CASE REPORT

Tumor of the liver (hepatocellular and high grade

neuroendocrine carcinoma): a case report
and review of the literature
Monica T. Garcia & Pablo A. Bejarano & Maria Yssa &
Efren Buitrago & Alan Livingstone
Received: 1 April 2006 / Accepted: 7 June 2006 / Published online: 1 August 2006
# Springer-Verlag 2006
Abstract We describe a rare hepatic collision tumor
composed of a hepatocellular carcinoma and a high-grade
neuroendocrine carcinoma. The patient, a 50-year-old man,
underwent a partial hepatectomy because of a 5.0-cm mass.
The tumor had two distinctive patterns. The majority of the
tumor was a high-grade neuroendocrine carcinoma with
features of a small cell carcinoma that was positive for
chromogranin, synaptophysin, and cytokeratin 19 and
negative for hepatocellular antigen and alpha-fetoprotein
(AFP). The second component was a moderately differen-
tiated hepatocellular carcinoma that was positive for
hepatocellular antigen and AFP and negative for neuroen-
docrine markers. The two tumors were separated by fibrous
bands. In areas where they collided, there was no transition
or intermingling of cells between the two components, thus,
it is different from the combined type of tumors. After
removal of the tumor, the patient had intrahepatic and
mesenteric recurrences within a follow-up period of
16 months.
Keywords Collision tumor
.
Combined tumor
.
Liver neoplasms
Introduction
A collision tumor is an unusual neoplasm that is defined as
having two histologically distinct tumors simultaneously
involving the same organ with no transition between them.
They are different from combined tumors, which are not
only contiguous, but also intermingle with each other. In
the liver, both types are rare, but the combined type is more
frequent. It represents 2.0 to 3.6% of all primary hepatic
malignancies [2, 5]. It is postulated that these combined
tumors arise from stem cells that evolve into divergent
differentiation [3, 13]. The most frequent combined tumor
consists of hepatocellular and cholangiocarcinoma (hepa-
tocholangiocarcinoma). Hepatic collision tumors are even
rarer with an incidence of 0.1 to 1% [2, 3]. Most of the
collision tumors also show a hepatocellular carcinoma
accompanied by a cholangiocarcinoma. Single case reports
of primary collision tumors include hepatocellular carcino-
ma with sarcoma [7] and the rare occurrence of hepatocel-
lular carcinoma with neuroendocrine tumor [4], such as the
one described in this article.
Clinical history
The patient is a 50-year-old Hispanic man who has a
medical history of hepatitis C treated with interferon
monotherapy, which was terminated in 1994. Since then,
his hepatitis C virusRNA was not detectable (less than
5 IU/ml). Periodic hepatic ultrasound follow up showed a
mass on the left lobe of the liver 3 months before surgery. A
CT scan of the abdomen revealed a 5.0-cm mass located in
the hepatic segment IV-B (Fig. 1). The serum level of
alpha-fetoprotein (AFP) at this time was 1,191 ng/ml. The
patient had mild hypoalbuminemia (3.4 g/dl); normal liver
Virchows Arch (2006) 449:376381
DOI 10.1007/s00428-006-0251-0
M. T. Garcia (*)
:
P. A. Bejarano
:
M. Yssa
Department of Pathology, University of Miami,
Miller School of MedicineJackson Memorial Hospital,
1611 NW 12th Avenue, Holtz Building, Room 2042 G,
Miami, FL 33136, USA
e-mail: mgarcia22@med.miami.edu
E. Buitrago
:
A. Livingstone
Department of Surgery, University of Miami,
Miller School of Medicine,
Miami, FL, USA
enzymes, including 30 U/l aspartate aminotransferase,
45 U/l alanine aminotransferase, and 65 U/l alkaline
phosphatase; and total bilirubin of 0.4 mg/dl. CA19-9 and
CA125 were normal. CT of chest and extrahepatic abdomen
showed no abnormalities. At our institution, a liver core
biopsy was performed, which showed an extensively
necrotic, epithelial malignant neoplasm (Fig. 2). An intra-
operative ultrasound showed that the mass was located in
segment IV-B extending to segment V for which an
extended left hepatectomy was performed. Intraoperatively,
the abdominal cavity, including omentum, peritoneum,
intestines, stomach, and pancreas, were free of lesions.
The specimen showed both a hepatocellular carcinoma and
a neuroendocrine carcinoma. Because of the latter compo-
nent, an OctreoScan was performed in the 14th day after
surgery. There was no evidence of abnormal activity that
could have suggested somatostatin receptor positive tumor.
A follow-up serum level of AFP was 8.1 ng/ml on the first
month after the operation. Four months after surgery, a CT
scan of the abdomen showed 2.5-cm and 1.1-cm nodules in
the posterior and anterior segments of the right liver,
respectively. Two weeks later, a repeat CT scan of the
abdomen with contrast demonstrated a 4.5-cm mass
involving segments VII and VIII and a 2.0-cm mass in
segment V. The patient was treated with chemoinfusion
with 75 mg/m
2
of cisplatin and the right hepatic branch was
embolized with Gelfoam. The post chemoembolization
arteriogram showed no blood flow to the mass involving
segments VII and VIII and less flow to the mass located in
segment V. However, there were persistent liver lesions in
mid to lower liver lobe. At the time of this procedure, the
serum level of AFP was 570 ng/ml and decreased to
213 ng/ml 1 month after. Subsequently, the patient was
placed on chemotherapy with doxorubicin. A follow-up CT
scan showed an increased size in the liver masses,
peripancreatic adenopathy, and multiple nodular densities
in the anterior mesenteric area consistent with omental
caking. Then, thalidomide and bevacizumab (Avastin)
were added. At last visit on May 2006, the chemotherapy
treatment of the patient was still continued and he showed
evidence of active disease in the liver and mesenteric areas,
which have slightly decreased in size and showed possible
necrosis on the last CT. No biopsy was performed to
determine the histopathology of the recidivant tumors.
Materials and methods
The liver specimen was fixed with 10% buffered formalin,
embedded in paraffin, cut in 4-m-thick sections, and
stained with hematoxylin and eosin using the standard
methods. Immunohistochemistry was performed on select-
ed deparaffinized tissue sections using the avidin-biotin-
peroxidase method in a Dako AutoStainer (Carpinteria, CA,
USA). After antigen retrieval, the following panel of
primary antibodies was used: Hep Par1 (hepatocellular
antigen, Dako 1:50), AFP (Dako 1:1,500), synaptophysin
(Dako 1:10), chromogranin (Dako 1:50), cytokeratin (CK)
cocktail (AEI-3: Dako 1:200; HMW: Dako 1:500; and
CAM5.2: Becton Dickinson 1:1,500), CK7 (Dako 1:1,500),
CK19 (Dako 1:50), CK20 (Dako 1:25), neuron-specific
enolase (NSE) (Dako 1:5,000), CD56 (Vision BioSystem
1:50), thyroid transcription factor (TTF)-1 (Dako 1:150),
MIB-1 (Dako 1:100), insulin (Dako 1:50), glucagon (Dako
1:2,500), and vasoactive intestinal peptide (VIP) (Chemicon
1:300).
Tissue from paraffin blocks was recovered for electron
microscopy, deparaffinized, postfixed in 2% buffered
glutaraldehyde, and embedded in Epon epoxy resin. The
ultrathin sections were stained with uranyl acetate and lead
citrate and examined with a JEOL CX-100 transmission
electron microscope.
Fig. 1 CT scan of liver showing a 5.0-cm mass in the left lobe with
areas of necrosis. Both components cannot be distinguished
Fig. 2 Initial liver biopsy showing a necrotic poorly differentiated
carcinoma (hematoxylin and eosin, 200)
Virchows Arch (2006) 449:376381 377
Results
Gross findings
The resected specimen consisted of a 220-g 17.59.57.1-cm
portion of a noncirrhotic liver with attached gallbladder.
Sections revealed a well circumscribed and demarcated,
but nonencapsulated 5.34.54.0-cm mass that was
composed of two sharply defined and distinctive areas
(Fig. 3). The first occupied about 70% of the tumor and
was tan-white and friable. The second distinct area was
green, nodular, and extended into the resection margin.
The initial resection margin of the liver showed
malignancy on frozen section. Therefore, an additional
3.1-cm resection was performed in which a negative
margin was obtained. No satellite lesions were identified.
The gallbladder was unremarkable. No lymph nodes
were identified.
Histological findings and immunohistochemistry
The initial biopsy showed an extensively necrotic poorly
differentiated carcinoma. The neoplastic cells were positive
for cytokeratin cocktail and negative for CK7, CK20,
TTF1, and Hep Par1. The surgical specimen revealed a
hepatic mass that had two distinct morphologies with
different immunophenotypic profiles (Figs. 4 and 5). The
green and nodular component showed large cells with
abnormal nucleoli and abundant eosinophilic cytoplasm.
These cells were arranged in cords and plates of various
thicknesses separated by sinusoids lined by flat endothelial
cells. This component corresponded to a moderately
differentiated hepatocellular carcinoma, which was con-
firmed by immunohistochemical staining, as it was positive
for Hep Par1 and AFP. It was negative for synaptophysin,
chromogranin, CD56, NSE, CK7, CK19, CK20, and TTF1.
The second component corresponding to the tan-white and
friable mass contained smaller cells with a lesser amount of
cytoplasm and the nuclei had dispersed chromatin. The
tumor cells grew in a solid pattern interrupted with
pseudoacinar areas and rosette formation. It showed
Fig. 3 Cut surface of collision tumor showing the two components.
The green nodular area represents the hepatocellular component and
the white tan area corresponds to the neuroendocrine component
Fig. 4 a Sharp demarcation
of the both components of
moderately differentiated hepa-
tocellular carcinoma and the
neuroendocrine carcinoma with
the latter showing rosettes
(hematoxylin and eosin, 100).
b Hepatocellular carcinoma
(hematoxylin and eosin, 200)
378 Virchows Arch (2006) 449:376381
extensive necrosis and Azzopardi phenomena. This tumor
corresponded to a high-grade neuroendocrine carcinoma
with features of a small cell carcinoma. It was positive for
chromogranin, synaptophysin, NSE, CD56, and VIP;
strongly positive for CK19; and negative for Hep Par1,
CK7, AFP, CK20, TTF1, insulin, and glucagon. MIB-1
immunostain demonstrated different proliferative activity in
both components. The neuroendocrine component showed
high proliferative activity (7080% of the cells were
positive) while the hepatocellular component had lower
proliferative activity (1020% of the cells were positive).
The tumors were separated from each other by broad
fibrous bands. No transition areas were present. Even in the
areas of closest proximity the tumors were sharply
demarcated and were compressing, rather than infiltrating.
The American Joint Committee Classification pathologic
staging was determined to be T3NxMx. The nonneoplastic
liver showed mild chronic hepatitis and portal fibrosis.
Ultrastructural findings
The cells of hepatocellular carcinoma exhibited giant
lysosomes, myelin figures, megamitochondria, and abnor-
mal accumulations of glycogen and different degenerative
products. In the neuroendocrine tumor there were cytoplas-
mic neurosecretory granules that ranged in diameter from
360 to 410 nm and were not present in the hepatocellular
carcinoma (Fig. 6).
Discussion
True primary hepatic collision tumors are unusual, but the
presence of hepatocellular carcinoma growing synchro-
nously with a neuroendocrine tumor in a patient with no
existing extrahepatic tumor is even rarer. We report one
such case where the hepatocellular carcinoma grew inde-
pendently from an adjacent high-grade neuroendocrine
carcinoma in a noncirrhotic liver. Although hepatocellular
carcinoma is essentially considered a complication of liver
Fig. 5 a Borderline area be-
tween both tumors showing im-
munoreactivity for Hep Par1 in
the hepatocellular carcinoma,
whereas it is negative in
the neuroendocrine tumor
(immunoperoxidase, 100).
b Neuroendocrine carcinoma
showing immunoreactivity
for chromogranin
(immunoperoxidase, 100)
Fig. 6 Ultrastructural findings of the neuroendocrine tumor cells
showing dense-core granules that measured up to 410 nm (inset;
original magnification, 18,000)
Virchows Arch (2006) 449:376381 379
cirrhosis, studies showed that about 2040% of these
tumors develop in noncirrhotic livers [6, 8]. There are a
few reports of primary neuroendocrine tumors in the liver
combined with hepatocellular carcinoma, but these repre-
sented differentiation of the malignant liver cells into a
neuroendocrine tumor [1, 15]. The only case that appears to
fulfill the criteria for collision tumor is the study reported
by Ishida et al. [4]. Their patient was a 72-year-old man
with a 3-cm high-grade neuroendocrine carcinoma in
segment 8 and a 1.5-cm moderately differentiated hepato-
cellular carcinoma in segment 5. The liver was cirrhotic and
lymph nodes showed metastatic neuroendocrine carcinoma.
However, the authors favored the view that the neuroendo-
crine tumor did not arise de novo and speculated that it was
a hepatocellular carcinoma that underwent neuroendocrine
differentiation despite the fact that it lacked morphologic,
immunohistochemical, and ultrastructural features of hepa-
tocellular carcinoma.
In our case, the two tumors were independent of each
other, as evidenced by their gross and microscopic features.
Grossly, the tumors were separated by fibrous bands and
had distinctly different color qualities. The larger tan-white
and friable tumor corresponded with the morphologic
features of neuroendocrine carcinoma and comprised about
70% of the mass. The green and more nodular hepatocel-
lular carcinoma was well defined and sharply demarcated
from the first tumor by fibrous bands.
Microscopically, both tumors were distinctive morpho-
logically, immunophenotypically, and ultrastructurally.
They were separated by fibrous bands and they were in
direct contact with each other only focally. Even in the
areas of contact, the cellular components were markedly
different and did not intermingle. In these areas of
juxtaposition the tumors appeared to be pushing rather than
infiltrating each other. Also, electron microscopy showed
no neuroendocrine features in the hepatocellular carcinoma
component. Immunohistochemical stains highlighted the
differences between both tumors with one showing an
immunophenotype of hepatocellular carcinoma while the
other featured neuroendocrine markers. The rosette forma-
tion in the neuroendocrine tumor suggests that it could have
been initially low or intermediate grade neoplasm that later
acquired a more aggressive morphology in the form of a
small cell carcinoma. These features distinguish collision
tumor from the combined type reported Barsky et al. [1]
and Yamaguchi et al. [15] where two tumors showed
intermingled cells in the transition zone that could not be
morphologically separated. In addition, some of the cells in
the previously reported tumors had morphologic features of
hepatocellular carcinoma on paraffin sections stained by
hematoxylin and eosin sections but displayed neurosecre-
tory granules by electron microscopy. These features
support the view that although morphologically different,
the tumors may have originated from a liver cell that
eventually acquired neuroendocrine features.
Apart from the collision and combined types, neuroen-
docrine tumors can also occur in an isolated fashion
primarily in the liver in the form of carcinoids or high-
grade tumors represented by small cell carcinomas [9, 12].
However, the issue regarding the origin of primary
neuroendocrine tumors of the liver is not well elucidated
yet. Hepatic progenitor cells found in the epithelial lining of
intrahepatic bile ducts could potentially serve as the origin
of neuroendocrine tumors [10, 11]. This hypothesis is
supported by the presence of carcinoids and small cell
carcinomas in noncirrhotic livers. In our case, the strong
positivity for CK19 in the neuroendocrine component
supports the theory that these cells originated from hepatic
stem cells. A second hypothesis postulates that a stem cell
with pluripotential capability is the precursor for liver cell
carcinoma, neuroendocrine malignancies, and other tumors
with polyphenotypic expression. This is supported by
descriptions of hepatocellular carcinomas with neuroendo-
crine features [14]. Zhao et al. [16] found neuroendocrine
differentiation in 60% of their hepatocellular carcinomas.
This high rate is incongruent with the rarity of primary
neuroendocrine tumor in the liver.
The prognosis and treatment of hepatic neuroendocrine
carcinoma and hepatocellular carcinoma collision tumor are
uncertain due to the small number of cases studied.
Likewise, it is not known which of the two components
carries a negative influence in patients survival. Clinically,
our case had an aggressive clinical behavior during a 16-
month follow-up period. The other patients with solitary
high-grade neuroendocrine tumors described died within a
few months after diagnosis [4]. More cases of collision and
combined tumors of this type need to be documented to
obtain a better insight on their pathogenesis, behavior, and
treatment.
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