pISSN 2287-2728 eISSN 2287-285X Liver Imaging http://dx.doi.org/10.3350/cmh.2012.18.4.420 Clinical and Molecular Hepatology 2012;18:420-423 Hepatic metastases from hepatoid adenocarcinoma of stomach mimicking hepatocellular carcinoma Jae Myeong Jo1, Jin Woong Kim1, Suk Hee Heo1, Sang Soo Shin1, Yong Yeon Jeong1, and Young Hoe Hur2 1Department of Diagnostic Radiology and 2Department of Hepato-Pancreato-Biliary Surgery, Chonnam National University Hwasun Hospital, Chonnam National University College of Medicine, Hwasun, Korea Keywords: Hepatoid adenocarcinoma; Hepatocellular carcinoma; Liver; Stomach INTRODUCTION laboratory tests at the time of admission showed an aspartate aminotransferase (AST) level of 90 U/L, alanine aminotransferase Hepatoid adenocarcinoma is a special type of extrahepatic level (ALT) of 17 U/L, total bilirubin level of 0.9 mg/dL, alkaline adenocarcinoma that morphologically mimics hepatocellular phosphatase level of 67 U/L. The serum level of AFP (5,714 IU/mL) carcinoma (HCC). Clinical and immunohistochemical features of and protein induced by vitamin K absence or antagonist-II (PIVKA- hepatoid adenocarcinoma are similar to those of HCC, such as II; 1,005 mAU/mL) were markedly elevated. The CEA level was elevated serum alpha-fetoprotein (AFP) level, immunoreactivity within normal limits. His serum was positive for hepatitis B surface with AFP, polyclonal carcinoembryonic antigen (CEA), and alpha-1 antibody, but negative for hepatitis B surface antigen and anti- antitrypsin.1 Because of these clinical and pathological features, it HCV. is difficult to differentiate hepatic metastasis of hepatoid adeno- The ultrasonographic images showed a 9 cm sized hyperechoic carcinoma from HCC. Moreover, the imaging findings of hepatoid mass with internal anechoic portion in right hepatic lobe with adenocarcinoma are not well known. Therefore, we report a case adjacent small hypoechoic nodules (Fig. 1A). We then performed of hepatic metastases from hepatoid adenocarcinoma of stomach contrast-enhanced multidetector-row CT. The contrast-enhanced mimicking HCC with image findings and a review of the literature. dynamic CT images revealed a 9.5×7 cm sized mass in the liver, comprised of a central necrotic portion and a peripheral solid enhancing portion. Liver cirrhotic changes were not observed on CASE CT or ultrasonographic images. After contrast enhancement, the peripheral solid portion of the huge hepatic mass showed het- A 65-year-old man was admitted to our hospital for evaluation erogeneous enhancement on arterial phase image and washout of a huge hepatic tumor that was incidentally detected during an of contrast enhancement on delayed phase image. The tumor abdominal sonographic screening examination. He complained thrombus was visualized in adjacent right portal vein and a 1.3 cm of mild abdominal discomfort. He had a medical history of hyper- sized mass was observed in inferior aspect of huge hepatic mass. tension and a social history of alcohol for several decades. The The tumor thrombi were observed in proximal main portal vein Abbreviations: Corresponding author : Jin Woong Kim AASLD, the American Association for the Study of Liver Diseases; AFP, Department of Diagnostic Radiology, Chonnam National University alpha fetoprotein; CC, cholangiocarcinoma; CT, computed tomography; Medical School, Chonnam National University Hwasun Hospital, 322 EASL, European Association for the Study of the Liver; HBV, hepatitis Seoyang-ro, Hwasun-eup, Hwasun-gun 519-763, Korea B virus; HCC, hepatocellular carcinoma; HCV, hepatitis C virus; KLCSG/ Tel. +82-61-379-7104, Fax. +82-61-379-7133 NCC, the Korean Liver Cancer Study Group and the National Cancer E-mail; [email protected] Center; LC, liver cirrhosis; MRI, magnetic resonance imaging; NCCN, National Comprehensive Cancer Network; PPV, positive predictive value Copyright © 2012 by The Korean Association for the Study of the Liver This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Jae Myeong Jo, et al. Metastasis from hepatoid stomach cancer A B C D E F Figure 1. Hepatic metastases from gastric hepatoid adenocarcinoma in 65-year-old man. (A) Abdominal ultrasonography shows hyperechoic mass (arrows) with internal anechoic portion in right hepatic lobe, without evidence of liver cirrhosis. Also abdominal ultrasonography shows small hypoechoic mass (arrowhead) around main huge hepatic mass. (B, C) An enhanced abdomen CT image (B) shows irregular wall thickening of gastric antrum (arrows) and tumor thrombus (arrowheads) in the main portal vein. On the lower section image (C) shows multiple conglomerate enlarged lymph nodes (arrows) along gastroduodenal artery and right gastroepiploic artery. Also tumor thrombus (arrowheads) is shown in superior mesenteric vein. (D-F) Gadoxetic acid-enhanced MR images show huge central necrotic hepatic mass (arrows) and small hepatic mass (arrowhead), with heterogeneous early enhancement on arterial phase (D), low signal intensity on late dynamic phase (E) and hepatobiliary phase (F). to superior mesenteric vein. The multiple enlarged, conglomerate late dynamic and hepatobiliary phase images (Fig. 1D, 1E, 1F). lymph nodes were observed along the left gastric artery, gastro- Dynamic MRI revealed several small nodules that were unclear on duodenal artery and right gastroepiploic artery. The CT images abdominal CT. These lesions showed typical enhancement pattern also revealed irregular wall thickening of gastric antrum (Fig. 1B, of HCC such as early enhancement on arterial phase and delayed 1C). For evaluation of gastric abnormality, an endoscopic biopsy washout on late dynamic and hepatobiliary phases. was performed. An infiltrative mass with ulceration at the gastric Based on laboratory tests showing marked elevated AFP and antrum was detected on the endoscopic image and endoscopic PIVKA-II, existence of pathologic proven gastric adenocarcinoma, specimens were obtained in the gastric lesion. The specimen was and typical enhancement pattern of HCC of huge and small he- pathologically confirmed as poorly differentiated adenocarcinoma. patic tumors on CT and MRI, we thought two possible diagnoses; For further evaluation of the hepatic tumors, contrast enhanced the one was double primary malignancy as primary advanced liver magnetic resonance imaging (MRI) using gadoxetic-acid was gastric malignancy and primary HCC in the liver. The other was performed. The huge hepatic mass consisted of a central necrotic AFP producing gastric malignancy and its hepatic metastases. portion and a peripheral solid portion. The peripheral solid portion The ultrasonography-guided biopsy of the hepatic tumors was showed low signal intensity on T1WI and high signal intensity on performed. Microscopic examination revealed that the histology T2WI. After contrast enhancement, the peripheral solid portion of the hepatic tumor was similar to that of specimens from the of the huge hepatic mass showed heterogeneous enhancement gastric cancer. The results of immunohistochemical stains were on arterial phase image, low signal intensity on portal venous, positive for AFP, Glypican-3, Glutamine synthase, Cytokeratin, and 421 http://www.e-cmh.org http://dx.doi.org/10.3350/cmh.2012.18.4.420 Clin Mol Hepatol Volume_18 Number_4 December 2012 CK8/18. But CK20, CK7, and human serum albumin were nega- both patterns. The pattern of tumor thrombi remote from the he- tive. These histologic features resulted in the diagnosis of this case patic mass was helpful for differential diagnosis. as a gastric hepatoid adenocarcinoma with hepatic metastases. In conclusion, metastatic carcinoma from hepatoid adenocar- He had eight cycles of chemotherapy with FOLFOX and he remains cinoma should be included in the differential diagnosis in older alive for five months after diagnosis. patients with elevated serum AFP level and hepatic masses with imaging features of HCC in the absence of risk factors of HCC. In that situation, concomitant primary gastric cancer and tumor DISCUSSION thrombus remote from the hepatic mass are helpful in differential diagnosis of metastatic carcinoma from hepatoid adenocarcinoma Hepatoid adenocarcinoma is an AFP producing adenocarci- and HCC. When a metastatic carcinoma from hepatoid carcinoma noma, which has a histological similarity to HCC. It was first de- is highly suspected, gastroscopy should be performed even if a scribed by Ishikura et al.2 Since its first description in the stomach, primary gastric cancer is not clearly demonstrated on imaging which is the most common location, it had been found in a variety studies. of organs such as lung, pancreas, esophagus, colon, urinary blad- der, renal pelvis, ovaries, uterus, cervix and ampulla of Vater. Hepatoid adenocarcinoma is reported to comprise 0.38 % of all SUMMARY gastric cancer. Clinically, the neoplasm is characterized by older age, a high serum AFP level, aggressive behavior and the presence Hepatoid adenocarcinoma is a special type of extrahepatic ad- of a hepatic tumor in the absence of the risk factors of HCC. Its enocarcinoma that mimics hepatocellular carcinoma morphologi- poor prognosis is due to a strong tendency toward liver and lymph cally. The stomach is one of the most common sites of hepatoid node metastases and venous invasion.3-5 adenocarcinoma. Hepatoid