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Arch Surg. 2007;142(1):96.

Answer: Pedunculated Hepatocellular Carcinoma
Histopathological findings showed the mass to be a well-differentiated, pedunculated hepatocellular carcinoma (HCC) with regions of necrosis and cystic degeneration. On immunohistochemical analysis, the tumor stained positively for alpha fetoprotein. Excision was complete, with a clear margin of 11 mm within the pedicle.

Pedunculated HCC can be defined as carcinoma protruding from the liver with or without a pedicle and was first described by Roux in 1897.¹ It is a rare variant of HCC; more frequently occurring variants are classified as nodular, massive, and diffuse.² Pedunculated tumors do not differ significantly from HCCs in terms of patient demographics, viral infection, or associated liver disease.³ It has been proposed to subclassify the macroscopic appearances of pedunculated HCC into pedunculated type with a pedicle (subtype I, as is this case) and pedunculated type without a pedicle and attached to the liver surface (subtype II).⁴

In Japan, pedunculated HCC represents 0.24% to 3.00% of all cases of HCC.⁵ In the largest published series to date, Yeh et al³ found that 18 (4.2%) of 432 patients with HCC had pedunculated growth. Of the pedunculated HCC group, 11 patients (61%) had well-differentiated histological characteristics and a significantly improved overall survival. The mean survival in the pedunculated group was 94 months, compared with 54.5 months for nonpedunculated HCCs. The pedunculated tumors tended to be larger and to have a more prominent capsule. Although increased tumor size is associated with poorer prognosis in HCC,⁶ a wider resection margin was obtained with pedunculated tumors despite a tendency for larger tumor size. Yeh et al³ suggest that pedunculated tumors protrude from a pedicle; thus, growth into the liver is limited. Most importantly, the pedunculated tumors exhibited less vascular invasion than did the nonpedunculated HCCs. Vascular invasion is widely accepted as the most consistently reported risk factor for recurrence after resection,⁷ which likely explains the improved survival seen in patients with pedunculated HCC in that series.

AUTHOR INFORMATION

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Corresponding Author: Lucy Tzouliadis, MBChB, MRCS, Department of Hepatobiliary Surgery, North Hampshire Hospital, Aldermaston Road, Basingstoke RG24 9NA, England (ltzouliadis{at}hotmail.com).

Accepted for Publication: December 18, 2005.

Author Contributions: Study concept and design: Tzouliadis, Hulin, Shaw, and Rees. Acquisition of data: Tzouliadis. Analysis and interpretation of data: Rees. Drafting of the manuscript: Tzouliadis and Shaw. Critical revision of the manuscript for important intellectual content: Tzouliadis, Hulin, Shaw, and Rees. Administrative, technical, and material support: Tzouliadis and Hulin. Study supervision: Tzouliadis, Hulin, Shaw, and Rees.

Financial Disclosure: None reported.

REFERENCES

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1. Roux C. Un cas de cancer primitive du foie avec pericholecystite calculeuse, perforation intestinale: hemostase hepatigue. Rev Med Suisse Romande. 1897;17:114-119. 2. Eggel H. Uber das primare Carcinom der Leber. Betir Pathol Anat Allg Pathol. 1901;30:506-604. 3. Yeh CN, Lee WC, Jeng LB, Chen MF. Pedunculated hepatocellular carcinoma: clinicopathologic study of 18 surgically resected cases. World J Surg. 2002;26:1133-1138. FULL TEXT | ISI | PUBMED 4. Nakashima T, Okuda K, Kojiro M; et al. Pathology of hepatocellular carcinoma in Japan: 232 consecutive cases autopsied in ten years. Cancer. 1983;51:863-877. FULL TEXT | ISI | PUBMED 5. Horie Y, Katoh S, Yoshida H, Imaoka T, Suou T, Hirayama C. Pedunculated hepatocellular carcinoma: report of three cases and review of literature. Cancer. 1983;51:746-751. FULL TEXT | ISI | PUBMED 6. Chen MF, Jeng LB. Partial hepatic resection for hepatocellular carcinoma. J Gastroenterol Hepatol. 1997;12:S329-S334. ISI | PUBMED 7. Yamamoto J, Kosuge T, Takayama T; et al. Recurrence of hepatocellular carcinoma after surgery. Br J Surg. 1996;83:1219-1222. FULL TEXT | ISI | PUBMED

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