A 46-year-old woman presented with right upper quadrant pain and a 15-pound weight loss over the past five weeks before admission in January 2010. There was no radiating pain, vomiting, jaundice, fever, chill, cough or irregular vaginal bleeding. She had a history of hepatitis A, but without a history of alcohol drinking, smoking or surgery. On physical examination, the abdomen was soft, and no tenderness, rebound tenderness and palpable abdominal mass were found. The biochemical data were as follows: hemoglobin 110 g/L, white cell count 5.2 × 109/L with neutrophil 82.5%, platelet 334 × 109/L, alanine aminotransferase 28 μ/L, serum total protein 70 g/L, serum albumin 34.1 g/L, serum total bilirubin 15 μmol/L, serum direct bilirubin 9.5 μmol/L, alpha-fetal protein 7.33 ng/mL, and carcinoembryonic antigen (CEA) 8.5 ng/L, and serologic markers for the hepatitis-B virus were not detected. The plasma retention rate of indocyanine green at 15 min was 1.2%. Subsequent abdominal ultrasonography showed a mixed echoic mass measuring about 5.0 cm × 6.0 cm occupying the right lobe of the liver. The abdominal computed tomography (CT) showed a regular mass measuring about 5 cm × 6 cm at its greatest dimension with inhomogeneous density, mild delayed enhancement in the peripheral zone, necrosis in the central zone of the tumor and dilated secondary biliary ducts with intraductal lithiasis (Figures and ). Gastrointestinal endoscopy and colonoscopy showed negative findings. Chest CT revealed no mass over the lung.
Computed tomography scan showed a regular mass with inhomogeneous density, mild delayed enhancement in the peripheral zone, and necrosis in the central zone. R: Right.
The bile ducts adjacent to the tumor were obviously dilated and full of biliary calculi. R: Right.
The initial diagnosis before operation was intrahepatic cholangiocarcinoma (ICC) according to the CT findings (a regular mass, periductal dilatation and intraductal lithiasis). Surgery remains the exclusive choice of curative therapy for ICC. The patients underwent right hepatectomy and cholecystectomy in February 2011. A hard and yellowish white tumor mass was found, measuring about 5 cm × 6 cm at the greatest dimension with central necrosis occupying mainly S5 of a non-cirrhotic liver and numerous biliary calculi in the dilated intrahepatic bile duct adjacent to the tumor. The specimen appeared with a 1-cm negative margin without cysts on its cut surface.
Histopathological examination showed a poorly-moderately differentiated SCC composed of squamous cells with keratinization and large areas of necrosis (Figure ). The secondary bile ducts adjacent to the tumor were obviously dilated and full of biliary calculi. Chronic inflammatory lesions were found in the biliary epithelial and gallbladder mucosa without evidence of squamous metaplasia. Immunohistochemical tests were positive for cytokeratin (CK) 14, CK19 and CEA, but negative for CK 18 and thyroid transcription factor 1 (TTF-1). CK 14 positive indicated that basal cells of keratinized squamous epithelium were originated from the cancer cells. Metastatic lung or thyroid cancer to the liver could be ruled out, as TTF-1, an indicator of small cell carcinoma of the lung or thyroid, was negative. Subsequently a thorough search for a primary tumor showed a negative finding in the oral cavity and nasopharynx and a mild inflammatory change in cervical smear. Taken together, the final diagnosis of primary SCC of the liver was made.
Histology of the tumor: Squamous cells with keratinization and areas of necrosis. Hematoxylin-eosin stain, × 10.
The post-operative course was uneventful and the patient was discharged on the 14th day after operation. The patient was started on radiotherapy 2 mo after operation. Routine follow-up was continued in the hepatobiliary clinic. No tumor recurrence and distant metastasis were found during the 19-mo follow-up period.