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A case of focal confluent hepatic fibrosis in the patient with hepatitis C virus-related liver cirrhosis: a mimic of cholangiolocellular carcinoma

Abstract

During routine ultrasound examination, a hyperechoic mass was detected in the anterior segment of the liver in an 80-year-old woman with hepatitis C virus-related cirrhosis. Computed tomography and magnetic resonance imaging findings suggested a malignant tumor with abundant fibrous stroma, similar to cholangiolocellular carcinoma. However, subsequent partial hepatectomy revealed a mass characterized by abundant fibrosis without tumor cells, dilated blood vessels, and marginal ductular reaction. Accordingly, focal confluent fibrosis was diagnosed. Generally, the diagnosis of focal confluent fibrosis is straightforward because of its well-established imaging characteristics. However, its differentiation from a malignant tumor can occasionally be difficult because of variation in presentation depending on the amount of fibrous stroma and the degree of inflammatory cell infiltration. In the present case, diagnosis was difficult because the lesion was more localized than usual, presenting a mass-like shape, and there was obvious hyperintensity on T2-weighted imaging and ring-shaped hyperintensity on diffusion-weighted imaging. Moreover, hepatic capsular retraction was indistinct, which can be one of the key findings of focal confluent fibrosis. When a hepatic mass is associated with a fibrous lesion, focal confluent fibrosis should be considered in the differential diagnosis, even though the lesion is associated with several atypical findings.

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References

  1. Ohtomo K, Baron RL, Dodd GD 3rd et al (1993) Confluent hepatic fibrosis in advanced cirrhosis: appearance at CT. Radiology 188(1):31–35. https://doi.org/10.1148/radiology.188.1.8511316

    Article  PubMed  CAS  Google Scholar 

  2. Ohtomo K, Baron RL, Dodd GD 3rd et al (1993) Confluent hepatic fibrosis in advanced cirrhosis: evaluation with MR imaging. Radiology 189(3):871–874. https://doi.org/10.1148/radiology.189.3.8234718

    Article  PubMed  CAS  Google Scholar 

  3. Ozaki K, Matsui O, Gabata T, Kobayashi S, Koda W, Minami T (2013) Confluent hepatic fibrosis in liver cirrhosis: possible relation with middle hepatic venous drainage. Jpn J Radiol 31(8):530–537. https://doi.org/10.1007/s11604-013-0222-8

    Article  PubMed  Google Scholar 

  4. Brancatelli G, Baron RL, Federle MP, Sparacia G, Pealer K (2009) Focal confluent fibrosis in cirrhotic liver: natural history studied with serial CT. AJR Am J Roentgenol 192(5):1341–1347. https://doi.org/10.2214/AJR.07.2782

    Article  PubMed  Google Scholar 

  5. Kelekis NL, Makri E, Vassiou A, Patsiaoura K, Spiridakis M, Dalekos GN (2004) Confluent hepatic fibrosis as the presenting imaging sign in nonadvanced alcoholic cirrhosis. Clin Imaging 28(2):124–127. https://doi.org/10.1016/S0899-7071(03)00243-2

    Article  PubMed  Google Scholar 

  6. Kim SK, Kim SR, Imoto S et al (2016) Confluent hepatic fibrosis in alcohol liver cirrhosis with elevated pivkaii value - usefulness of immunostaining for EZH2 and p16(INK4a) in differentiating it from cholangiolocellular carcinoma - Confluent hepatic fibrosis. Pathol Int 66(9):543–545. https://doi.org/10.1111/pin.12435

    Article  PubMed  Google Scholar 

  7. Park YS, Lee CH, Kim BH et al (2013) Using Gd-EOB-DTPA-enhanced 3-T MRI for the differentiation of infiltrative hepatocellular carcinoma and focal confluent fibrosis in liver cirrhosis. Magn Reson Imaging 31(7):1137–1142. https://doi.org/10.1016/j.mri.2013.01.011

    Article  PubMed  CAS  Google Scholar 

  8. Paradis V, Fukayama M, Park YN, Schirmacher P (2019) Tumors of the liver and intrahepatic bile ducts. In: WHO classification of tumours of the digestive system, 5th edn. IARC, Lyon, pp 215-264

    Google Scholar 

  9. Wallace K, Burt AD, Wright MC (2008) Liver fibrosis. Biochem Genet 411(1):1–18. https://doi.org/10.1042/BJ20071570

    Article  CAS  Google Scholar 

  10. Blachar A, Federle MP, Sosna J (2009) Liver lesions with hepatic capsular retraction. Semin Ultrasound CT MR 30(5):426–435

    Article  PubMed  Google Scholar 

  11. Husarik DB, Gupta RT, Ringe KI, Boll DT, Merkle EM (2011) Contrast enhanced liver MRI in patients with primary sclerosing cholangitis: inverse appearance of focal confluent fibrosis on delayed phase MR images with hepatocyte specific versus extracellular gadolinium based contrast agents. Acad Radiol 8(12):1549–1554. https://doi.org/10.1016/j.acra.2011.08.007

    Article  Google Scholar 

  12. Ooi CG, Chan KL, Peh WC, Saing H, Ngan H (1999) Confluent hepatic fibrosis in monozygotic twins. Pediatr Radiol 29(1):53–55. https://doi.org/10.1007/s002470050534

    Article  PubMed  CAS  Google Scholar 

  13. Ahn IO, de Lange EE (1998) Early hyperenhancement of confluent hepatic fibrosis on dynamic MR imaging. AJR Am J Roentgenol 171(3):901–902. https://doi.org/10.2214/ajr.171.3.9725360

    Article  PubMed  CAS  Google Scholar 

  14. Matsuo M, Kanematsu M, Kondo H et al (2001) Confluent hepatic fibrosis in cirrhosis: ferumoxides-enhanced MR imaging findings. Abdom Imaging 26(2):146–148. https://doi.org/10.1007/s002610000181

    Article  PubMed  CAS  Google Scholar 

  15. Galia M, Taibbi A, Marin D et al (2014) Focal lesions in cirrhotic liver: what else beyond hepatocellular carcinoma? Diagn Interv Radiol 20(3):222–228. https://doi.org/10.5152/dir.2014.13184

    Article  PubMed  PubMed Central  Google Scholar 

  16. Itai Y, Saida Y (2002) Pitfalls in liver imaging. Eur Radiol 12(5):1162–1174. https://doi.org/10.1007/s00330-001-1178-0

    Article  PubMed  Google Scholar 

  17. Brancatelli G, Federle MP, Ambrosini R et al (2007) Cirrhosis: CT and MR imaging evaluation. Eur J Radiol 61(1):57–69. https://doi.org/10.1016/j.ejrad.2006.11.003

    Article  PubMed  Google Scholar 

  18. Semelka RC, Chung JJ, Hussain SM et al (2001) Chronic hepatitis: correlation of early patchy and late linear enhancement patterns on gadolinium-enhanced MR images with histopathology initial experience. J Magn Reson Imaging 13(3):385–391. https://doi.org/10.1002/jmri.1055

    Article  PubMed  CAS  Google Scholar 

  19. Martin DR, Lauenstein T, Kalb B et al (2012) Liver MRI and histological correlates in chronic liver disease on multiphase gadolinium-enhanced 3D gradient echo imaging. J Magn Reson Imaging 36(2):422–429. https://doi.org/10.1002/jmri.23668

    Article  PubMed  Google Scholar 

  20. Mwangi I, Hanna RF, Kased N et al (2010) Apparent diffusion coefficient of fibrosis and regenerative nodules in the cirrhotic liver at MRI. AJR Am J Roentgenol 194(6):1515–1522. https://doi.org/10.2214/AJR.09.3484

    Article  PubMed  Google Scholar 

  21. Maetani Y, Itoh K, Watanabe C et al (2001) MR imaging of intrahepatic cholangiocarcinoma with pathologic correlation. AJR Am J Roentgenol 176(6):1499–1507. https://doi.org/10.2214/ajr.176.6.1761499

    Article  PubMed  CAS  Google Scholar 

  22. Park HJ, Kim YK, Park MJ, Lee WJ (2013) Small intrahepatic mass-forming cholangiocarcinoma: target sign on diffusion-weighted imaging for differentiation from hepatocellular carcinoma. Abdom Imaging 38:793–801. https://doi.org/10.1007/s00261-012-9943-x

    Article  PubMed  Google Scholar 

  23. Takahashi Y, Sato S, Ishitobi H et al (2017) Intrahepatic Cholangiolocellular and Cholangiocellular Carcinoma - Differences in the 18F-FDG PET/CT Findings. Intern Med 56(22):3027–3031. https://doi.org/10.2169/internalmedicine.8839-17

    Article  PubMed  PubMed Central  Google Scholar 

  24. Kaneko K, Honda H, Kajiyama K et al (1996) Radiologically identifiable intratumoral portal vein in intrahepatic cholangiomas: a diagnostic pitfall. Abdom Imaging 21(5):445–447. https://doi.org/10.1007/s002619900100

    Article  PubMed  CAS  Google Scholar 

  25. Haradome H, Unno T, Morisaka H et al (2017) Gadoxetic acid disodium-enhanced MR imaging of cholangiolocellular carcinoma of the liver: imaging characteristics and histopathological correlations. Eur Radiol 27(11):4461–4471. https://doi.org/10.1007/s00330-017-4811-2

    Article  PubMed  Google Scholar 

  26. Zhao YJ, Chen WX, Wu DS, Zhang WY, Zheng LR (2016) Differentiation of mass-forming intrahepatic cholangiocarcinoma from poorly differentiated hepatocellular carcinoma: based on the multivariate analysis of contrast-enhanced computed tomography findings. Abdom Radiol (NY) 41(5):978–989. https://doi.org/10.1007/s00261-015-0629-z

    Article  Google Scholar 

  27. Yoshimitsu K, Honda H, Kaneko K et al (1997) MR signal intensity changes in hepatic parenchyma with ductal dilation caused by intrahepatic cholangiocarcinoma. J Magn Reson Imaging 7(1):136–141. https://doi.org/10.1002/jmri.1880070119

    Article  PubMed  CAS  Google Scholar 

  28. Donato F, Galatti U, Tagger A et al (2001) Intrahepatic cholangiocarcinoma and hepatitis C and B virus infection, alcohol intake, and hepatolithiasis: a case-control study in Italy. Cancer Causes Control 12(10):959–964. https://doi.org/10.1023/a:1013747228572

    Article  PubMed  CAS  Google Scholar 

  29. Perumal V, Wang J, Thuluvath P, Choti M, Torbenson M (2006) Hepatitis C and hepatitis B nucleic acids are present in intrahepatic cholangiocarcinomas from the United States. Hum Pathol 37(9):1211–1216. https://doi.org/10.1016/j.humpath.2006.04.012

    Article  PubMed  CAS  Google Scholar 

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Correspondence to Kumi Ozaki.

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Ozaki, K., Takeshita, M., Saito, K. et al. A case of focal confluent hepatic fibrosis in the patient with hepatitis C virus-related liver cirrhosis: a mimic of cholangiolocellular carcinoma. Abdom Radiol 45, 2249–2256 (2020). https://doi.org/10.1007/s00261-020-02428-3

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  • DOI: https://doi.org/10.1007/s00261-020-02428-3

Keywords

  • Confluent hepatic fibrosis
  • Cholangiolocellular carcinoma
  • Cholangiocellular carcinoma
  • Cirrhosis
  • Ductular reaction