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Volume 7(1); June 2007
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Review Articles
Hypervascular hepatic nodules which needs to be differentiated from hepatocellular carcinoma
Mi-Suk Park, Ki Whang Kim
Journal of the Korean Liver Cancer Study Group. 2007;7(1):1-7.   Published online June 30, 2007
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The frequency of hepatic nodular lesion detection has increased due to recent advances in imaging diagnostic techniques. There are many hypervascular hepatic nodules which need to be differentiated from hepatocellular carcinoma. Of these lesions, hepatic adenoma, focal nodular hyperplasia, nodular regenerative hyperplasia, and focal nodular hyperplasia-like nodules will be described in this review article. All of them are hypervascular and so it is needed to differentiate hepatocellular carcinoma.
Tumorigenesis of Combined hepatocellular and cholangiocarcinoma
Si Hyun Bae
Journal of the Korean Liver Cancer Study Group. 2007;7(1):8-12.   Published online June 30, 2007
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Combined hepatocellular-cholangiocarcinoma (CHC) is an extremely rare form of primary liver cancer having features of both hepatocellular and biliary epithelial differentiation. The incidence of CHC was 1.0-6.3% of all primary liver cancers. Since Allen and LIsa first described the features of this tumor in 1949, Allen’s classification has been widely used. This classification includes: type A, double cancer of HCC and CC, with HCC and CC present at different sites without contact; type B, HCC and CC are present at adjacent sites and mingle with continued growth; and type C, HCC and CC are mixed, growing within the same tumor. CHC are often confused with pseudoglandular growth pattern in HCC, but this has led to the mistaken impression that CHC are common. Histologically, only type C displays the characteristic of genuine mixture of both HCC and CC elements, and only Allen’s type C was included and regarded as true CHC in many published studies of CHC. With regard to the tumorigensis of CHC, the following possibilities have been proposed: 1st, the CC component arises from the main HCC tumor, and 2nd, the entire cancer arises from a stem cell potentially differentiating into hepatocytes and bile duct epithelium. In this review, I will describe the tumorigenesis of CHC and introduce the hepatic stem cell, such as hepatic progenitor cells.
Primary hepatic carcinoma with mixed features
Young Nyun Park
Journal of the Korean Liver Cancer Study Group. 2007;7(1):13-15.   Published online June 30, 2007
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Radiology of the Combined HCC and CC
Jin-Young Choi
Journal of the Korean Liver Cancer Study Group. 2007;7(1):16-21.   Published online June 30, 2007
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AbstractAbstract PDF
Combined hepatocellular-cholangiocarcinoma (HCC-CC) is a rare tumor showing histological evidence of both hepatocellular and biliary epithelial differentiation. Because of its rarity, there have been few reports about the imaging findings of this tumor. The CT findings of the combined HCC-CC include well-defined tumor with signs of malignancy such as hepatic hypervascularity, biliary obstruction, satellite nodules, and lymphadenopathy. Some portions may show hypoattenuation on arterial phase, whereas other portions show delayed persistent enhancement. The signal intensity of this tumor on magnetic resonance (MR) imaging is not specific. However, when the tumor resembles cholangiocarcinoma on gross pathologic exam, it shows peripheral rim-like enhancement, infiltrative margin, and portal vein invasion in patients with liver cirrhosis. On the other hand, when the tumor has gross appearance of HCC, imaging findings are not helpful for diagnosis. Cross-sectional imagings are helpful for predicting the predominant component of the combined HCC-CC and determining the treatment strategy.
Surgical treatment of combined hepatocellular and cholangiocarcinoma
Chul Soo Ahn
Journal of the Korean Liver Cancer Study Group. 2007;7(1):22-27.   Published online June 30, 2007
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AbstractAbstract PDF
Combined hepatocellular and cholangiocarcinoma (HCC-CC) is an uncommon form of primary liver cancer (PLC) with features of hepatocellular and biliary epithelial differentiation. According to publishing records HCC-CC accounts for 0.4% to 14.2% of all PLC cases. Large number of HCC-CC is associated with chronic viral hepatitis or cirrhosis, especially in asian countries. The tumor markers of HCC-CC (AFP, CA19-9) shows the intermediate level between hepatocellular carcinoma (HCC) and cholangiocarcinoma (CC). The clinical features of HCC-CC resembled with HCC but its post operative result and metastatic pattens are similar to that of CC. Surgical results of this tumor can yield results that are intermediate between HCC and CC in characteristics. But complete resection is the only effective therapy and can result in long term survival. And there are hot debates for the additional hilar lymph node dissection. The survival rate of HCC-CC is higher than CC but lower than HCC. The recurrence after resection has been frequently reported. Most of them are intrahepatic recurrences as HCCs but extrahepatic recurrences are much more frequent like CC. The CC component of HCC-CC seem to determine the prognosis. So more effective approaches for treating recurrent disease, such as local ablation therapy and or combination systemic chemotherapy and neoadjuvant chemoradiation, should be applied for long term and better results.
Surgical Treatment for Hepatocellular carcinoma with invasion to Portal vein and Inferior Vena Cava
Young Joo Lee
Journal of the Korean Liver Cancer Study Group. 2007;7(1):28-34.   Published online June 30, 2007
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It is not common that hepatocellular carcinomas (HCC) grow into portal vein (PV), inferior vena cava (IVC) and even into right atrium (RA). Tumor thrombus in PV may soon cause esophageal bleeing and tumor thrombus in the IVC/RA may cause fatal complications such as heart failure and lung embolism. Even if the prognosis in these patient is very poor, the need for operation is imminent for above complications. Surgical excision can be performed safely and reliably by using Hanging maneuver, Anterior approach, Glissonian approach and Total hepatic vascular exclusion. Surgical principle and treatments were described in these patients with tumor thrombus in PV, IVC and RA.
Hepatocellular carcinoma and Liver transplantation
Myoung Soo Kim
Journal of the Korean Liver Cancer Study Group. 2007;7(1):35-40.   Published online June 30, 2007
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AbstractAbstract PDF
Liver transplantation is the prime management for early hepatocellular carcinoma with liver cirrhosis that is not candidate for surgical resection. Milan criteria, single tumor less than 5 cm or less than three tumors with less than 3 cm, is accepted as an indication for liver transplantation. The extended criteria do not show reliable result in long-term recurrent-free survival rate. Shortage of donor and following high drop-out rate during waiting time are main obstacle to liver transplantation, which can be alleviated by the living donor liver transplantation and priority policies in deceased donor liver allocation. The pre-operative loco-regional therapy, such as transarterial chemoembolization (TACE), radiofrequency ablation (RFA) and regional surgical resection, decreases the drop-out rate for waiting time and supplies time for preparing the liver transplantation. Generally acceptable recurrence rate after liver transplantation is less than 15%. The size of mass, vascular or lymphatic-invasion, low grade tumor and high pre-operative level of alpha-Fetoprotein (AFP) are risk factors for recurrence. The prognosis of recurred hepatocellular carcinoma is fatal. Neoadjuvant chemotherapy after liver transplantation cannot prolong the patient survival rate and decrease the recurrence rate. Above 50% of recurrence-free patient survival rate at post-transplant 5 years is reliable result after liver transplantation in hepatocellular carcinoma. The survival rate is improved after mid-1990, and is reported as 60-70% at post-transplant 5 years. The living donor liver transplantation shows more superior survival rate than deceased donor liver transplantation.
Case Reports
A Case of Focal Nodular Hyperplasia-like Nodules in Cirrhosis
Young Joon Yoon, Ki Tae Yoon, Jun Yong Park, Hyun Woong Lee, Hwa Sook Kim, Jae Kyung Kim, Young Nyun Park, Kwang-Hyub Han, Chae Yoon Chon, Young Myung Moon, Mi-Suk Park, Sang Hoon Ahn
Journal of the Korean Liver Cancer Study Group. 2007;7(1):41-44.   Published online June 30, 2007
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AbstractAbstract PDF
Focal nodular hyperplasia (FNH) usually occurs in non-cirrhotic livers and was defined as a nodule composed of benign appearing hepatocytes occurring in a liver that is otherwise histologically normal or nearly normal. However, due to improvements in imaging techniques and pathological evaluation of explant livers, a focal lesion that is very similar to the classic form of focal nodular hyperplasia that occurs in cirrhotic liver has been described by several reports. Therefore, the term FNH-like nodules has been proposed. In this report, we report a case of focal nodular hyperplasia-like nodules in cirrhosis. A 59 year old woman with known hepatitis B virus infection visited our institution for routine check up. She was diagnosed as having liver cirrhosis and 3.5 cm sized liver mass on abdomen ultrasonography (US). Because tumor marker was negative and US findings are not compatible with hepatocellular carcinoma, other imaging modalities were performed. Magnetic resonance imaging (MRI) documented a 3.5 cm sized hypervascular nodule with internal aberrant vascular structure and multiple small sized nodules in remaining liver. Needle biopsy was targeted to the liver main mass. Microscopic finding revealed FNH-like nodule and underlying liver cirrhosis.
A Case of Benign Hepatic Nodule Difficult to Differenciate from Hepatocellular Carcinoma
Byoung Kuk Jang, Woo Jin Chung, Kyung Sik Park, Kwang Bum Cho, Jae Seok Hwang, Sung Hoon Ahn, Young Hwan Kim, Jung Hyeok Kwon, Yu Na Kang
Journal of the Korean Liver Cancer Study Group. 2007;7(1):45-48.   Published online June 30, 2007
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AbstractAbstract PDF
Improved imaging techniques have led to increasing detection of hepatic nodules incidentally. In many cases, a lesion that has been detected by imaging studies is not sufficiently characteristic, or there are other clinical concern, so that an imaging guided percutaneous needle biopsy is performed for definitive diagnosis. But sometimes, there are diagnostic difficulty due to limited diagnostic samples. We report a case of diagnosis to benign nodule, but not confirmed specific disease, by repeated CT guided fine needle biopsy.
Combined hepatocellular and cholangiocarcinoma
Jung Hyun Kwon, Si Hyun Bae, Jung Pil Suh, Ho Sung Park, Chan Ran You, Jong Young Choi, Seung Kew Yoon, Dong Hoon Lee, Ho Jong Chun, Byung Gil Choi, Chan Kwon Chung, Eun Sun Jung, Mi Ryung Ryu
Journal of the Korean Liver Cancer Study Group. 2007;7(1):49-54.   Published online June 30, 2007
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AbstractAbstract PDF
A 43 year-old-women patient was admitted for one month of jaundice. She was diagnosed hepatitis B carrier 17 years ago and has not done a routine check. Abdominal CT showed a large ill defined mass in left hepatic lobe with inhomogenous enhancement in arterial and delayed phase. The result of biopsy including the immunohistochemical stains showed the combined hepatocellular and cholangiocarcinoma (stage IVa, type C by Allen and Lisa). With the radiation therapy (3,910 cGy), six times of transarterial chemo-lipiodolization and two times of percutaneous ethanol injection, huge mass was markedly decreased in size and no stain in hepatic angiogram. She underwent left lobectomy.
A Case of Combined Hepatocellular-Cholangiocarcinoma Mimicking Focal Nodular Hyperplasia
Dong Hyun Shin, Kwang Cheol Koh, Geum Youn Gwak, Dong Il Choi, Cheol Keun Park, Moon Seok Choi, Joon Hyoek Lee, Seung Woon Paik, Byung Chul Yoo
Journal of the Korean Liver Cancer Study Group. 2007;7(1):55-58.   Published online June 30, 2007
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AbstractAbstract PDF
Combined hepatocellular and cholangiocarcinoma (cHCC-CC) is an uncommon form of primary liver cancer having features of both hepatocellular and billiary epithelial differentiation. We report a case of cHCC-CC in a patient who was serologically positive for hepatitis B virus. A 39-year-old male was diagnosed by ultrasonography with an asymptomatic tumor in the left lobe of the liver. Based on radiologic and serologic findings of elevated serum alpha-fetoprotein level, a preoperative diagnosis of hepatocellular carcinoma was made, but differential diagnosis included focal nodular hyperplasia, because tumor was enhanced in delayed phase in Godolinium MRI scan. A final diagnosis of cHCC-CC was made after operation.
A Case of Combined Hepatocellular and Cholangiocarcinoma
Woo Jin Chung, Sang Hun Jeon, Dong Choon Kim, Ju Yup Lee, Kyung In Lee, Hye Jin Seo, Byung Kuk Jang, Kyung Sik Park, Kwang Bum Cho, Jae Seok Hwang, Sung Hoon Ahn, Ku Jeong Kang, Young Hoon Kim, Jung Hyeok Kweon, Young Hwan Kim, Yu Na Kang
Journal of the Korean Liver Cancer Study Group. 2007;7(1):59-61.   Published online June 30, 2007
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AbstractAbstract PDF
A 51 years-old man who had postnecrotic liver cirrhosis due to chronic hepatitis B had elevated serum alpha fetoprotein level. According to computed tomographic findings, about 2.4cm sized mass was noted at segment 7 and he underwent segmentectomy. After 9 months later, multicentric recurrence was detected at segment 5-6, So, he underwent transcatheter arterial chemoembolization (TACE) and percutaneous ethanol injection therapy. After 22 months later, marginal recurrence was noted again at segment 6. So, he underwent 2nd TACE and he was following up over 30 months until now.
A Case of Combined hepatocellular carcinoma and cholangiocarcinoma (CHC) without underlying liver disease.
Jae Hoon Jung, Jung Il Kim, Sun Hyung Kang, Seok Hee Moon, Seok Hyun Kim, Byung Seok Lee, Heon Young Lee, Joon Sik Cho, Kyung Sook Shin, Dae Young Kang, Hyun Mo Kang
Journal of the Korean Liver Cancer Study Group. 2007;7(1):62-65.   Published online June 30, 2007
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AbstractAbstract PDF
Combined hepatocellular carcinoma and cholangiocarcinoma (CHC) is a rare form of primary liver cancer having features of both hepatocelluar and biliary epithelial differentiation and is related to cirrhosis. Recently, a 64-oldmale who was admitted to our hospital for evaulation of hepatic mass which was detected on ultrasonography. He had no underlying cirrhosis. Based on serologic findings of high alpha-fetoprotein(AFP) level, a preoperative diagnosis of hepatocellular carcinoma was made. A right lobectomy was done. On histologic examination, the resected tumor was shown to consist of two different tissues. On immunohistochemistry, the tumor is postitive for both anti-hepatocyte, CK-7 and CK-19. Finally we confirm combined hepatocellular carcinoma and cholangiocarcinoma (CHC).
A long-term survival case of advanced hepatocellular carcinoma with portal vein thrombosis successfully treated with multimodal treatments
Ju Hyun Choi, Han Eul Song, Chang Il Kwon, Kwang Hyun Ko, Sung Pyo Hong, Seong Gyu Hwang, Pil Won Park, Kyu Sung Rim, Man Deuk Kim, Sung Won Kwon
Journal of the Korean Liver Cancer Study Group. 2007;7(1):66-70.   Published online June 30, 2007
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AbstractAbstract PDF
We reported a 52-year-old women with hepatocellular carcinoma (HCC) of 10 cm in diameter involving entire right lobe with advanced tumor thrombosis in the both branches and main trunk of portal vein. She was treated with multimodal treatments resulting in a long-term survival of more than 5 years. At first, she was treated with hepatic arterial chemotherapy (HAC) using cisplatin and 5-FU for 5 cycles and radiation therapy in September 2002. The tumor size decreased and the main and left portal vein thrombosis was disappeared. Although, she had been treated with the 3th radiofrequency ablation (RFA) and the 3th transarterial chemoembolization (TACE) three times for the treatment of main tumor, follow-up CT scan still showed marginal viable tumor at the segment 5. Therefore, she was underwent right lobectomy of the liver and splenectomy. Further TACE was performed once for the small remnant tumor around inferior vena cava at the postoperative 4 months. Finally, she has been survived for over 5 years from the initial treatment and 23 months after operation without evidence of recurrence. We suggest that the long-term survival was achieved in this patient through appropriate treatment selections at the right time, such as HAC, RFA, TACE, hepatic resection and external radiotherapy based on changes in diagnostic imaging and tumor markers.
Two cases of Vessel invasion of Hepatocellular carcinoma
Sae Byeol Choi, Jae Yeon Seok, Kyung Sik Kim, Young Nyun Park, Kwang-Hyub Han, Jong Tae Lee
Journal of the Korean Liver Cancer Study Group. 2007;7(1):71-76.   Published online June 30, 2007
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Despite growing information on the clinical behavior of hepatocellular carcinoma(HCC), the histologic features associated with survival are not well characterized. Several different staging systems are suggested for use in predicting the prognosis of HCC. American Joint Committee on Cancer/International Union Against Cancer Staging System (AJCC/UICC) 6th edition divided T stages according to vessel invasion, T1 without microvessel invasion, T2 showing microvessel invasion and T3 showing major vessel invasion. The vessel invasion is generally considered a poor prognostic factor for HCC. Our report of the two patients with HCC run along similar terms. The patient diagnosed HCC with microvessel invasion underwent left lateral sectionectomy. Although the presence of microvessel invasion was found, this patient has survived without any recurrence for over 5 years now. The other patient underwent S8 segmentectomy and lived 10 years disease-free. After 10 years, although an intrahepatic recurred HCC successfully treated with local therapy, the recurred and newly developed multiple lesions were found again leading to a decision to perform operation. The HCC invaded into the portal vein and constituted portal vein thrombosis. The patient expired after 3 months postoperatively due to intrahepatic dissemination of the tumor. Therefore the impact of the vascular invasion on long-term survivors remains to be determined.

JLC : Journal of Liver Cancer