CASE REPORT
Eleni Vrettou . Prodromos Hytiroglou . Nikolaos Sikas · Ioannis Soultoyannis · Zachary D. Goodman
Hepatic adenocarcinoma expressing inhibin in a young patient on oral contraceptives
Received: 12 January 2005 / Accepted: 24 February 2005 / Published online: 7 April 2005 C Springer-Verlag 2005
Abstract A case of primary hepatic carcinoma is reported, which occurred in a 24-year-old woman with a 10-year history of oral contraceptive use, and demonstrated unique morphologic and immunohistochemical features. The tumor was located in the left hepatic lobe, measured 14 cm at its widest, and showed histologic heterogeneity. The neoplastic cells were mostly arranged in trabecular and pseudoglan- dular growth patterns simulating hepatocellular carcinoma; however, in focal areas, small cystic, organoid and tubular patterns predominated. Immunohistochemical stains showed a phenotype consistent with biliary differentiation (positive staining for cytokeratin 7, cytokeratin 19, carcinoembryonic antigen and CA 19-9 antigen). The tumor cells were neg- ative for markers that would be suggestive of hepatocytic or neuroendocrine differentiation. Interestingly, they were positive for inhibin, a protein that is known to be expressed in sex cord-stromal tumors of the ovary, trophoblastic neo- plasms and adrenal cortical tumors, but not in hepatic tu- mors. However, no definite evidence of gonadal stromal, trophoblastic, or adrenocortical differentiation was identi- fied on extensive immunohistochemical work-up. In con- clusion, this unique case may represent a rare variant of cholangiocarcinoma expressing inhibin.
Keywords Adenocarcinoma · Cholangiocarcinoma · Inhibin · Liver
E. Vrettou · P. Hytiroglou ☒ · I. Soultoyannis
Department of Pathology, Aristotle University Medical School, 540 06 Thessaloniki, Greece
e-mail: phitir@med.auth.gr Tel .: +30-2310-999218 Fax: +30-2310-999229
N. Sikas The Interbalkan Medical Center, Thessaloniki, Greece
Z. D. Goodman The Armed Forces Institute of Pathology, Washington, DC, USA
Introduction
Adenocarcinomas of the liver (intrahepatic cholangiocar- cinomas) represent approximately 10% of primary carci- nomas of this organ, and are thought to be derived from biliary epithelial cells. These tumors are known to be etiolog- ically associated with parasitosis of the bile ducts, hepato- lithiasis, congenital anomalies of the biliary tree, primary sclerosing cholangitis and Thorotrast exposure [2, 4]. Oral contraceptive steroids have also been suggested as possible etiologic agents of both intrahepatic and extrahepatic chol- angiocarcinoma [1, 8]. In western countries, the majority of cholangiocarcinomas occur in patients without obvious pre- disposing factors.
While the commonest histologic appearance of cholan- giocarcinoma is that of a tubular adenocarcinoma with abun- dant fibrous stroma, other architectural patterns may also be observed, including trabecular and papillary structures [2, 4]. Immunohistochemical stains typically show positivity for “biliary-type” cytokeratins (cytokeratins 7 and 19), carcino- embryonic antigen, epithelial membrane antigen, and an- tigen CA 19-9. Expression of inhibin is not a feature of either cholangiocarcinoma or any other primary hepatic tumor. This protein is commonly detected in gonadal stro- mal tumors and, occasionally, in other ovarian, trophoblas- tic and adrenal cortical neoplasms [3, 5-7, 9].
We report a unique case of hepatic adenocarcinoma with unusual histologic features, which expressed inhibin and occurred in a young patient on oral contraceptives.
Clinical history
A 24-year-old white woman presented with a 15-day his- tory of nausea, vomiting and abdominal discomfort. Phys- ical examination was remarkable for a palpable mass in the mid-upper abdomen. There were no other findings on com- plete systemic examination. The patient’s past medical history was unremarkable. She was a non-smoker and occa- sionally consumed very small amounts of alcohol. She had
been on oral contraceptives (combination of 0.02 mg ethi- nylestradiol and 0.15 mg desogestrel) for 10 years.
Computed tomography (CT) scan of the abdomen showed a well-circumscribed mass, located in the left hepatic lobe and occupying the inferior and lateral borders. On admin- istration of intravenous contrast, the lesion showed inho- mogeneous enhancement, which was more intense on late images (Fig. 1a). On magnetic resonance images, the mass appeared well defined and measured 16.7×16.2 cm. It was multilobulated and inhomogeneous, with cystic changes, and showed enhancement after intravenous administration of paramagnetic contrast material (Fig. 1b). Biochemistry and hematology results were within normal limits. The serum levels of tumor markers, including carcinoembryon- ic antigen, CA 19-9 antigen and CA 125 antigen, were also within normal limits. A full hormonal screen, including follicle stimulating hormone, luteinizing hormone, prolac- tin, estradiol, progesterone, testosterone, dehydroepiandros- terone-S and thyroid-stimulating hormone, did not reveal any abnormality.
At laparotomy, the tumor mass was found to involve hepatic segments II and III and appeared to have a “push- ing” rather than infiltrating border. A left lobectomy was performed. The lesion was excised intact, together with a 3-cm rim of hepatic parenchyma. The patient had an un-
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| Antigen | Source of antibody | Clone | Result |
|---|---|---|---|
| Pancytokeratin | DAKO | AE1/AE3 | Moderately positive |
| Cytokeratin 8/18 | Becton Dickinson | cam5.2 | Moderately positive |
| Cytokeratin 7 | DAKO | OV TL 12/30 | Strongly positive |
| Cytokeratin 19 | DAKO | RCK108 | Strongly positive |
| Cytokeratin 20 | DAKO | Ks 20.8 | Negative |
| HepPar-1 | DAKO | OCH1E5 | Negative |
| pCEA | DAKO | Polyclonal | Positive |
| (cytoplasmic and membranous) | |||
| mCEA | DAKO | 11-7 | Negative |
| EMA | DAKO | E29 | Negative |
| CA 19-9 | DAKO | 116-NS-19-9 | Focally positive |
| CA 125 | Novocastra | NCL-CA125 | Negative |
| «-Fetoprotein | Signet | Polyclonal | Negative |
| hCG | Biocare | Polyclonal | Negative |
| NSE | Biocare | DT01-BC10 | Negative |
| Chromogranin | Sanbio | Polyclonal | Negative |
| Synaptophysin | Ventana | Polyclonal | Negative |
| Somatostatin | Chemicon | Polyclonal | Negative |
| Insulin | DAKO | Polyclonal | Negative |
| Thyroglobulin | DAKO | DAK-Tg6 | Negative |
| Calcitonin | Biogenex | Polyclonal | Negative |
| Vimentin | Biocare | V-9 | Negative |
| Inhibin | DAKO | R1 | Strongly positive |
| ER protein | DAKO | 1D5 | Negative |
| PR protein | Novocastra | 1A6 | Negative |
| PAP | DAKO | PASE/4LJ | Negative |
| S-100 protein | DAKO | Polyclonal | Rare positive cells |
| HMB-45 | DAKO | HMB-45 | Negative |
| CD10 | Novocastra | 56C6 | Negative |
| CD34 | Biogenex | Qbend/10 | Negative |
| CD56 | Novocastra | ERIC-1 | Moderately positive |
| CD117 (c-kit) | Biotechnology | C-19 | Negative |
| Ki-67 | Immunotech | MIB1 | 5-10% of nuclei positive |
| p53 | DAKO | D0-7 | Negative |
eventful postoperative course and was discharged home 7 days following surgery. Since then (almost 3 years ago), she has been on follow-up with physical examination and tumor markers every 3 months, abdominal ultrasound scan every 6 months, and CT scan of thorax and abdomen every year. She has remained free of recurrence. No further treatment has been given.
Materials and methods
Multiple sections of tumor and non-tumorous hepatic pa- renchyma were routinely processed for paraffin sections. Sections 4 um thick were stained with hematoxylin-eosin and mucicarmine. Additional paraffin sections were used for immunohistochemical stains with a standard streptavi-
din-biotin staining protocol. The primary antibodies uti- lized and their sources are shown in Table 1.
Results
The surgical specimen weighted 940 g and measured 15× 14×7.5 cm. On sectioning, the specimen was almost com-
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pletely occupied by a well-demarcated tumor, measuring 14 cm at its widest. The cut surface was tan, solid, with focal areas of microcystic change and extensive areas of hemorrhage.
Microscopic examination showed a carcinoma with pre- dominantly trabecular architecture (Fig. 2a, b). The tumor
cells were columnar or cuboidal, with roundish, hyperchro- matic nuclei and moderate amounts of eosinophilic or am- phophilic cytoplasm (Fig. 2c). Mitotic activity was mild. The trabeculae were several cells thick, and were lined by endothelial cells. The neoplastic cells within the trabeculae were often arranged in pseudoglandular structures, some-
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times containing amorphous eosinophilic material in the lumina (Fig. 2d). No bile production was seen. Mucicarmin stain was negative for mucin. In the central portion of some trabeculae, the tumor cells contained increased amounts of eosinophilic cytoplasm, resembling hepatocytes (Fig. 2e). In some areas, the neoplastic cells lined small cystic spaces (Fig. 2a, f) or formed organoid structures (Fig. 2f, g). In a small area close to the tumor edge, the tumor cells formed tubular structures, surrounded by a loose fibroconnective tissue stroma (Fig. 2h). The tumor contained foci of he- mosiderin deposition, small foci of necrosis and occasional microcalcifications. The surrounding hepatic parenchyma appeared compressed, without evidence of pre-existing dis- ease. The surgical margins of resection were free of tumor.
Due to the unusual histologic features of the tumor, exten- sive immunohistochemical stains were performed (Table 1). The neoplastic cells were positive for “biliary-type” cyto- keratins (cytokeratins 7 and 19), carcinoembryonic antigen (cytoplasmic and membranous staining with polyclonal, but not with monoclonal antibodies), CA 19-9 antigen and CD56 antigen (Fig. 3a-f). They were also positive for in- hibin (Fig. 3g). The tumor cells were negative for a variety of other markers, including those which would be sug- gestive of hepatocytic or endocrine differentiation (Table 1, Fig. 3h).
Discussion
Several aspects of the case reported herein are unusual. In the absence of chronic liver disease, hepatic carcinomas are rare in the 3rd decade of life, and, as a rule, represent he- patocellular carcinomas of the fibrolamellar variant. Our case did not demonstrate histologic features characteristic of fibrolamellar carcinoma. Since our patient did not have any other predisposing factor for tumor development, at- tention must be focused on the 10-year-long history of oral contraceptive use. In an analysis of possible etiologic fac- tors in a series of 42 patients with intrahepatic cholangio- carcinoma, Altaee et al. found that 35% of the women had used oral contraceptives [1]. In a different study, a sta- tistically significant association between the use of contra- ceptives and extrahepatic bile duct cancer was observed among women under 60 years of age [8].
The histologic features of our case are also unusual. In most areas, the predominant growth patterns were trabec- ular and pseudoglandular, simulating hepatocellular carci- noma. In several trabeculae, a neoplastic cell subpopulation with features suggestive of hepatocellular differentiation was also found. However, the tumor cell immunophenotype (cytokeratin 7 and 19 positive, carcinoembryonic antigen positive, CA 19-9 positive, hepatocyte specific antigen neg- ative, «-fetoprotein negative) was consistent with a biliary tumor. Immunopositivity for CD56 antigen may also be supportive of biliary differentiation [10]. Because of the tendency of the neoplastic cells to form organoid structures, a variety of markers of endocrine differentiation were as- sessed, but were found to be negative.
The most unusual feature of this case was the strongly positive immunostaining for inhibin. This glycoprotein is known to be synthesized by granulosa cells, luteinized the- cal cells, and hilus cells of the normal ovary, and to regu- late reproductive functions in conjunction with activin [3]. Inhibin is widely accepted as a marker for sex cord tumors, especially for granulosa cell tumors, and appears to be helpful in the differential diagnosis of such tumors from other neoplasms affecting the ovary [5]. In addition, inhibin is expressed by syncytial trophoblastic cells and in neoplasms of trophoblastic origin, such as hydatidi- form moles, placental site nodule, placental trophoblastic tumors, and choriocarcinoma [3, 7]. This protein is also expressed by the majority of adrenocortical adenomas and carcinomas [6, 9].
Inhibin expression is not considered a feature of primary hepatic neoplasms. On immunohistochemical studies, both hepatocellular carcinoma and cholangiocarcinoma have been found to be negative for this protein, with the ex- ception of a single case of high-grade pleomorphic hepa- tocellular carcinoma [11-13]. In the absence of histologic and immunohistochemical evidence of gonadal stromal, trophoblastic or adrenocortical differentiation in the tumor we are reporting, we must conclude that this neoplasm represents a unique case of cholangiocarcinoma expressing inhibin. A possible association with oral contraceptive use may be suggested, but cannot be proven at the present time.
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