Page 105 - ARNM-3-3

Advances in Radiotherapy
& Nuclear Medicine Sarcomatoid HCC therapy

In May 2024, the patient was hospitalized due to differentiation, higher recurrence rates, and worse
extreme fatigue, jaundice, dark urine, right upper quadrant prognosis. Patients with SHC exhibit shorter disease-
2
abdominal pain, and anorexia. Laboratory tests indicated free survival and overall survival than those with non-
liver failure, characterized by thrombocytopenia, elevated sarcomatous HCC. 2
liver enzymes, hyperbilirubinemia, and decreased albumin At present, there is no specific biomarker for
levels (Table 1). Due to physical exhaustion and worsening SHC diagnosis. However, the distinct morphological
liver function despite aggressive medical treatment, the characteristics, as well as the immunohistochemical
patient’s family requested transfer to a local medical facility expression of both epithelial and mesenchymal markers, aid
for palliative care.
in pathological confirmation. Typically, SHC demonstrates
3. Discussion positive for both epithelial markers (cytokeratin [CK],
HepPar-1) and mesenchymal markers (vimentin),
SHC is defined as HCC with sarcomatoid components. while being negative for true sarcoma markers (desmin,
The accurate diagnosis relies on histopathological CD34, S100). In our case, the typical HCC component
and immunohistochemical features. Primary SHC is was positive for epithelial markers (CK), markers of
characterized by spindle-shaped cells with pleomorphic hepatocellular origin (HepPar-1), and the sarcomatoid
nuclei, abundant mitotic activity, and, in some cases, component expressed arginase—another hepatocellular
osteogenic or chondrogenic differentiation. Compared marker. Meanwhile, desmin, epithelial membrane antigen,
2
to other histopathological types of HCC, SHC is and CD34 were negative, distinguishing the spindle cell
often associated with larger tumor sizes, poorer cell component as a sarcomatoid transformation of HCC
rather than a carcinoma combined with true sarcoma
(carcinosarcoma). These findings are consistent with
previous clinical reports in both clinical and pathological
features.

The pathogenesis of SHC remains unclear. Most cases
occur in elderly patients with a history of locoregional
therapies such as TACE or PEI, but relapse rapidly following
1
treatment. Ablative therapies, including TACE, RFA, and
PEI, cause cellular damage and hepatocyte degeneration,
3-5
Figure 8. CT scan revealing an enlarged right hepatic mass (red arrow) which may induce transformation from HCC to SHC.
with heterogeneous enhancement, demonstrating substantial interval However, some cases of SHC have been reported in
growth compared to the November 2023 scan. patients without prior treatment. Several hypotheses have
Abbreviation: CT: Computed tomography. been proposed regarding the pathogenesis of sarcomatoid
carcinoma: (i) differentiation or dedifferentiation from
Table 1. Laboratory tests during hospitalization primary carcinoma cells, (ii) biphasic differentiation

Parameters February March April May from pluripotent stem cells, (iii) metaplasia of carcinoma
2024 2024 2024 2024 cells, and (iv) redifferentiation of immature pluripotent
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WBC (G/L) 4.38 2.85 5.36 4.9 carcinoma cells transformed from carcinoma cells. Our
NEU (G/L) 3.23 1.34 3.99 3.5 patient had undergone multiple sessions of TACE before
being diagnosed with SHC postoperatively. This supports
RBC (T/L) 4.33 3.62 3.59 3.54 the hypothesis that locoregional treatments of HCC may
Hb (g/L) 131 113 100 119 exert selective pressure driving the progression of SHC
PLT (G/L) 210 184 175 84 from HCC.
Albumin (g/L) 43.8 37.8 34.6 23.4 At present, there is no standardized treatment for SHC.
Total bilirubin (µmol/L) 13.0 12.5 17.8 67.8 Surgery remains the mainstay of treatment. However,
Conjugated bilirubin (U/L) 2.9 3.1 5.5 48.5 because of the tumor’s high malignancy and propensity
ALT (U/mL) 128 129 109 86 for early recurrence, patients still have a poor prognosis
AST (U/L) 150 170 128 299 even after radical surgery. About 50% of SHC patients
AFP 17.62 N/A 33.1 72.1 experience recurrence within 6 months and die within the
2
st
Abbreviations: ALT: Alanine aminotransferase; AFP: Alpha-fetoprotein; 1 year following surgical resection. Other therapeutic
AST: Aspartate aminotransferase; Hb: Hemoglobin; NEU: Neutrophils; approaches include liver transplantation, local ablative
7
PLT: Platelets; RBC: Red blood cells; WBC: White blood cells. therapies, chemotherapy, and targeted therapy. However,
Volume 3 Issue 3 (2025) 97 doi: 10.36922/ARNM025220024