Hepatic mucosa-associated lymphoid tissue lymphoma and hepatocellular carcinoma in a patient with hepatitis B virus infection

Primary hepatic mucosa-associated lymphoid tissue (MALT) lymphoma is an extremely rare disease. A 65-year-old female patient with chronic hepatitis B presented with multiple solid masses in segment (S) 4, S5, and S6 of the liver. The nodule in S5 was diagnosed preoperatively as hepatocellular carcinoma by computed tomography, magnetic resonance imaging, and angiography. The nodule in S4 was initially interpreted as lymphoid follicles by needle biopsy. Segmentectomy of S5 and partial resection of S6 were performed. Microscopic examination of the S5 nodule revealed moderately differentiated hepatocellular carcinoma. The nodule from S6 showed nodular proliferation of atypical intermediate to medium-sized lymphoid cells in the portal area and lymph epithelial lesions of bile ducts. The atypical lymphoid cells were positive for LCA, L-26 and bcl-2 and negative for UCHL-1. These features were consistent with the diagnosis of MALT lymphoma. This is the first case report of synchronous hepatic MALT lymphoma and hepatocellular carcinoma associated with chronic hepatitis B.     

Well-to moderately-differentiated HCC manifesting hyperattenuation on both CT during arteriography and arterial portography

We present a rare case of well- to moderatelydifferentiated hepatocellular carcinoma （HCC） in a 71-year-old woman with hepatitis C virus-related cirrhosis and unusual radiologic features. A 20-mm hypoechoic nodule disclosed by ultrasound in segment two showed hyperattenuation on both computed tomography hepatic arteriography and computed tomography during arterial portography. Contrast-enhanced ultrasound revealed hypervascularity in the early vascular phase and defect in the post-vascular phase, with the same pattern detected by the two imaging techniques. SPIO-MRI revealed a hyperintense nodule. These findings were compatible with those of moderately-differentiated HCC. An ultrasound-guided biopsy showed histological features of well- to moderately-differentiated HCC characterized by more than two-fold the cellularity of the non-tumorous area, fatty change, clear cell change and mild cell atypia with a thin to mid-trabecular pattern. Further studies may provide insights into the correlation between tumor neovascularity in multistep hepatocarcinogenesis and dual hemodynamics, including the artery and the portal vein.     

Surgically treated cases of mixed hepatocellular carcinoma and cholangiocarcinoma

The mixed type of combined hepatocellular carcinoma and cholangiocarcinoma is particularly rare. Hepatic resection was performed for two patients with mixed hepatocellular carcinoma and cholangiocarcinoma. In case 1, a 55-year-old Japanese man was found to have a hepatic tumor on ultrasonography. Since ultrasonically-guided needle biopsy revealed that the tumor was poorly differentiated hepatocellular carcinoma, the patient underwent a limited hepatic resection. Histologic and immunohistochemical examination revealed that the tumor had elements of both hepatocellular carcinoma and cholangiocarcinoma. Six months after surgery, the patient died of systemic recurrences. In case 2, a 58-year-old man was found by ultrasonography to have a hepatic tumor occupying the entire right hepatic lobe. Computed tomography revealed that the tumor had a portal tumor thrombus. The diagnosis of hepatocellular carcinoma was made because of a markedly elevated serum alpha-fetoprotein concentration, and a right hepatic lobectomy was performed. Histologic and immunohistochemical examination confirmed that the lesion was mixed hepatocellular and cholangiocellular carcinoma. The patient died of multiple recurrent tumors in the remnant liver 3 months after surgery. Surgical control of mixed hepatocellular carcinoma and cholangiocarcinoma is difficult.     

Significant regression of a cavernous hepatic hemangioma to a sclerosed hemangioma over 12 years: a case study

A sixties woman was found to have diagnosed by abdominal ultrasonography with a tumor in the left lobe of the liver and was referred to our institution in 1998. Abdominal magnetic resonance imaging (MRI) showed a typical, 70×45 mm cavernous hemangioma, which was followed up by annual MRI. In 2006, 8 years after the initial diagnosis, the MRI showed that the tumor had reduced to 30×15 mm. Although atypical of hemangioma, review of the annual observations indicated a diagnosis of regressive hemangioma, which also accorded with clinical observations. In 2009, a liver biopsy was performed by laparotomy during gastrectomy for gastric cancer. Pathological examination of the biopsy revealed sclerosed hemangioma tissue, confirming the diagnosis of regression of a cavernous hemangioma to a sclerosed hemangioma over 12 years.     

Well-differentiated HCC manifesting hyperattenuation on CT during arterial portography

A rare case of well-differentiated minute hepatocellular carcinoma (HCC) with hepatitis C virus-related cirrhosis, with unusual radiologic features, is presented. A 10-mm hypoechoic nodule disclosed by ultrasound in segment six showed hypoattenuation on computed tomography hepatic arteriography and hyperattenuation on computed tomography during arterial portography, indicating that the portal vein may have been the dominant vascularity of the nodule. Contrast-enhanced ultrasound revealed hypovascularity in the early arterial phase, isovascularity in the late vascular phase, and the same perfusion as that surrounding the liver parenchyma in the post-vascular phase, with the same pattern observed on the two imaging techniques. These findings were considered not compatible with those of well-differentiated HCC. Ultrasound-guided biopsy showed histological features of well-differentiated HCC with over two-fold the cellularity of the non-tumorous area with a high nuclear/cytoplasmic ratio, increased cytoplasmic eosinophilia, slight atypia and fatty change with an irregular thin trabecular pattern. Further studies may provide insights into the correlation between tumor neovascularity in multistep hepatocarcinogenesis and dual hemodynamics, including the artery and the portal vein.     

Portal thrombosis due to intrahepatic cholangiocarcinoma following successful treatment for hepatocellular carcinoma

A 57-year-old man, who had undergone hepatic arterial infusion chemotherapy with right portal occlusion for hepatocellular carcinoma was admitted to our hospital because of severe abdominal pain. Contrast-enhanced computed tomograms revealed that most areas of the liver were not enhanced, a finding suspicious for perfusion disturbance in the liver. Angiography revealed an interrupted right hepatic artery. Arterial portograms revealed complete obstruction of the right portal vein and a small left branch of the portal vein. Despite anticoagulant therapy with urokinase for portal vein thrombosis, the patient died from hepatorenal failure. Autopsy revealed that cholangiocarcinoma occupied almost the entire parenchyma of the right lobe, although the treated hepatocellular carcinoma lesion was completely necrotic. The right hepatic artery was obstructed due to direct invasion of tumor. There were diffuse thrombi in the left portal branches surrounded by tumor infiltrating along Glisson's sheath to the peripheral portion of the left lobe.     

Diagnosis of hepatic cavernous hemangioma by fine needle aspiration biopsy under ultrasonic guidance

Percutaneous aspiration biopsy of the liver using a heparinized 22-gauge needle was performed under ultrasonic guidance in 11 patients with hepatic cavernous hemangioma. Ten (91%) of 11 biopsy specimens obtained were cytologically diagnostic for hemangioma. No indications of malignancy were found. There was no relation between the cytological diagnosis and the location, size, or ultrasonographic findings. No complications were encountered. These findings indicate that cytological examination of the liver by fine needle aspiration biopsy is useful in diagnosing hepatic cavernous hemangioma of any size and in any location, provided optimal route to the lesions is chosen.     

Non-invasive diagnosis and follow-up of benign liver tumours

Hepatocellular benign liver tumours are mainly developed on normal liver and include hepatic hemangioma, focal nodular hyperplasia and hepatocellular adenoma from the most frequent to the less frequent. The diagnosis of hepatic hemangioma and of simple hepatic biliary cysts can be performed using non-invasive criteria using liver ultrasonography or contrast enhanced MRI. Most of the time the diagnosis of focal nodular hyperplasia can be achieved using contrast-enhanced ultrasonography or contrast enhanced MRI with an additional value of hepatobiliary contrast-agent in this setting. Rarely, if a doubt persists, a tumour and non-tumour liver biopsy can be required in order to establish the diagnosis. As hepatic hemangioma, simple hepatic biliary cysts and focal nodular hyperplasia are not associated with complications, they don't require any treatments or follow-up. Hepatocellular adenomas are mainly diagnosed at histology on surgical samples or liver biopsy even if some radiological features are highly suggestive of several subtypes of hepatocellular adenomas. Finally, the management of hepatocellular adenomas should be guided according to the tumour size, gender but also to the molecular subtypes.     

Focal nodular hyperplasia coexistent with hemangioma and multiple cysts of the liver

We report here a case of hepatic focal nodular hyperplasia (FNH) associated with hepatic hemangioma and multiple hepatic cysts in a 71-year-old man. He was admitted to our hospital because of body weight loss. Ultrasonography detected multiple cysts, and two tumors in the liver one, 3.5 cm and one, 1.6 cm. Color Doppler ultrasonography showed arterial signals within the large tumor. On dynamic computed tomography, the large tumor was a hypodense lesion which was enhanced during the arterial phase and almost isodense during the delayed phase; the small tumor was also a hypodense lesion, and was enhanced during both the arterial and delayed phases. On magnetic resonance imaging using superparamagnetic iron oxides, the large tumor had decreased signal intensity on the T2-weighted image. On hepatic arteriography, the feeding artery of the large tumor showed a spoke-wheel appearance and that of the small tumor showed a cotton-wool appearance. Ultrasonographically guided fine-needle aspiration biopsy of the large tumor revealed hepatocellular hyperplasia. Finally, we diagnosed the two hepatic tumors as FNH and hemangioma. There was no intracranial lesion. The cause of the patient's emaciation was psychogenic anorexia. To our knowledge, this is the first case report that describes the simultaneous occurrence of these three kinds of hepatic lesions. The pathogene-sis of FNH still remains unclear, but this association suggests that FNH may arise because of a vascular anomaly. Received: January 20, 2000 / Accepted: May 26, 2000     

Right hepatectomy for giant cavernous hemangioma with diffuse hemangiomatosis around Glisson’s capsule

Diffuse liver hemangiomatosis with giant cavernous hemangioma in adult is extremely rare. A 35 year-old woman presented to hospital with main complaint of epigastric pain and abdominal fullness. An enhanced computed tomography scan revealed a massive liver tumor in right lobe about 150 mm in size. There was contrast enhancement at the periphery of the mass consistent with a cavernous hemangioma. She underwent right hepatectomy. Histologically, it was diagnosed as a cavernous hemangioma. And also, hemangiomatous lesions were scattered around the Glisson’s capsule on the back ground liver. These hemangiomatous lesions were not recognized preoperatively. Even if we couldn’t diagnose hemangiomatosis around the main giant hemangioma preoperatively, we need to take enough surgical margins because the giant hemangioma has the potential to have small hemangiomatous lesions around the tumor. We reported right hepatectomy for giant cavernous hemangioma with diffuse hepatic hemangiomatosis without an extrahepatic lesion in an adult.     

Pancreatic cavernous hemangioma: CT, MRI, US, and angiography characteristics

A large pancreatic cavernous hemangioma was found in a 30-year-old man with abdominal distention. Plain and contrast-enhanced computed tomography (CT), magnetic resonance imaging (MRI), ultrasonography (US), and angiography were performed prior to operation. Contrast-enhanced CT and angiography showed a large poorly enhanced hypovascular tumor at the head of the pancreas. But MRI and US disclosed findings compatible with a cavernous hemangioma.     

Hepatocellular carcinoma with extensive peliotic change

Peliosis hepatis is a rare lesion histologically characterized by multiple cavities representing dilated sinusoids filled with blood in the liver. Although it has been observed in the liver parenchyma in association with several diseases and medications, there are few reports of nodules of hepatocellular carcinoma (HCC) showing extensive peliotic change. We describe a case of HCC showing extensive peliotic change in the cancer nodule. A 73-year-old man with a liver tumor was referred to our hospital for further investigation. Abdominal ultrasonography revealed an 8-cm hyperechoic lesion with a halo and mosaic pattern in segment 8 (S8) of the liver. Dynamic magnetic resonance imaging of the liver showed early irregular enhancement of the peripheral part of the lesion, and the effect persisted into the late phase, spreading into the central part of the nodule. Hepatic arteriography showed the “cotton–wool” sign, usually observed in cavernous hemangiomas. Fine-needle aspiration biopsy revealed the diagnosis of HCC. Anterior sectionectomy of the liver was conducted. Histological examination of the resected specimen showed that the tumor was a well-differentiated HCC with extensive dilated sinusoid-like structures in the main portion of the nodule, suggestive of peliotic change.     

Long-term survival following resection of peritoneal implantation from hepatocellular carcinoma: a case report

This study presents a rare case of long-term survival following the resection of peritoneal implantation from hepatocellular carcinoma (HCC). A 33-year-old female patient with hepatitis B infection presented with a huge pedunculated HCC and underwent left lateral segmentectomy in 1995. She received regular follow-up and peritoneal implantation was diagnosed 30 months after hepatic resection using abdominal computed tomography due to elevated alpha-fetoprotein (AFP). Subsequently, the patient received segmental resection of jejunum and a solitary peritoneal implantation from HCC in the mesentery of the jejunum. No peritoneal carcinomatosis, direct invasion of the surrounding tissue, or lymph node involvement existed and the postoperative course was uneventful. Meanwhile, histopathological examination of the resected nodule revealed metastatic hepatocellular carcinoma. With regular follow-up with AFP, abdominal ultrasonography, and or computed tomography, no intrahepatic tumor recurrence or extrahepatic metastasis was observed. The patient survived for 90 months following hepatic resection, and survived disease free for 60 months after resection of peritoneal implantation from HCC.     

Cavernous liver hemangioma with arterio-portal fistula]

Evidence of a cavernous hemangioma of the liver with fistula between hepatic artery and the portal vein of a 52 year-old woman with colickly upper abdominal pain and ascites was obtained using Duplex-Doppler-ultrasound. The diagnosis was confirmed by selective arteriography. After ligation of the left hepatic artery clinical symptoms abated. The cavernous hemangioma was followed up over 7 1/2 years with ultrasound. Ultrasound has been shown to be a valuable test for diagnosis and follow up of cavernous hemangioma.     

Atypically enhanced cavernous hemangiomas of the liver: centrifugal enhancement does not preclude the diagnosis of hepatic hemangioma

The imaging features of an atypically enhanced hepatic hemangioma have not been well described in the literature, and the presence of such atypia may sometimes cause clinical problems in the differential diagnosis. Herein, we report a case of hepatic hemangioma demonstrating a previously unreported atypical enhancement pattern. On dynamic computed tomography during hepatic arteriography, a centrifugal enhancement pattern and subsequent peritumoral ring-shaped enhancement mimicking corona enhancement were found in cavernous hemangiomas of the liver in a 68-year-old Japanese man. Histopathological diagnosis of cavernous hemangioma of the liver was made on a biopsy specimen. Considering the importance of differentiating benign hepatic tumor from various forms of malignancy, radiologists and hepatologists should be aware of rare enhancement patterns sometimes seen in hepatic hemangioma. Establishing knowledge of the entire spectrum of atypical hepatic hemangioma may benefit the rational approach to future cases.     

Scanning electron microscopy of a liver cavernous hemangioma

A 39-year-old female with a large cavernous hemangioma of the liver was successfully treated by ligation of the left hepatic artery. A wedge biopsy specimen of the hemangioma was obtained after the ligation and was examined by scanning electron microscopy. The hemangioma was demarcated from the surrounding normal liver parenchyma and had a labyrinth of caves 50-150 microns in diameter. The caves were separated by fibrous septa 20-40 microns in width. Endothelial cells of the caves were spindle-shaped and arranged in parallel. The surface property of the caves resembled that of the hepatic artery and differed from that of the portal vein or hepatic vein. These findings support that the cavernous hemangioma of the liver was supplied by the hepatic artery. The labyrinthine structure of the cavernous hemangioma may explain the long standing contrast enhancement of the hemangioma after hepatic arteriography.     

Utility of contrast-enhanced ultrasonography with perflubutane in evaluating indications for diagnostic percutaneous tumor biopsy in a case of hepatic sclerosed hemangioma

Sclerosed hemangioma is difficult to distinguish from intrahepatic cholangiocarcinoma or liver metastasis due to their imaging resemblance, thus pathological diagnosis is often required; however, percutaneous biopsy entails a risk of dissemination if the tumor is malignant. Perflubutane, a contrast agent of ultrasonography, has a characteristic feature of being phagocytosed by Kupffer cells. Hepatic malignant lesions contain few or no Kupffer cells, therefore, they are shown as a contrast defect. We report a case in which contrast enhanced ultrasonography (CEUS) with perflubutane was useful to evaluate indications for percutaneous tumor biopsy. A 69-year-old woman had a hypoattenuating mass with slight enhancement in peripheral lesion of the tumor in the arterial phase on dynamic computed tomography. From the arterial phase to the delayed phase, the hypoattenuating area was gradually and slightly enhanced, and peripheral enhancement also increased gradually, appearing as ring enhancement. We considered intrahepatic cholangiocarcinoma, liver metastasis, and sclerosed hemangioma as differential diagnoses. Most of the tumor did not display contrast defects in the post-vascular phase on CEUS, therefore, we considered the possibility of malignancy was low and performed percutaneous biopsy. The tumor was diagnosed as sclerosed hemangioma. CEUS may be useful in evaluating indications for diagnostic percutaneous tumor biopsy.     

Giant Hepatic Regenerative Nodule in a Patient With Hepatitis B Virus-related Cirrhosis

Hepatic regenerative nodules are reactive hepatocellular proliferations that develop in response to liver injury. Giant hepatic regenerative nodules of 10 cm or more are extremely rare and have only been reported in patients with biliary atresia or Alagille syndrome. A 50-year-old man presented with a pathologically confirmed giant 11.3×9.4×11.2 cm hepatic regenerative nodule and hepatitis B virus-related cirrhosis. Imaging of intrahepatic nodule included mild hyperenhancement in the portal phase of contrast-enhanced CT and the hepatobiliary phase in the gadoxetic acid-enhanced MRI scan, as well as the portal vein crossing through sign in the setting of liver cirrhosis. This case highlights the imaging characteristics of giant hepatic regenerative nodules in hepatitis cirrhosis.     

Hepatocellular carcinoma with concomitant hepatic angiomyolipoma and cavernous hemangioma in one patient

The risk of developing hepatocellular carcinoma(HCC) is strongly associated with hepatitis B virus infection.Hepatic angiomyolipoma(AML),a rare benign tumor,is composed of a heterogeneous mixture of adipose cells,smooth muscle cells and blood vessels.Here,we report the case of a 44-year-old man who developed HCC with a concomitant hepatic AML and a cavernous hemangioma,in the absence of cirrhosis.To our knowledge,based on an extensive literature search using the www.pubmed.gov website,this is the first report of an HCC case with both concomitant AML and cavernous hemangioma at the same position in the liver.The presence of the hepatitis B surface antigen was detected,but the liver function was normal.Clinical and pathological data were collected before and during the treatment.Hepatic AML was diagnosed based on the typical histological characteristics and immunohistochemical staining,which revealed,a positive staining with a melanocytic cell-specific monoclonal antibody.There was no evidence of tuberous sclerosis complex in this patient.Although the HCC was poor- to moderately-differentiated,the characteristics of the AML and the cavernous hemangioma in this patient did not match any criteria for malignancy.Hepatectomy followed by transarterial chemoembolization treatment were effective therapeutic methods for the adjacent lesions in this patient.This case is an interesting coincidence.     

Four-dimensional ultrasonography for therapeutic radiofrequency ablation for hepatocellular carcinoma

BACKGROUND/AIMS: We examined whether four-dimensional real-time flow imaging on ultrasonography (US) is valuable to display the accurate position of percutaneous radiofrequency ablation (RFA) needle in the nodule of hepatocellular carcinoma (HCC). METHODOLOGY: Ten patients with 12 HCC nodules were studied; nine were infected with hepatitis C virus (HCV) and one was diagnosed as non-B non-C. Diagnosis was done by helical dynamic CT and/or celiac angiography. Tumor vascularities in the early arterial and post-vascular phases after injection of a microbubble contrast agent were assessed by real-time US scanning of coded harmonic imaging and intermittent interval-delay scanning with a wide-band power Doppler technology. Percutaneous RFA was performed with four-dimensional real-time flow imaging under US to display the accurate position of cool-tip needle. RESULTS: It was possible to obtain accurate position of the needle during RFA procedure in all 12 nodules. The needle was confirmed to be inserted into the center of the tumor nodule by various angles. The simultaneous study before RFA therapy showed the inflow of arterial blood and tumor staining in all nodules at early arterial phase of coded harmonic angio on contrast-enhanced US scan. Posttreatment study to evaluate the therapeutic efficacy showed no blood flow at both early vascular and post-vascular phases. No residual blood flow was noted on early phase of CT scan with adequate safety margin. There was no discrepancy in the finding at early phase between contrast-enhanced US and dynamic CT. CONCLUSIONS: It appeared that four-dimensional real-time US provided more perceptible information on the spatial relationship between RFA needle and the target lesion, and resulted in accurate therapeutic efficacy for percutaneous RFA procedure.