Advanced Combined Hepatocellular Carcinoma and Cholangiocarcinoma (cHCC-CC) in a Patient With Alcoholism and Chronic Hepatitis C

Abstract

Introduction: A combined hepatocellular and cholangiocarcinoma (cHCC-CC) is rare subtype of primary liver cancer accounting for 0.87% of primary liver tumors. It is a distinct type of primary liver cancer with aggressive behavior, which is morphologically and phenotypically intermediate between HCC and CC. Although few studies have shown the increased occurrence of cHCC-CC in chronic hepatitis B patients, there is a lack of association with chronic hepatitis reported in US studies. We present a patient with advanced cHCC-CC and history of alcoholism and chronic hepatitis C(CHC). Case: A 64-year-old man with history of alcohol abuse and CHC, treatment naive, was referred to hepatology for jaundice for 2 weeks (blood work in table 1). Ultrasound of the abdomen showed a 6.6cm mass in left hepatic lobe extending to the hilum causing intrahepatic ductal dilatation(IHD), a 5.5cm mass in right hepatic lobe and scattered small liver lesions. MRI of the abdomen with Eovist revealed an 8.6cm mass in segment 4 extending to the hilum resulting in right(RT) and left (LT) IHD dilation and a 6cm mass in posterior right hepatic lobe. There were also smaller satellite nodules in both lobes, occlusion of the main portal vein with extensive cavernous transformation, and thrombus within the RT and LT intrahepatic portal veins. Liver was non-nodular while enhancement suggested CC. Liver biopsy showed CK7 positive, poorly differentiated CC with rare glandular architecture(Image 1). It also showed poorly differentiated HCC with giant cell features consistent with cHCC-CC (Image 2,3). Jaundice worsened and total bilirubin(TB) trended up to 30. A biliary drain was placed and TB decreased to 18. After the drain was capped 5 days later, he developed acute renal failure, leukocytosis and encephalopathy. Antibiotics, rifaximin, and albumin were given and his renal function and mental status improved. Palliative care was consulted for advanced cHCC-CC and the patient was discharged to home hospice. Conclusion: The diagnosis and treatment of cHCC-CC can be challenging due to clinical, imaging and histological features that overlap with pure HCC and CC. Our patient, although did not have ascites, had advanced stage disease with satellite lesions, multiple tumors, biliary, vascular and regional lymph node involvement. Further studies are needed to evaluate the risk of CHC in development of cHCC-CC. This may ultimately help us to screen for early disease and to improve prognosis.Table 1: LabsFigure 1Figure 2Figure 3