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Hepatic Metastasis from Hepatoid Adenocarcinoma of the Stomach Mimicking Hepatocellular Carcinoma: Diagnostic Challenge
Renu Sukumaran1*, Anitha Mathews1, Neelima Radhakrishnan1
1Department of Pathology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India.
Abstract
Hepatoid adenocarcinoma (HAC) is a unique type of extrahepatic adenocarcinoma that histologically mimics the appearance of hepatocellular carcinoma (HCC). Hepatoid adenocarcinoma of the stomach has a poor prognosis with increased potential for liver metastasis. HCC and HAC share clinicopathological and immunohistochemical features. The diagnosis of metastatic hepatoid adenocarcinoma to the liver is challenging. It is often misdiagnosed as hepatocellular carcinoma. The diagnostic dilemma is more when the primary tumour is unknown and the first diagnosis is to be established on liver biopsy. Herein, we present the case of a 68-year-old male patient who presented with dysphagia and abdominal discomfort for a three-month duration. Imaging studies showed multiple hypodense lesions in both lobes of the liver. Serum AFP level was markedly elevated to a level of 83,000 ng/ml). A liver biopsy showed atypical polygonal cells in the trabecular pattern. The atypical cells were CK7 negative, CK 20 negative, Hep Par-1 positive and AFP positive. Features were suggestive of hepatocellular carcinoma. Endoscopy showed ulceroproliferative growth in the distal body and antrum of the stomach, a biopsy of which showed atypical cells of similar morphology. The cells were showing focal positivity for CK7, CK20, Hep Par-1 and AFP. On further evaluation, tumour cells in both locations showed positivity for SALL 4. Correlating clinical features, radiology, serum marker values and IHC profile, diagnosis of hepatoid adenocarcinoma of the stomach with liver metastasis was given.
Keywords: Adenocarcinoma, Hepatocellular carcinoma, Hepatoid adenocarcinoma, Metastasis, Stomach
Hepatoid adenocarcinoma of the stomach (HAS), is a unique subtype of gastric cancer with specific clinicopathological features. In addition to histological resemblance, HAS and HCC will show positive immunostaining for AFP, Hep Par -1, polyclonal CEA, SALL 4 and Glypican-3. Hepatoid adenocarcinoma of the stomach is characterized by older age, aggressive behaviour and poorer prognosis than usual type adenocarcinoma.[1] The aggressive biologic behaviour is due to the early involvement of lymph nodes and extensive haematogenous metastasis to the liver.
The pathogenesis of hepatoid adenocarcinoma is still unclear. Recent studies have demonstrated that the increased incidence of hepatoid adenocarcinoma in the stomach may be due to the common embryonic origin of the stomach and liver from the foregut. The tumour may evolve through genetic progression and/or genetic divergence.[1-6]
Address for correspondence: Renu Sukumaran, Department of Pathology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India. E‑mail: [email protected]
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A 68-year-old male patient presented with dysphagia and abdominal discomfort for a three-month duration. Imaging studies showed multiple hypodense lesions in both lobes of the liver largest measuring 8.4x7.5x5.1cm in segment VII. Another large lesion was noted in segment IVa measuring 6x5cm. Serum AFP was markedly elevated to a level of 83,000ng/ml. A liver biopsy showed atypical cells in a trabecular pattern with surrounding necrosis. Cells were large
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Figure 1. a) Liver biopsy showing large atypical cells surrounded by necrosis (H&E, 100X), b) Higher magnification showing large atypical polygonal cells (H&E, 200X), c) Neoplastic cells showing positivity for Hep par-1 (IHC, 200X), d) AFP positivity (IHC, 200X) |
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