7:30 PM, Monday, March 24
Marriott Ballroom, Salon 3
University of Chicago
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
Abbott Northwestern Hospital
The patient is a 54 year old woman who has Type II diabetes, hypertriglyceridemia, and obesity. She had
a mild increase in serum AST level with normal serum alkaline phosphatase and total bilirubin values. A
liver biopsy was performed to assess the putative fatty liver disease, the presence of which was
confirmed. However, hemosiderin was present in the liver, prompting several issues for the pathologist:
- Would you quantitate the liver iron? If so, how would you do it? Is it necessary to perform
quantitative iron analysis in this case?
- In your daily practice, would you describe the iron and hope the clinician knows what to do to work
it up, or would you actively intervene and join the attempt to determine the cause of the hemosiderosis?
- What additional clinical testing would you advise?
Hanlin L. Wang
St. Louis, Missouri
The patient was a 21-year-old man, status post allogeneic bone marrow transplantation (BMT) for acute T
cell leukemia. His clinical course was complicated by gastrointestinal graft-versus-host disease (GVHD),
grade ¾, one month after transplantation diagnosed by colonoscopic biopsies. Four months later, the
patient developed fulminant hepatic failure with jaundice. Laboratory studies showed a total bilirubin
level of 9.8 mg/dL, aspartate transaminase 7352 U/L, alanine transaminase 2501 U/L, alkaline phosphatase
1074 U/L, plasma ammonia 53.0 mmol/L, prothrombin time 26.5 seconds, partial thromboplastin time 67.1
seconds, total plasma protein 4.8 g/dL, and albumin 2.2 g/dL. Serologic tests were negative for
hepatitis A, B and C viruses, and negative for anti-Epstein-Barr virus IgM antibody. A clinical
diagnosis of hepatic GVHD was suspected and a transjugular liver biopsy was performed. Liver tissue and
blood cultures were also sent. The patient died next day following liver biopsy despite supportive
measures. An autopsy was not performed.
Elizabeth M. Brunt
St. Louis University
St. Louis, Missouri
A 35 year old woman presented to the Saint Louis University Liver Clinic for re-evaluation of abdominal
discomfort. Prior evaluation at an outside hospital for severe abdominal pain 3 months before included
numerous imaging studies of the abdomen and pelvis. CT scan showed a 16 cm subcapsular hematoma in the
right lobe of the liver, and multiple hyperdense lesions throughout the liver, that ranged from a few
millimeters to 5 centimeters. The latter were considered unusual for hemangioma or adenomas and the
interpretation of the scan was metastatic disease. A primary source could not be identified and no
further treatment was given. When the patient came to SLU, further history and tests were obtained. The
PMH was significant for 4 children (ages 7-15 years old). Other than occasional alcohol use, there was
no history of drug or medication use. Liver tests were normal, and serum tumor markers were negative.
Repeat CT scan confirmed the subcapsular hemorrhage and organized hematoma; however, the hyperdense
lesions were considered consistent with adenomas. Further questioning found estrogen-based oral
contraception use for three years, 21 years ago. Two years prior to the current presentation, a
subcutaneous levonorgestrel implant (Norplant) was placed in her arm. Because of concern of further
bleeding and/or rupture, the patient underwent resection of the hematoma and two of the larger separate
Gregory Y. Lauwers
Massachusetts General Hospital
A 47-year old woman presented with right upper quadrant pain for 5 months. She never experienced
jaundice, gastrointestinal bleeding and changes in bowel habits. She had only minimal alcohol use and no
intravenous drug use in the past. She had never received blood products. Abdominal ultrasound and CT
scans, revealed a 16 cm cystic and solid mass with areas of increased echogenicity in the left lobe of
the liver. No retroperitoneal lymphadenopathy was noted. A biopsy was unsuccessful, revealing mostly
inflammatory cells. The patient eventually underwent enucleation of the tumor in segments 4, 5 and 8,
but due to the firm adherence of the mass to the hepatic veins posteriorly, only approximately 80% of the
tumor could be resected. There were no postoperative complications and the patient reported no symptoms
following the surgery. Three years of follow-up revealed no metastasis or significant growth of the
Case 4 - Figure 1 - Low power view showing an area composed of densely compressed small tubules.
Case 4 - Figure 2 - Another area is composed of microcysts with thin fibrous septa.
Case 4 - Figure 3 - Higher magnification showing a staghorn pattern reminiscent of serous cystadenoma
Case 4 - Figure 4 - Small tubules lined by a short cuboidal epithelium showing rare mitoses. Note the inconspicuous surrounding stroma.
J. Thomas Stocker
Uniformed Services University of the Health Sciences
This 4 year old girl was noted by her mother to be jaundiced but otherwise unremarkable. Laboratory
findings included a total bilirubin of 5.2 mg/dl with a direct portion of 4.9 mg/dl. CT demonstrated a
mass lesion in the hilus of the liver.