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Special Feature
January 1, 2007

Image of the Month—Diagnosis

Arch Surg. 2007;142(1):96. doi:10.1001/archsurg.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 1897.1It is a rare variant of HCC; more frequently occurring variants are classified as nodular, massive, and diffuse.2Pedunculated tumors do not differ significantly from HCCs in terms of patient demographics, viral infection, or associated liver disease.3It 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.5In the largest published series to date, Yeh et al3found 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,6a wider resection margin was obtained with pedunculated tumors despite a tendency for larger tumor size. Yeh et al3suggest 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,7which likely explains the improved survival seen in patients with pedunculated HCC in that series.

Corresponding Author:Lucy Tzouliadis, MBChB, MRCS, Department of Hepatobiliary Surgery, North Hampshire Hospital, Aldermaston Road, Basingstoke RG24 9NA, England (ltzouliadis@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.

Roux  C Un cas de cancer primitive du foie avec pericholecystite calculeuse, perforation intestinale: hemostase hepatigue.  Rev Med Suisse Romande 1897;17114- 119
Eggel  H Uber das primare Carcinom der Leber.  Betir Pathol Anat Allg Pathol 1901;30506- 604
Yeh  CNLee  WCJeng  LBChen  MF Pedunculated hepatocellular carcinoma: clinicopathologic study of 18 surgically resected cases.  World J Surg 2002;261133- 1138PubMedArticle
Nakashima  TOkuda  KKojiro  M  et al.  Pathology of hepatocellular carcinoma in Japan: 232 consecutive cases autopsied in ten years.  Cancer 1983;51863- 877PubMedArticle
Horie  YKatoh  SYoshida  HImaoka  TSuou  THirayama  C Pedunculated hepatocellular carcinoma: report of three cases and review of literature.  Cancer 1983;51746- 751PubMedArticle
Chen  MFJeng  LB Partial hepatic resection for hepatocellular carcinoma.  J Gastroenterol Hepatol 1997;12S329- S334PubMedArticle
Yamamoto  JKosuge  TTakayama  T  et al.  Recurrence of hepatocellular carcinoma after surgery.  Br J Surg 1996;831219- 1222PubMedArticle