—  SPECIALTY CONFERENCE HANDOUT  — Liver Pathology Tuesday, March 20, 2012, 7:30 PM Convention Centre Ballroom C Clinical histories are printed below. Click on the case numbers for text and references of each case. Click on each slide thumbnail image for an enlarged view Just Some Good Cases Moderator: KENNETH BATTS Hospital Pathology Associates Maple Grove, MN Disclosure: In accordance with ACCME guidelines regarding disclosure, the USCAP policy requires that faculty members who have a significant financial or other relationship with a commercial company, entity, or service (which will be discussed in this Symposium) must disclose this to attendees. The Academy also requires that speakers disclose any products that are not labeled for the use under discussion. The speakers listed below have indicated they have nothing to disclose. Panelists: Sanjay Kakar, VA & UCSF Medical Ctr, San Francisco, CA Frank A. Mitros, University of Iowa, Iowa City, IA Schuyler Sanderson, University of Iowa, Iowa City, IA David A. Owen, University of British Columbia, Vancouver, BC, Canada Clinical histories are displayed below. For the fastest viewing of virtual slides, click: under each thumbnail image below. You must have Aperio ImageScope installed on your PC. If you do not already have Aperio ImageScope, Windows users with administrator privileges may download and install a free version in order to view USCAP Virtual Slides. Click the icon on the right to get your free copy:   Or, click on slide thumbnail images to view each slide in a Web-based slide viewer, which is somewhat slower. If you have any difficulties viewing these slides, email or call George Clay at +1.724.449.1137. Case 1 - Click here for Text and References Submitted by: Sanjay Kakar - VA & UCSF Medical Ctr, San Francisco, CA Clinical Summary: 55/M had a CT scan as part of investigation for abdominal pain and hepatomegaly. The liver showed a 7 cm mass that was suspicious for hepatocellular carcinoma on fine needle aspiration biopsy. The provided images are representative of the tumor from the resection specimen. Case 1 - Figure 1 Interface of tumor and non-neoplastic liver. Case 1 - Figure 2 This component of the tumor (designated area 1) shows trabeculae and nests of polygonal ('hepatoid') cells in a densely sclerotic stroma. Case 1 - Figure 3 This component (designated area 2) shows densely sclerotic stroma with thin cords, ill-formed glands and columns of tumor cells that are smaller but otherwise similar to those in area 1. Small sized cells with scanty cytoplasm and high nuclear cytoplasmtic ratio (akin to 'stem cells') are not seen. Case 1 - Figure 4 Area 2 (left) merging with another component of the tumor (right, designated area 3) composed of nests and glands. The cells in this component have delicate to clear cytoplasm, open chromatin and prominent nucleoli. Case 1 - Figure 5 Area 3 showing tumor with gland formation and dense sclerotic stroma. Case 1 - Figure 6 Another view of area 3 showing tumor with gland formation and dense sclerotic stroma. Case 1 - Figure 7 Immunohistochemistry for Hep Par 1 is negative in area 1. Other areas were also negative. Case 1 - Figure 8 Immunohistochemistry for glypican-3 is positive in area 1. Other areas were negative. Case 1 - Figure 9 Immunohistochemistry for CK19 is negative in area 2. Area 1 was also negative. Case 1 - Figure 10 Immunohistochemistry for CK19 is positive in area 3. Case 2 - Click here for Text and References Submitted by: Frank A. Mitros - University of Iowa, Iowa City, IA Clinical Summary: The patient is a 30 year old woman from rural Iowa who had been in good health until 3 days before admission. At that time she developed the sudden onset of right upper quadrant pain. She was evaluated at her local Emergency Room and was given an analgesic and was sent home. She returned the next day with persistent pain, now radiating to her chest and back. An ultrasound revealed a mass in the right lobe of her liver. A CT revealed a 9 by 12 cm mass with hematoma in the right lobe of liver. Her hemoglobin was 10.8 g/dl with a hematocrit of 32%. Her AST was 298 u/l. She had a past history of tonsillectomy and wisdom teeth extraction in the remote past without incident. She is on no medication other than oral contraceptives. She was transferred to the University of Iowa Hospitals and Clinics, and a right hepatic lobectomy was performed. The pathology report described the gross appearance as follows: "The liver lobe surface is dark red-purple and shiny. The capsule is ruptured and there is a 13.0 cm by 15.5 cm subcapsular hematoma. The specimen had been previously excised. This incision displays a subcapsular cavity measuring 7.0 cm by 3.5 cm by 3.0 cm. It is lined by an irregular hemorrhagic surface. The liver parenchyma away from the cavity is dark red and hemorrhagic." (this was not one of our finest gross descriptions !) Case 2 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 2 - Figure 1 Large dilated vessels surrounded by hemorrhage into the parenchyma with subsequent necrosis of hepatocytes Case 2 - Figure 2 Blood filled space with no endothelial lining typical for peliosis. Case 2 - Figure 3 Note the dilated and congested sinusoids. Case 2 - Figure 4 The triads were normal except for some mild lymphocytic infiltrate. Case 2 - Figure 5 Necrotic granuloma with thick fibrous rim. Case 2 - Figure 6 Higher power of the necrosis. Case 3 - Click here for Text and References Submitted by: Schuyler Sanderson - Hospital Pathology Associates, Minneapolis, MN Clinical Summary: 26 year old female presented to Emergency Department with leg pain and swelling. Physical examination revealed pitting edema, facial swelling, and a distended abdomen. Bright red blood was identified on rectal examination. The patient was in respiratory distress and continued to deteriorate requiring intubation. Abdominal imaging revealed fatty infiltration of the liver. Endoscopic examination (colonoscopy and EGD) revealed only small hemorrohoids without varices or other source of GI bleeding. The patient developed progressive hypotension and bradycardia within days of presenting to the Emergency Department. Resuscitation efforts failed and she was pronounced dead on hospital day 3. Pertinent Laboratory Data: Laboratory data on admission: AST: 89 (10-42) ALT: 23 (10-40) Alk P: 137 (34-104) Bili (T): 9.9 Ammonia: 135 (11-35) INR: 2.7 Ethanol: 0.225 (<0.010) Case 3 - Figure 1 This H&E stained section reveals a moderate degree of macrovesicular steatosis in the lobular parenchyma that shows general architectural disorder due to extensive pericellular fibrosis. There is only minimal mononuclear inflammatory cell inflammation but scattered apoptotic hepatocytes are identified. Occasional ballooned hepatocytes are present. Case 3 - Figure 2 This H&E stained section demonstrates a severely injury hepatic parenchyma. Ballooning degeneration, Mallory body formation, apoptotic hepatocytes, and scattered foci of canalicular bile plugging are apparent. Case 3 - Figure 3 This H&E stained section reveals a focus of sclerosing hyaline necrosis in this liver. The central vein (right lower corner) is mostly occluded and the surrounding parenchyma demonstrates necrosis with marked hepatocellular injury and fibrosis. Case 3 - Figure 4 This H&E stained section represents a region of lobular parenchyma with moderate hepatocellular injury. Ballooning degeneration and Mallory body formation are conspicuous. Case 3 - Figure 5 HE 5 Case 3 - Figure 6 The trichrome stained slide reveals marked pericellular fibrosis. Mallory bodies are readily identified as blue-gray amorphous structures in the injured hepatocytes Case 3 - Figure 7 The trichrome stained slide reveals marked pericellular fibrosis and Mallory bodies. Case 3 - Figure 8 The trichrome stained slide reveals sclerosing hyaline necrosis. Case 4 - Click here for Text and References Submitted by: David A. Owen - University of British Columbia, Vancouver, BC, Canada Clinical Summary: The patient is a 44 year old woman who presented with several masses in the liver. Clinically, they were assumed to represent metastatic carcinoma, but a needle biopsy did not confirm the diagnosis. The patient remained well for the next 10 years with no active medical treatment. At this time the masses were slowly enlarging and because of vague upper abdominal pain a surgical resection was performed. A representative section of these masses is provided. Pertinent Laboratory Data: At surgery, three liver masses were encountered with the largest measuring 10.0 X 6.0 X 6.0cm. The masses were poorly circumscribed and were rubbery in consistency. The largest mass extended to the inner margin of the liver capsule but not on to the serosal surface. Case 4 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 4 - Figure 1 Case 4 - Figure 2 Case 4 - Figure 3 Case 4 - Figure 4 CK7 Case 4 - Figure 5 CD34 Case 4 - Figure 6 CD31 Case 4 - Figure 7 FactorVIII Handouts for all Specialty Conferences will be accessible via the "Educational Materials" section on the homepage the morning after each respective conference. Printed copies of the handout will not be available at the meeting.