Hepatocellular carcinoma composed of two different histologic types: imaging features on gadoxetic acid-enhanced liver MRI
A 62-year-old man visited our institution on May 17, 2010, due to hoarseness that had developed one week before. Under the clinical suspicion of a laryngeal mass, he was scheduled for surgery at the department of otolaryngology. He used to be a heavy alcoholic and an 80 pack-year smoker. At the admission, high blood pressure and high blood sugar level were suspected. Family history was negative. On physical examination, the abdomen was soft with no tenderness, rebound tenderness or guardingno palpable mass was detected. Laboratory studies revealed the following values: white blood cell count, 6,800/mm3; hemoglobin, 15.9 g/dL; hematocrit, 46.4%; platelet count, 131,000/mm; total protein, 6.5 g/dL; albumin,4.3 g/dL. Aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, total bilirubin, and tumor markers including serum α-fetoprotein and protein induced by vitamin K antagonist-II (PIVKA-II) were all in the normal range. Hepatitis B virus surface antigen and anti-hepatitis C virus antibody were negative. During a routine ultrasound evaluation, a 3.3 cm-sized mass was incidentally discovered in segment VII of the liver. The mass was heterogeneously echogenic and the surrounded liver demonstrated generally increased echogenicity.\nThe patient subsequently underwent contrast-enhanced abdomen CT () which demonstrated underlying cirrhotic change of the liver and the mass in that was previously detected on ultrasound. The mass showed enhancement during the arterial phase and wash-out during the portal phase. After being lost to follow-up for a period of 16 months, the patient revisited our hospital and underwent an MRI of the liver (). The mass, which had not increased in size, showed rim enhancement during the arterial phase and wash-out during the delayed phase. The mass was hyperintense on T2-weighted images and restricted diffusion was seen on diffusion-weighted imaging sequences. On the 20-minutes delayed scans, heterogeneously low SI was seen in the central portion while the peripheral rim demonstrated high SI. The patient's hepatic function suggested a Child-Pugh score of 5 points.\nThe surgeon at our institution performed a wedge resection of hepatic segment VII. Histologic examination of the surgical specimen, measuring 8×5×3 cm in dimensions, disclosed an encapsulated greenish white, ovoid nodular and solid mass situated within the liver parenchyma showing macronodular cirrhotic change (). Microscopic examination of the mass revealed a well differentiated HCC composed of microtrabecular pattern in the central portion and pseudoglandular pattern in the periphery, features which correlated well with the findings from the hepatobiliary phase of enhanced MR imaging (). In the immunohistochemical studies, CD34 revealed increased sinusoidal capillarization, but glypican-3, AFP and cytokeratin 7 were negative in tumor.\nThe patient underwent a follow up CT scan 6 months after surgery demonstrating no evidence of recurrence.