case_images: PMC8392794_01
case_images: (a) Computerized tomography (CT) of the abdomen and pelvis revealed a left liver mass in a 78-year-old female. (b) Abdominal magnetic resonance imaging (MRI) without contrast confirmed the presence of a 5.1 x 2.8 x 2.3 cm T2 hyperintense and T1 hypointense irregular lesion in the lateral portion of the left liver lobe, which demonstrated enhanced signal on the diffusion weighted scan indicating an infiltrative intrahepatic neoplasm. (c) A follow-up CT scanning highlighted an ill-defined low-density mass at the same location.
case_images: 10.1177_2050313X211041838-fig1.jpg
case_images: PMC8392794_01_10.1177_2050313X211041838-fig1.jpg
case_images: fig1-2050313X211041838
case_images: Additional abdominal magnetic resonance imaging (MRI) without contrast confirmed the presence of a 5.1 x 2.8 x 2.3 cm T2 hyperintense and T1 hypointense irregular mass in the lateral segment of the left hepatic lobe, which demonstrated increased signal on the diffusion weighted scan, raising the concern for an infiltrative intrahepatic neoplasm (Figure 1(a) and (b)). A separate CT scanning reveals an ill-defined low-density mass at the same location (Figure 1(c)).
case_images: (a, b) A CT-guided needle core biopsy of the liver mass revealed a tumor composed of closely packed tubular and acinar structures in a desmoplastic stroma. Tumor cells were positive for (c, d) CK7, S100P, and negative for (e) HepPar 1, TTF-1, GATA3, PAX 8, CDX2, and Villin by immunostaining (images not shown), with a (f) Ki67 proliferation index at 11.5% by manual morphometric quantitative analysis. The morphological and immunohistochemical findings are most consistent with intrahepatic cholangiocarcinoma (IHCC).
case_images: 10.1177_2050313X211041838-fig2.jpg
case_images: PMC8392794_01_10.1177_2050313X211041838-fig2.jpg
case_images: fig2-2050313X211041838
case_images: A CT-guided needle core biopsy of the liver revealed a tumor with closely packed small tubular and acinar structures in a desmoplastic stroma with a prominent inflammatory aggregate (Figure 2(a) and (b)). TTF-1, GATA3, PAX 8, CDX2, and Villin by immunohistochemical (IHC) study (images not shown), with a Ki67 proliferation index at 11.5% by manual morphometric quantitative analysis (Figure 2(f)). The morphological and immunohistochemical findings are consistent with adenocarcinoma, moderately to poorly differentiated, with pancreaticobiliary features and negative for synaptophysin, chromogranin, and P40, arguing against neuroendocrine neoplasm and squamous cell carcinoma.
case_images: (a, b) This intrahepatic cholangiocarcinoma shows small glands and ducts embedded in solid growth patterns in close contact with markedly dense mononuclear infiltrate, (c-f) composed of monomorphous, medium-sized lymphoid proliferation. (d) These lymphoid populations show slightly irregular nuclei, moderately dispersed chromatin, inconspicuous nucleoli, and a moderate amount of pale cytoplasm. A few lymphoepithelial lesions were easily identified (arrows in d, e).
case_images: 10.1177_2050313X211041838-fig3.jpg
case_images: PMC8392794_01_10.1177_2050313X211041838-fig3.jpg
case_images: fig3-2050313X211041838
case_images: Microscopically, this IHCC was composed of neoplastic small tubular glands, duct-like structures, and frequent areas of solid growth patterns embedded within a desmoplastic stroma (Figure 3(a) and (b)). The tumor is composed of low cuboidal to columnar cells with eosinophilic cytoplasm and round to oval nuclei (Figure 3(c)). A dense monomorphous population of mildly atypical, medium-sized lymphoid cells was seen intimately admixed with the carcinomatous glands and surrounding stroma (Figure 3(c)-(f)). A few lymphoepithelial lesions were identified (Figure 3(d) and (e)).
case_images: (a, b) By immunostaining these atypical lymphoid lesions are positive for CD20 and BCL2, with a Ki67 proliferation index at approximately 10% (not shown). They are negative for (c, d) CD3 and BCL6, (e, f) CD43 and Cyclin D1.
case_images: 10.1177_2050313X211041838-fig4.jpg
case_images: PMC8392794_01_10.1177_2050313X211041838-fig4.jpg
case_images: fig4-2050313X211041838
case_images: By IHC study, these atypical lymphoid cells are positive for CD20 and BCL2 (Figure 4(a) and (b)), with a Ki67 proliferation index approximately at 5%-10% (not shown). These lymphoid cells are negative for CD3 and BCL6 (Figure 4(c) and (d)), CD43 and Cyclin D1 (Figure 4(e) and (f)); they are also negative for CD5, CD23, and LEF1 (these three markers are commonly positive in small lymphocytic lymphoma) (not shown).