presence of LLCD and SLCD in the needle liver biopsy taken at the initial work-up of 115 patients with chronic hepatitis B or C was assessed retrospectively. LLCD and SLCD were present in the initial biopsy of, respectively, 35 (30%) and 25 patients (22%). During a mean follow-up of 107 months, 16 patients (14%) developed HCC and this occurred significantly more frequently in patients with cirrhosis, age > or = 55 years, LLCD or SLCD. Cirrhosis and LLCD were independent risk factors for HCC development. CONCLUSIONS: Our findings indicate that the presence of LLCD in a needle liver biopsy of patients with viral-induced chronic liver disease is an independent risk factor for the development of HCC. If these results are confirmed, the presence of LLCD can be used to identify a subgroup of patients at high risk for HCC requiring more intensive screening.