Case 1

submitted by:
Kenneth Batts
Abbott Northwestern Hospital
Minneapolis, Minnesota

Clinical Summary:

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:

1. Would you quantitate the liver iron? If so, how would you do it? Is it necessary to perform quantitative iron analysis in this case?
2. 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?
3. What additional clinical testing would you advise?

Case 1 - Figure 1 - Fatty liver disease - non-cirrhotic

Case 1 - Figure 2 - Mild zone 1 hemosiderosis (Prussian blue stain)

Case 1 - Figure 3 - Mild zone 1 hemosiderosis - hepatocellular (Prussian blue stain)

Case 2

submitted by:
Hanlin L. Wang
Washington University
St. Louis, Missouri

Clinical Summary:

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.

Case 2 - Figure 1 - Low power view

Case 2 - Figure 2 - Intranuclear inclusions

Case 2 - Figure 3 - Immunohistologic stain for adenovirus

Case 3

submitted by:
Elizabeth M. Brunt
St. Louis University
St. Louis, Missouri

Clinical Summary:

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 lesions.

Case 3 - Figure 1 - Low power of interface between lesion and surrounding parenchyma

Case 3 - Figure 2 - Medium power of lesion. Note the naked arterioles

Case 3 - Figure 3 - High power of lesion. Note the pseudoacinar formation.

Case 4

submitted by:
Gregory Y. Lauwers
Massachusetts General Hospital
Boston, Massachusetts

Clinical Summary:

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 residual mass.

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.

Case 5

submitted by:
J. Thomas Stocker
Uniformed Services University of the Health Sciences
Bethesda, Maryland

Clinical Summary:

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.

Case 5 - Figure 1 - Low power of lesion

Case 5 - Figure 2 - Medium power of lesion

Case 5 - Figure 3 - High power of lesion. Note mitotic figures

Case 5 - Figure 4 - High power of lesion