Diagnosis of metastatic fibrolamellar hepatocellular carcinoma by endoscopic ultrasound-guided fine needle aspiration

Abstract

The fibrolamellar variant of hepatocellular carcinoma (FL-HCC) is distinguished from other hepatocellular carcinomas (HCC) by its unique clinical and pathologic features. Cytological features for this tumor on fine needle aspiration (FNA) of primary tumors have been described earlier. We present here a unique case of metastatic FL-HCC diagnosed by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of mediastinal adenopathy. A 32-year-old woman with a history of oral contraceptive use presented with nausea and severe abdominal pain but no ascites or stigmata of cirrhosis. She had a past history of resection of a liver lesion. Serial computed tomography scans revealed mediastinal lymphadenopathy and the patient was referred for endoscopic ultrasound (EUS). A transesophageal EUS-FNA was performed and tissue was collected for cytological evaluation by an on-site pathologist with no knowledge of prior history. Based on morphology correlated with prior history received later, a final diagnosis of metastatic FL-HCC in the retrocardiac lymph node was rendered on the EUS-FNA samples. There are very few reports in the literature where a diagnosis of FL-HCC is rendered at unusual sites. This case highlights that EUS-FNA is a relatively non-invasive, rapid, accurate and effective modality in obtaining tissue from otherwise hard-to-reach areas. It also suggests that metastasis of FL-HCC can be observed in mediastinal nodes and that diagnosis based on cytological features can be rendered even when the tumor is identified at unusual locations.

Utility of endoscopic ultrasound and endoscopy in diagnosis and management of hepatocellular carcinoma and its complications: What does endoscopic ultrasonography offer above and beyond conventional cross-sectional imaging?

“…Since this study did not include any patients with primary HCC, its results cannot be fully extrapolated to HCC patients. Similar studies were conducted by DeWitt et al[ 18 ] in 2003, Prasad et al[ 30 ] in 2004 and Crowe et al[ 31 ] in 2006, underscoring the benefits of EUS and EUS-FNA in diagnosis of liver metastasis (Figure 3 ). More recently, Fujii-Lau et al[ 32 ] proposed EUS-derived criteria for distinguishing benign from malignant metastatic solid hepatic masses, but are not specific for HCC.…”

Utility of cytokeratin7 immunocytochemistry in the cytopathological diagnosis of fibrolamellar hepatocellular carcinoma

“…[ 11 12 13 ] There are also a few reports of cytological diagnosis of FL-HCC in metastatic sites and role of EUS-FNA has been highlighted. [ 14 15 ] There is only a single case series of 6 cases, which only describes the cytology along with morphometry. [ 16 ] Presence of large polygonal cells with abundant eosinophilic cytoplasm having large vesicular nuclei, and large nucleoli are characteristic and in conjunction with the lamellar fibrosis, which also can be appreciated in cytology smears are the defining features of FL-HCC.…”

Fibrolamellar hepatocellular carcinoma in ascitic fluid: A case report with cytohistological correlation

“…Fibrolamellar variant of hepatocellular carcinoma (FL‐HCC) is an infrequently seen primary liver cancer more often seen in younger patients (mean age, 39 years), and affects males and females equally . FL‐HCC is not associated with underlying liver disease such as cirrhosis or hepatitis, and is not associated with birth control pills, which are all risk factors for development of hepatocellular carcinoma .…”