肝肉瘤样癌的影像表现及临床病理分析

Imaging manifestations and clinicopathological analysis of sarcomatoid hepatocellular carcinoma

目的探讨肝肉瘤样癌影像表现及临床病理特征。方法收集解放军总医院第五医学中心2012年1月至2021年3月11例肝肉瘤样癌患者的临床资料。分析患者的临床症状、CT及MRI影像学表现、病理特征、免疫组织化学染色检查等。结果11例肝肉瘤样癌患者中男7例,女4例,其中6例为单发病变,5例为多发病变,1例合并肝细胞癌及胆管细胞癌。1例行CT增强扫描,5例行MRI增强扫描,5例行CT增强及MRI增强扫描。影像学检查CT平扫呈低密度,增强扫描动脉期呈环形或斑片状不均匀强化,门脉期及延迟期呈低信号;MR平扫呈稍长T1稍长T2信号,其中1例瘤内出血呈局灶性稍短T1信号,病变强化方式与CT表现相似;3例病变可见假包膜强化;1例病变可见分隔样改变;肿瘤内有坏死囊变区;1例混合癌患者增强扫描呈延迟强化。免疫组化结果显示,9例患者的Vimentin呈阳性表达,8例Hepa呈阴性表达,4例CK19呈阳性表达,8例CD34呈阳性表达,Ki67均呈阳性且其中6例Ki67>75%,5例EMA呈阳性,3例SMA呈阳性。随访11例患者中,3例术前已转移,5例出现术后复发及转移。结论肝肉瘤样癌的临床特征及影像表现不典型,如发现肝内较大肿瘤,伴肿瘤内较大坏死囊变区,增强扫描动脉期病变呈现环状、斑片状边缘强化或者不均匀强化,需考虑肝肉瘤样癌可能。

Objective The aim of the present study was to retrospectively analysis the imaging manifestations and clinicopathological characteristics of sarcomatoid hepatocellular carcinoma(SHC)patients,in order to improve the efficiency of clinical diagnosis of SHC.Methods The clinical data of 11 patients with pathologically confirmed SHC from January 2012 to March 2021 were collected.The clinical symptoms,Computed tomography(CT)and magnetic resonance imaging(MRI)findings,pathological features,immunohistochemical staining,and other findings during followed-up were retrospectively analyzed.Results Among the 11 patients with SHC,7 were male and 4 were female,of which 6 patients have single lesions,5 patients have multiple lesions,and 1 patient was complicated with hepatocellular carcinoma and cholangiocellular carcinoma.One patient underwent CT enhanced scan,5 patients underwent MRI enhanced scan,and 5 patients underwent CT and MRI enhanced scan.The imaging examination of the SHC lesions showed low-density on CT plain scan,circular or patchy uneven enhancement in the arterial phase of the enhanced scan,and low-intensity in the portal phase and the delayed phase;MR plain scan showed slightly longer T1 and longer T2 signals,and one case of intratumoral hemorrhage showed focal and shorter T1 signals,and the lesion enhancement method was similar to CT findings;Pseudocapsular enhancement was observed in 3 cases.Septal changes were seen in 1 case,with necrotic cystic areas within the tumor.One patient with mixed carcinoma showed delayed enhancement on enhanced scan.Immunohistochemical results showed that Vimentin was positive in 9 patients;Hepa was negative in 8 patients;CK19 was positive in 4 patients;CD34 was positive in 8 patients;Ki67 was positive in 6 patients(Ki67>75%);EMA was positive in 5 patients;SMA was positive in 3 patients.Three patients had metastasis before surgery and 5 patients had recurrence and metastasis after surgery.Conclusion The clinical features and imaging manifestations of SHC are atypical and rare.If a large intrahepatic tumor is found with large necrotic cystic areas within the tumor,ring-shaped,patch-like edge enhancement or uneven enhancement arterial phase lesions shown in enhanced scan,the possibility of SHC should be considered.