Synchronous development of HCC and CCC in the same subsegment of the liver in a patient with type C liver cirrhosis

Abstract

As a result of having undergone computed tomography (CT), a 75-year-old woman with type-C liver cirrhosiswas shown to have two tumors on the ventral and dorsal sides of subsegment 3 (S3). The tumor on the ventral side was diagnosed as a classic hepatocellular carcinoma (HCC), while that on the dorsal side was considered atypical for a HCC. Although the indocyanine green (ICG) findings indicated poor hepatic reserve, the prothrombin time (PT) was relatively good. An operation was performed in February 2007; however, this resulted in exploratory laparotomy. Dynamic CT performed 12 mo after the operation revealed that the tumor on the dorsal side of S3 had apparently increased. The marginal portion of the tumor was shown to be in the early and parenchymal phases, while the internal portion was found to have grown only slightly in the delayed phase. We diagnosed this tumor as a cholangiocellular carcinoma (CCC). S3 subsegmentectomy was performed in April 2008. The tumor on the ventral side was pathologically diagnosed as a moderately differentiated HCC, and that on the dorsal side was diagnosed as a CCC. We can therefore report a rare case of synchronous development of HCC and CCC in the same subsegment of the liver in a patient with type-C liver cirrhosis. We also add a literature review for all the reported cases published in Japan and around the world, and summarize the features of double cancer exhibiting both HCC and CCC.

Keywords: Cholangiocellular carcinoma; Double cancer; Hepatocellular carcinoma; Literature review; Synchronous.

Figure 1

Dynamic computed tomography findings at the onset of double cancer with hepatocellular and cholangiocellular carcinomas. Two tumors, ~1 cm in diameter, were detected on the ventral and dorsal sides of S3. Arrows indicate the tumors (A1, A2 arterial phase; B1, B2 parenchymal phase; C1, C2 delayed phase). Angiographic findings at the onset of double cancer; D: A superior mesenteric arterial angiogram showing a large shunt through the epigastric vein during the portal phase (the arrows); E: Computed tomography during arterial portography (CTAP) showing a ~1 cm defect on the ventral side of S3 (the arrow), which was diagnosed as a classic hepatocellular carcinoma. No defect can be seen on the dorsal side of S3.

Figure 2

Dynamic computed tomography performed 12 mo after the first operation. The tumor on the ventral side of S3 appears to be a classic hepatocellular carcinoma and that on the dorsal side of S3 appears to be increased to ~3 cm in diameter. Typical findings including enhancement of the peripheral portion of the tumor in the early (A1) and parenchymal (B2) phases, and the slight and gradual enhancement of the internal portion in the delayed phase were observed (C2). Arrows indicate the tumors (A1, A2 arterial phase; B1, B2 parenchymal phase; C1, C2 delayed phase). Subcutaneous ultrasonography performed 12 mo after the first operation (D); The tumor on the ventral side of S3 is represented by a hyperechoic mass, 14 mm in diameter, a finding characteristic of hepatocellular carcinoma rich in fat. The tumor on the dorsal side of S3 is also represented by a hyperechoic lesion, ~30 mm in diameter, with irregular and unclear margins. Arrows indicate the tumors (D).

Figure 3

Gross findings of the resected S3 subsegment. A: The cut surface of the tumor on the ventral side of S3; B: The cut surface of the tumor on the dorsal side of S3. Histopathological findings of the two resected tumors; C: The tumor on the ventral side was pathologically diagnosed as a moderately differentiated hepatocellular carcinoma (HCC) (with nodular, trabecular, and plate-like components); D: The tumor on the dorsal side was pathologically diagnosed as a cholangiocellular carcinoma (CCC) (diffuse type showing a vestigial remnant of the tumor).