Primary hepatic carcinosarcoma with multimodal treatment

Abstract

Hepatic carcinosarcoma (HCS) generally presents in advanced stages, demonstrates aggressive behavior, and has a poor prognosis. Other than curative primary resection, no effective treatment options exist. We present a case of resected HCS with four repeat resections for solitary lymph node recurrence followed by chemoradiotherapy with doxorubicin and ifosfamide. A 67-year-old Japanese man was admitted to our hospital for evaluation of an asymptomatic hepatic tumor. The patient underwent right hepatectomy with a presumptive preoperative diagnosis of atypical hepatocellular carcinoma. Based on histopathological and immunohistochemical findings, the tumor was diagnosed as HCS containing osteosarcoma and chondrosarcoma components. After the initial surgery, the patient underwent four additional resections for solitary lymph node HCS recurrence, and then underwent chemoradiotherapy with doxorubicin and ifosfamide for an unresectable lymph node recurrence. Chemotherapy was stopped after two cycles because of severe adverse events, although chemoradiotherapy markedly reduced the size of the lymph node recurrence and provided a progression-free survival of 12 months. Thirty-seven months after the initial surgery, the patient died of cardiac invasion of multiple mediastinal lymph node metastases. The clinical course outlined in this case report suggests that chemoradiotherapy with doxorubicin and ifosfamide for metastatic HCS may prolong survival in patients with unresectable lesions.

Keywords: chemoradiotherapy; doxorubicin; hepatic carcinosarcoma; ifosfamide.

Fig. 1

(A) Dynamic CT revealed a heterogenous low-density tumor in the posterior hepatic segments with rim enhancement during the portal phase (arrowheads). (B) Tumor thrombus in the right posterior portal vein was also observed (arrows).

Fig. 2

(A) The cut surface of the resected specimen showed a yellowish-gray solid tumor. (B) The tumor contained elements of HCC (red), adenocarcinoma (orange), spindle-shaped sarcoma (blue), osteosarcoma and chondrosarcoma (gray), transitional zone (green), and necrosis (black).

Fig. 3

Hematoxylin-eosin stain (× 20) of the tumor showed the following: (A) spindle-shaped sarcoma; (B) osteosarcoma; (C) chondrosarcoma; (D) moderately differentiated clear cell HCC; (E) poorly differentiated adenocarcinoma; (F) transitional zone composed of atypical epithelial and sarcomatous cells; (G) lymph node metastasis composed of spindle-shaped sarcoma.

Fig. 4

(A) CT revealed an irregular-shaped tumor in the left supraclavicular region with infiltration of the internal carotid artery. (B) Chemoradiotherapy markedly reduced the size of the lymph node recurrence.