A hepatoid carcinoma of the pancreatic head
© The Author(s). 2016
Received: 23 March 2016
Accepted: 30 June 2016
Published: 3 August 2016
Hepatoid carcinoma (HC) is an extremely rare form of neoplasm. Its cellular structure resembles that of a hepatocellular carcinoma (HCC). To date, only 26 cases of hepatoid carcinoma of the pancreas have been reported in the literature. We report the diagnosis of a hepatoid carcinoma of the pancreatic head in a 78-year-old male patient. The tumor was detected incidentally during routine abdominal ultrasound scanning. Laboratory tests did not show any abnormalities except for a monoclonal gammopathy of undetermined significance. After CT, MRI, and laparoscopic biopsy that failed to obtain the diagnosis, the patient underwent a Whipple procedure. The final pathology report described a hepatoid carcinoma of the pancreatic head (pathological T3, N0 (0/10), L0, V0, R0, M0). After the patient recovered, no further therapy was recommended by the tumor board and he was discharged. Regular follow-up was suggested; however, the patient suddenly died of acute coronary artery disease 2 months after surgery.
Hepatoid carcinoma is an extremely rare form of neoplasm. Its cellular structure resembles that of a hepatocellular carcinoma (HCC). Hepatoid carcinoma (HC) has been described in various organs and systems such as the gastrointestinal tract, testes, ovaries, and lungs . We present a case of a HC of the pancreatic head in a 78-year-old male patient.
A 78-year-old male patient with diabetes underwent an annual abdominal ultrasound scan. He had no complaints, and his diabetes was controlled well. The patient denied experiencing weight loss, nausea, jaundice, fever, and other diseases. He was a non-smoker without increased alcohol consumption.
The postoperative recovery was slow due to gastric atony, which required parenteral nutrition, and a tendency to hypoglycemia.
Considering the age and clinical condition of the patient together with the stage of the disease, no further therapy was recommended by the tumor board and he was discharged home. Regular follow-up was to take place. Two months after surgery, the patient suddenly suffered an acute heart attack and was pronounced dead upon arrival at the emergency room.
Hepatoid carcinoma is an extremely rare form of neoplasm. The tumor has been found in various organs, including the gastrointestinal tract, testes, and ovaries [2–5]. Recently, Motooka and colleagues reported a new case of a hepatoid carcinoma of the lung . The diagnosis is complex, since the tumor can clinically mimic other neoplasms and the laboratory results are often unspecific as in this reported case. Discriminating from a HCC and neuroendocrine tumors using medical imaging is challenging. A CT- or an endoscopy-guided fine needle biopsy should be performed when possible.
The cellular structure of the tumor resembles that of a HCC. Typical histological features are islands of large tumor cells growing in a trabecular or perisinusoidal pattern, displaying an eosinophilic cytoplasm and round nuclei as well as prominent nucleoli [1, 7, 8]. It is assumed that HC derives from ectopic liver tissue because both the pancreas and liver have a common embryologic origin—the foregut endoderm . Some tumor cells express AFP, hepatocyte antigen, and cytokeratin. AFP  and PIVKA-II  have been suggested as a tumor marker for the disease. Staining for hepatocellular differentiation is typically positive, including hepatocyte paraffin 1 (HepPar1), polyclonal CEA (canalicular), and CD10 (canalicular). The differential diagnosis of hepatoid carcinoma includes acinar cell carcinoma and pancreatoblastoma, both can express AFP, as well asintraductaloncocytic papillary neoplasm, which consistently stains for HepPar1, but it does not possess true hepatocellular differentiation . In order to exclude a metastatic HCC, some authors suggest the examination of two specific hepatocyte-transporters (bile salt export pump (BSEP) and multidrug-resistance protein 3 (MDR3)) which are not usually expressed by HC tumor cells .
To date, only 26 cases of pancreatic HC have been reported in the literature. The patients’ age ranged from 21 to 80 years. Most of them were male (16M/10F). Thirteen patients were either asymptomatic or suffered from unspecific abdominal pain. Four patients however showed jaundice. All patients underwent surgery and/or chemotherapy. Nine of them died despite therapy within 2 to 101 months after diagnosis. In 7 cases, extensive hepatic metastases were noticed. There are reports which describe the tumor as highly aggressive with a tendency for early hepatic metastases . Most authors report pure HC [14–16]. These tumors have the highest incidence of metastasis and the worst prognosis. In some cases, the tumor has been found associated with a neuroendocrine carcinoma [9, 17, 18]. The latter showed a longer survival and sensitivity to radiochemotherapy . Three of the cases describe tumors with primarily hepatocellular differentiation [19–21], and the authors suspect the origin of the tumors to be ectopic liver tissue. In those cases, the tumors were not metastatic and the patients had improved survival. Association of HC , with a serous microcystic cystadenoma, has been reported in a single patient who remained free from metastases and showed no recurrence during the 8 months of follow-up. One case of Papilla vateri HC was also reported .
No standard therapy has been established due to the tumor rarity and the lack of evidence-based data. Tumor resection is, if possible, always recommended. Neoadjuvant and adjuvant chemotherapy can be considered; however, standard therapy usually used for pancreas neoplasm with gemcitabine is inefficient. The XELOX protocol with oxaliplatin and capecitabine led to remission in some cases . A short-term regression can be achieved with sorafenib [13, 15]. Unfortunately, the long-term outcome of the current therapy is poor. Further studies and new treatment approaches are needed to determine the biological behavior of the tumor and its sensitivity to chemotherapeutical agents.
We have presented a case of a non-metastatic HC of the pancreatic head. HC is an extremely rare form of neoplasm, which has morphological and immunohistochemical features similar to those of HCC. The patient was only treated operatively, owing to his clinical condition and considering the stage of the tumor. He died of a sudden coronary event 2 months after the operation.
MRI, magnetic resonance imaging; MGUS, monoclonal gammopathy of undetermined significance; AFP, alpha fetoprotein; CA 19-9, carbohydrate antigen/cancer antigen 19-9; CEA, carcinoembryonic antigen; CT, computed tomography; IgA, immunoglobuline A; HCC, hepatocellular carcinoma; H&E, hematoxylline/eosine stain; PIVKA-II, prothrombin induced by vitamin K absence-II
No grant support or funding from public institutions or private enterprises was received.
DS is the manuscript author and helped in the collection of clinical data. LT contributed to the case selection and critical revision of manuscript. CS contributed to the pathology examinations and images. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Written informed consent was obtained from the patient for the publication of this case report and the accompanying images. A copy of the written consent is available for review by the editor in chief of this journal.
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- Marchegiani G, Gareer H, Parisi A et al. Pancreatic hepatoid carcinoma: a review of the literature. Digestive Surgery Vol. 30, No. 4-6, 2013. http://www.karger.com/Article/FullText/355442
- Inagawa S, Shimazaki J, Hori M, et al. Hepatoid adenocarcinoma of the stomach. Gastric Cancer. 2001;4(1):43–52.View ArticlePubMedGoogle Scholar
- Devi NRS, Sathyalakshmi R, Devi J, et al. Hepatoid adenocarcinoma of the gall bladder—a rare variant. J Clin Diagn Res. 2015;9(8):ED09–10.PubMedPubMed CentralGoogle Scholar
- Randolph LK, Hopkins MK, Hopkins MP, et al. Hepatoid carcinoma of the ovary: a case report and review of the literature. Gynecol Oncol Rep. 2015;13:64–7.View ArticlePubMedPubMed CentralGoogle Scholar
- Horie Y, Kato M. Hepatoid variant of yolk sac tumor of the testis. Pathol Int. 2000;50(9):754–8.View ArticlePubMedGoogle Scholar
- Motooka Y, Yoshimoto K, Semba T, et al. Pulmonary hepatoid adenocarcinoma: report of a case. Surg Case Rep. 2016;2:1.View ArticlePubMedPubMed CentralGoogle Scholar
- Veerankutty FH, Yeldho V, Ali Tu S, et al. Hepatoid carcinoma of the pancreas combined with a serous cystadenoma: a case report and review of the literature. Hepatobiliary SurgNutr. 2015;5:354–62.Google Scholar
- Hameed O, Xu H, Saddeghi S, et al. Hepatoid carcinoma of the pancreas: a case report and literature review of a heterogeneous group of tumors. Am J Surg Pathol. 2007;31:146–52.View ArticlePubMedGoogle Scholar
- Xin BB, Li JA, Han X, et al. Successful treatment of a case with pancreatic neuroendocrine carcinoma with focal hepatoid differentiation: a case report and literature review. J Clin Exp Med. 2014;7(10):3588–94. eCollection 2014.Google Scholar
- Matsueda K, Yamamoto H, Yoshida Y, et al. Hepatoid carcinoma of the pancreas producing protein induced by vitamin K absence or antagonist II (PIVKA-II) and alpha-fetoprotein (AFP). J Gastroenterol. 2006;41(10):1011–9. Epub 2006 Nov 9.View ArticlePubMedGoogle Scholar
- von Robert D. Odze (Autor), John R. Goldblum (Autor) .Odze and Goldblum Surgical pathology of the GI tract, liver, biliary tract and pancreas. Verlag: Saunders W.B.; Auflage: 3rd edition. 2014. p.1091. http://www.elsevier.ca/ISBN/9781455707478/Odze-and-Goldblum-Surgical-Pathology-of-the-GITract-Liver-Biliary-Tract-and-Pancreas.
- Fujikura K1, Yamasaki T, Otani K et al.BSEP and MDR3: Useful immunohistochemical markers to discriminate hepatocellular carcinomas from intrahepatic cholangiocarcinomas and hepatoid carcinomas. Am J SurgPathol. 2016. http://www.ingentaconnect.com/content/wk/ajsp/2016/00000040/00000005/art00013?token=00531cf592c39b9b467041333c4a2f7a386a533b31464c7a6625704f6d6222346b62687630502191680.
- Petrelli F, Ghilardi M, Colombo S, et al. A rare case of metastatic pancreatic hepatoid carcinoma treated with sorafenib. J Gastrointest Cancer. 2012;43(1):97–102. doi:10.1007/s12029-011-92642.View ArticlePubMedGoogle Scholar
- Kai K, Nakamura J, Ide T, et al. Hepatoid carcinoma of the pancreas penetrating into the gastric cavity: a case report and literature review. Pathol Int. 2012;62(7):485–90.View ArticlePubMedGoogle Scholar
- Antonini F, Angelelli L, Rubini C et al. Endoscopic ultrasound diagnosis of a primary hepatoid carcinoma of the pancreas.G.Endoscopy. 2015;47Suppl 1 UCTN:E367-8. doi: 10.1055/s-0034-1392430. Epub 2015 Aug 11.
- Majumder S, Dasanu CA. Hepatoid variant of pancreatic cancer: insights from a case and literature review. CAJOP. 2013;14(4):442–5. doi:10.6092/1590-8577/1476. Review.Google Scholar
- Jung JY, Kim YJ, Kim HM, et al. Hepatoid carcinoma of the pancreas combined with neuroendocrine carcinoma. Gut Liver. 2010;4(1):98–102. doi:10.5009/gnl.2010.4.1.98. Epub 2010 Mar 25.View ArticlePubMedPubMed CentralGoogle Scholar
- Huang SC, Chang HC, Yeh TS, et al. Hepatoid microcarcinoma of the pancreas: a case report and review of the literature. Med J. 2012;35(3):285–91.Google Scholar
- Shih NN, Tsung JS, Yang AH, et al. A unique pancreatic tumor with exclusive hepatocytic differentiation. Lab Sci. 2006;36(2):216–21.Google Scholar
- Kubota K, Kita J, Rokkaku K, et al. Ectopic hepatocellular carcinoma arising from pancreas: a case report and review of the literature. World J Gastroenterol. 2007;13(31):4270–3.View ArticlePubMedPubMed CentralGoogle Scholar
- Cardona D, Grobmyer S, Crawford JM, et al. Hepatocellular carcinoma arising from ectopic liver tissue in the pancreas. Virchows Arch. 2007;450(2):225–9.View ArticlePubMedGoogle Scholar
- Gardiner GW, Lajoie G, Keith R. Hepatoid adenocarcinoma of the papilla of Vater. Histopathology. 1992;20(6):541–4.View ArticlePubMedGoogle Scholar