AJR:209, October 2017 767 tures similar to ICC in Western case series [5, 6], whereas other studies found that CHC showed intermediate clinical features with HCC and ICC [7–9], which indicated that the preoperative diagnosis of CHC was very dif- ficult. The prognosis of patients with CHC was still poor even after active interventions and treatments, and previous studies have shown that survival outcomes after resec- tion of patients with CHC were poorer than those of patients with HCC and were similar to or worse than those of patients with ICC [5–7, 9–11]. Furthermore, there is increas- ing evidence suggesting that the outcomes of liver transplants for patients with CHC were worse than those for patients with pure HCC [5, 12–14]. However, most often the diagnosis of CHC was established only after tumor re- section. Because of the overlap in the demo- graphics of patients with CHC and patients with HCC and patients with ICC, the indis- tinguishable clinical traits of CHC, and poor prognosis of CHC, a correct diagnosis of CHC with imaging findings may have prog- Combined Hepatocellular Cholangiocarcinoma (Biphenotypic) Tumors: Potential Role of Contrast-Enhanced Ultrasound in Diagnosis Fei Li 1 Jing Han 1 Feng Han 1 Jian-wei Wang 1 Rong-zhen Luo 2 An-hua Li 1 Jian-hua Zhou 1 Li F, Han J, Han F, et al. 1 Department of Ultrasound, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Rd E, Guangzhou, Guangdong 510060, PRC. Address correspondence to J. Zhou (zhoujh@sysucc.org.cn). 2 Department of Pathology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, PRC. Gastrointestinal Imaging • Original Research AJR 2017; 209:767–774 0361–803X/17/2094–767 © American Roentgen Ray Society C ombined hepatocellular cholan- giocarcinomas (CHCs) have been classified as a rare subtype of primary liver malignancies containing components of both hepatocellu- lar carcinomas (HCCs) and intrahepatic cho- langiocarcinomas (ICCs) [1]. CHCs are cate- gorized into three distinct types: Type A refers to separate neoplastic HCC and ICC masses that exist independently; type B de- scribes contiguous masses in which HCC and ICC masses grow close to one another and may combine but exist independently; and type C is defined as an individual mass that consists of both HCC and ICC compo- nents and may display characteristics of both. Most previous studies have shown that only CHCs of type C present biphenotypic features and traits [2–4]. There are a few studies in the literature that discuss the clinical characteristics of CHC, but the results of these studies dif- fer. Investigators have reported that CHC shared many demographic and clinical fea- Keywords: combined hepatocellular cholangiocarcinoma (CHC), contrast-enhanced ultrasound (CEUS), differential diagnosis, hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (ICC) DOI:10.2214/AJR.16.17513 F. Li and J. Han contributed equally to this work. Received October 13, 2016; accepted after revision February 24, 2017. Supported by the Fundamental Research Funds for the Central Universities (no. 13ykzd25) and Scientific Research Foundation for the Returned Overseas Chinese Scholars, State Education Ministry, and Program for New Century Excellent Talents in University. OBJECTIVE. The objective of this study was to evaluate the diagnostic performance of contrast-enhanced ultrasound (CEUS) in differentiating combined hepatocellular cholangio- carcinomas (CHCs) from hepatocellular carcinomas (HCCs) and intrahepatic cholangiocar- cinomas (ICCs). MATERIALS AND METHODS. Thirty-three patients with pathologically confirmed CHC and matched control subjects with pathologically confirmed HCC (n = 30) or ICC (n = 32) who underwent preoperative CEUS from January 2005 to December 2015 were en- rolled in this study. The CEUS images of the hepatic lesions were subjectively analyzed in consensus by two radiologists. The diagnostic performances were evaluated by ROC analysis. RESULTS. In the arterial phase, hyperenhancement was more common in CHCs (76%) and HCCs (100%) than in ICCs (22%), whereas in the late phase marked washout was more common in CHCs (76%) and ICCs (100%) than in HCCs (10%). Using marked washout in the late phase to differentiate CHC from HCC, the area under the ROC curve (AUC) was 0.829, and the sensitivity, specificity, and accuracy were 78%, 90%, and 83%, respectively. Using hy- perenhancement in the arterial phase followed by marked washout in the late phase to distin- guish CHC from ICC, the AUC value was 0.663, and the sensitivity, specificity, and accuracy were 55%, 78%, and 66%. CONCLUSION. Although the imaging features of CHC, HCC, and ICC on CEUS may overlap, CEUS could be used in the differential diagnosis of CHC from HCC and ICC. Li et al. CEUS to Differentiate CHC From HCC and ICC Gastrointestinal Imaging Original Research Downloaded from www.ajronline.org by 52.73.204.196 on 05/17/22 from IP address 52.73.204.196. Copyright ARRS. For personal use only; all rights reserved