Fibrolamellar hepatocellular carcinoma

Dr Henry Knipe and Assoc Prof Frank Gaillard et al.

Fibrolamellar hepatocellular carcinoma is a distinct histological variant of hepatocellular carcinoma characterized on microscopy by laminated fibrous layers between the tumor cells. It is important as it has different demographics and risk factors compared to 'standard' hepatocellular carcinomas.

Typically these tumors occur in young adults (20 to 40 years of age) without gender predilection. Unlike HCCs they do not have an association with cirrhosis, alcoholism, or hepatitis B/C infection 2.

Presentation is non-specific, with constitutional symptoms and occasionally gynecomastia due to elevated estrone levels 1. Hepatomegaly is usually evident as these masses are typically large.

These tumors are well-differentiated and well-circumscribed, with a dense fibrotic background 2. The tumor cells are arranged in cords that are separated by sheetlike fibrous bands arranged in a parallel or lamellar distribution 4: hence the name, fibrolamellar. 

Fibrolamellar carcinomas often do not produce alpha fetoprotein (AFP) 5.

  • variable sonographic appearance
  • contrast-enhanced ultrasound 6
    • arterial phase:
      • heterogeneous enhancement
    • portal venous phase:
      • decreased echogenicity relative to background liver ("wash out")

Fibrolamellar HCCs typically are single large tumors with dense fibrotic bands forming a central scar (seen in ~75% of cases) 1, which make it resemble focal nodular hyperplasia (FNH). A few small calcifications are seen in 35-65% of cases 1. Regional (hepatic hilum) nodal enlargement is seen in ~50% of cases. Enhancement is usually arterial. The central scar typically shows persistent enhancement on delayed contrast enhanced CT. 

The central scar, when present, is usually hypointense on all sequences. Occasionally it may be T2 hyperintense mimicking FNH 1. Fibrolamellar HCCs do not contain fat, and thus do not lose signal on out of phase imaging 7

  • T1: typically iso to hypointense to the liver
  • T2: hypo to slightly hyperintense
  • T1 C+ (Gd)
    • arterial phase: heterogeneous enhancement
    • portal venous / delayed phase: iso to hypointense
  • T1 C+ (Eovist)
    • liver-specific contrast agent uptake has not been reported in the hepatobiliary phase 7

Technetium-99m sulfur colloid scans (taken up by Kupffer cells) are useful as these tumors will not accumulate the agent, whereas focal nodular hyperplasia does.

Fibrolamellar carcinoma is less aggressive than HCC but usually, due to lack of symptoms until it becomes sizeable, and often a lack of secretion of AFP, stage at presentation tends to be advanced 5.

Resection is the treatment of choice, with a resulting 5-year survival of 76%. This compares favourably to generic HCC which, even when resectable, has a 5-year survival of only 37-56% 1.

If unresectable, this tumor is universally fatal.

General imaging differential considerations include:

Hepatobiliary pathology

Article information

rID: 6994
Synonyms or Alternate Spellings:
  • Fibrolamellar carcinoma
  • Fibrolamellar HCC
  • Fibrolamellar hepatocellular carcinomas
  • Fibrolamellar carcinomas

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Cases and figures

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  • Case 2
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