The Clinicopathological and Imaging Characteristics of Primary Hepatic Carcinosarcoma and a Review of the Literature

Abstract

Purpose: To improve the understanding of hepatic carcinosarcoma (HCS) by analyzing radiological imaging data and clinicopathological features.

Materials and methods: A retrospective analysis was performed on four patients with HCS confirmed immunohistochemically. The analysis included three males and one female, aged 29 to 64 years. Four patients underwent computed tomography (CT) scans, and one underwent magnetic resonance imaging (MRI) scans simultaneously.

Results: Three patients had a history of hepatitis B, cirrhosis or fibrosis, and two patients had schistosomiasis. Two cases tested positive for elevated serum carbohydrate antigen (CA) 19-9. The maximum diameters of the lesions ranged from 7.8 to 9.0cm. Pathologically, the carcinomatous and sarcomatous elements in two patients could not be classified, one of the patients had cholangiocellular carcinoma (CCC) and undifferentiated sarcoma, the other had hepatocellular carcinoma (HCC) and undifferentiated pleomorphic sarcoma (UPS). All tumors showed heterogeneous density/intensity, accompanied by vast cystic changes and necrosis, with two cases having cystic septations. Capsule formation was not identified. The margins of the radiological images showed irregular ring enhancement. One case presented continuous progressive enhancement, one case with "fast in fast washout" and two cases with "fast in late washout". Lymphonodus metastasis, satellite nodules, vascular embolism, and organ invasion (hepatic flexure of the colon) were identified.

Conclusion: HCS is a rare, high-grade malignancy with poor prognosis. The preoperative diagnosis is expected to improve by carefully analyzing the imaging features of the patients in combination with their clinical characteristics. Radical resection and postoperative chemoradiotherapy can improve the survival rate of patients.

Keywords: computed tomography; hepatic carcinosarcoma; imaging; magnetic resonance imaging.

Figure 1

The CT non-enhanced and enhanced images of Case 4. Case 4: 62 years old, male. (A) A lobulated mass located in the segments 5–6 of the right liver showed heterogeneous hypodense on non-enhanced CT images with septations inside. (B and D) On enhanced images, the tumor margin presented irregular ring enhancement with septations reinforced (C arrow), moderate enhancement in arterial phase, attenuation in portal vein phase and equilibrium phase. The mass protruded from the liver surface could be seen in coronal (E) and sagittal (F).

Figure 2

The CT non-enhanced and enhanced images of Case 3. Case 3: 42 years, male. (A) There was heterogeneous hypodense lesion in the segments 2–3 of the left liver, which was lobulated and irregular. On enhanced images, the margin showed irregular ring enhancement. The lesion showed moderate enhancement in the arterial phase (B) and continued in the portal phase (C), but attenuation in the equilibrium phase (D). A sub-foci (E arrow) was seen around the tumor.

Figure 3

Case 1 with T1WI, T2WI and T1WI-enhanced images. Case 1: 63 years old, female. There was a mass located in the segments S4b-5 with an inhomogeneous hyperintense (A, arrowhead) mixed with patchy hypointense (A, arrow) in the fat-suppression T2WI, (B) inhomogeneous hypointense was in fat-suppression T1WI, and scattered gas accumulation was observed (puncture drainage was performed 5 days before the examination). After enhancement, the mass presented irregular ring enhancement and continuous progressive reinforcement (C–E). (F) showed the mass invading the colonic hepatic flexure (arrow).

Figure 4

Pathological images of case 4: HE staining and immunohistochemical staining. Case 4: 62 years old, male. Magnification 10×10. Hematoxylin-eosin (HE) staining showed that the carcinomatous component was a poorly differentiated hepatocellular carcinoma, carcinomatous cells with nestlike distribution and obvious atypia, pathological nuclear division was observed, and neoplastic necrosis was found in the center of some nests (A). The sarcomatous component was undifferentiated pleomorphic sarcoma, with diffuse distribution of tumor cells, fusiform and epithelioid changes, tumor giant cells and pathological nuclear division, and neoplastic necrosis in some areas (B). Immunohistochemical staining: CK-P was positive in the carcinomatous component (C) and Vim was negative (D); Vim was positive in the sarcomatous component (E) and CK-P was negative (F).