|
Click on each Case number below to display the text and references for that section
Click on any thumbnail image for an enlarged view of that slide
Click on the PowerPoint icon to display the PowerPoint presentation for that section,
then within the presentation, click on the content window and advance slide with the space bar.
Introduction.
Primary tumors of the liver are divided into benign and malignant epithelial and
non-epithelial neoplasms. The epithelial neoplasms are the most common, and fall predominantly into the
hepatocellular and bile-ductular types. However, in addition, other nonneoplastic, tumor-like lesions of
various types can be of significance as well. The World Health Organization's classification scheme
which includes both neoplasms and tumor-like lesions is listed in Table 1.
Reporting of tumor resection specimens.
The verification of tumor type and status as a primary or metastatic neoplasm versus a
nonneoplastic tumor are the most important considerations in the diagnosis. The descriptive comments
should focus on information important for tumor staging such as tumor size (smaller or larger than 2 cm),
number of lesions (single or multiple), which lobes (or segments) are involved, local extension of the
lesion outside of the liver, and the presence or absence of gross vascular invasion, especially noting
which of the major vessels (portal or hepatic vein) are involved. Microscopic evaluation of a mass
should have adequate numbers of sections relative to tumor size in order to evaluate for vascular
invasion or extension outside of Glisson's capsule, since these factors which are associated with
decreased survival. Sections near the edge of the tumor are generally recommended to identify vascular
invasion if gross invasion is not noted. Any gross observation of possible large vessel invasion should
be documented microscopically. A section of nonneoplastic liver should also be included in order to
identify any significant pathology.
Generally, it is recommended that the surgical margins of the resection should be inked
prior to sectioning the tumor in order to more definitively evaluate the distance from the margin to the
tumor, and the status of the resection margins should be included in the report. Some studies have
suggested that a tumor-free margin of at least 1cm may be directly related to a better prognosis for some
malignant tumor types. Other studies have shown that more extensive resections of hepatocellular
carcinomas are preferable to limited excisions when the lesion is small. Thus, the distance from tumor
to the closest margin of resection should be documented.
Biopsy samples- special considerations
Both small core and fine needle aspiration biopsy (FNAB) are often utilized successfully
for the diagnosis of specific tumor types. However, it is important to remember that the accuracy of the
FNAB can be enhanced by utilizing extra tissue preprations such as cell buttons in order to evaluate the
microhistology of paraffin embedded sections of the sample collected from the FNAB material.
Utilization of such methodology is especially helpful in the evaluation of well-differentiatied lesions
of hepatocellular type, in which subtle cytologic features such as the cell size, crowding of nuclei, and
increased nuclear:cytoplasmic ratio or architectural features such as the formation of trabeculae or the
width of the cell plates may be difficult to assess on smears alone. In these instances, the use of
histologic sections in combination with well-prepared smears are highly successful in differentiating the
well-differentiated hepatocellular carcinoma from other lesions such as adenoma, focal nodular
hyperplasia, large regenerative nodules, or dysplastic nodules. In addition, preparation of the cell
button in cases of poorly differentiated neoplasms or in tumors with unusual morphology can result in
more accurate diagnoses by the application of immunoperoxidase techniques to these samples.
Since the biopsy material is often quite limited in amount, it is recommended that slides
of unstained material also be cut when the block is initially sectioned in order to insure that
sufficient material will be available if it becomes necessary to evaluate additional level sections or
other stains. It is also advised that the usual panel of stains (which often include trichrome,
reticulin, PASD, and iron stains) should not be ordered automatically at the time of gross examination as
this excess sectioning (before examination of the H&E morphology) often depletes the block of the
diagnostic material so that sufficient tissue may not be available for other more diagnostic stains.
41 year old man who was
undergoing a total proctocolectomy for rectal cancer was found at surgery to have a liver mass. The mass
measured 6 cm and was nodular. The surrounding liver was unremarkable.
Case 1 - Figure 1 - Nodular liver parenchyma with central scar (arrow), low power
|
Case 1 - Figure 2 - Large irregular vessel in an area of fibrosis, medium power
|
Case 1 - Figure 3 - Bands of fibrosis with chronic inflammation and proliferationg bile ductules (arrows), medium power
|
30 year old woman with chest pain
and RUQ pain for 6-9 months. Abdominal U/S demonstrated a liver mass that was confirmed with abdominal
CT and MRI. The tumor was 8 cm and hemorrhagic while the adjacent liver appeared normal.
Case 2 - Figure 1 - Hepatocellular proliferation with areas containing fibrin and hemorrhage, low power
|
Case 2 - Figure 2 - Bland hepatocytes and vessels with no bile ducts, medium power
|
Case 2 - Figure 3 - Bland hepatocytes and thin walled vessel with no bile ducts, high power
|
Case 2 - Figure 4 - Hepatocytes arranged in two-cell-think liver plates with intact reticulin Framework, H&E and reticulin stains, medium power
|
45 year old man with cirrhosis who underwent a liver
transplant. In his explant, a 1.5 cm nodule was found in the background of a cirrhotic liver.
Case 3 - Figure 1 - Cirrhotic liver with a dominant nodule (arrow), low power
|
Case 3 - Figure 2 - Atypical hepatocytes with thickened cell plates, medium power
|
Case 3 - Figure 3 - Atypical hepatocytes with thickened cell plates, hight power
|
Case 3 - Figure 4 - Cell plates greater than 2-3 cells thick, H&E and reticulin stains, medium power
|
62 year old man with history of colon cancer, presented
with 2 month history of shoulder and epigastric pain. Abdominal MRI showed a 5 cm tumor in the lateral
segment of the left hepatic lobe.
Case 4 - Figure 1 - Hepatocellular carcinoma, pseudoglandular pattern, medium power
|
Case 4 - Figure 2 - Hepatocellular carcinoma, clear cell variant, medium power
|
Case 4 - Figure 3 - Hepatocyte immunostain with granular cytoplasmic positivity, medium power
|
53 year old man who was found to have a 3 cm mass in his
liver on an abdominal CT scan.
40 year old man with cirrhosis who underwent a liver
transplantation. The explant liver contained a 1 cm tan firm nodule in that appeared different from the
surrounding nodules.
Case 6 - Figure 1 - Cirrhotic liver with a nodular proliferation of ducts in a fibrotic area, low power
|
Case 6 - Figure 2 - Ductular structures with a tubular appearance in a fibrotic stroma with some lymphocytes, medium power
|
Case 6 - Figure 3 - Ducts with no cytologic atypia, high power
|
32 year old asymptomatic woman with a large palpable
non-tender mass in her RUQ found on physical exam. CT scan showed a mass in the liver. The mass was
cystic and measured 8 cm
Case 7 - Figure 1 - Multilocular cyst partially denuded with an epithelial lining, low power
|
Case 7 - Figure 2 - Mucinous epithelium with basally oriented nuclei and an underlying "ovarian type" stroma, medium power
|
54 year old woman with cirrhosis and a history of
ulcerative colitis. She presented for pre-liver transplant evaluation and abdominal CT demonstrated
marked hepatomegaly and severe dilation of biliary tree, suggestive of obstruction of the common hepatic
duct. At gross examination, multiple ducts were found to contain papillary excrescences.
Case 8 - Figure 1 - Intraductal paillary proliferation of columnar epithelium and adjacent fibrotic liver, low power
|
Case 8 - Figure 2 - Intraductal papillary proliferation (arrow), medium power
|
Case 8 - Figure 3 - Severely dysplastic columnar epithelium (carcinoma in-situ) with mitotic figures (arrow), high power
|
50 year old man presented with 2 week history of
hematemesis and epigastric pain, and EGD and CT demonstrated a large gastric mass. At surgery he was
found to also have a 5 cm liver mass.
36 year old woman with one tumor in the right lobe and
other small nodules in the left lobe. The tumors had white-tan and firm surfaces.
Case 10 - Figure 1 - Nests of atypical cells embedded in a myxohyaline matrix, low power
|
Case 10 - Figure 2 - Nests and single atypical round cells with a rare intracytoplasmic vacuole containing erythrocytes, high power
|
Case 10 - Figure 3 - Atypical cells lining vascular spaces, high power
|
Case 10 - Figure 4 - CD31 immunoreactivity in the atypical cells and lack of staining in admixed benign bile ducts; Cytokeratin postive bile ducts, high power
|
22 month boy with Down's syndrome, presented with
failure to thrive and a large abdominal mass. Abdominal CT scan showed a large hepatic mass.
Case 11 - Figure 1 - Irregular lobules of atypical cells with increased nuclear to cytoplasmic ratio, low power
|
Case 11 - Figure 2 - Foci of extramedullary hematopoiesis within the sinusoids of the tumor, high power
|
Case 11 - Figure 3 - Foci of extramedullary hematopoiesis within the sinusoids of the tumor, high power
|
23 year old woman presented with 40 lb unintentional
weight loss, abdominal fullness, and non-specific abdominal pain. Abdominal CT demonstrated a hepatic
neoplasm, and at surgery, a greater than 10 cm hemorrhagic and necrotic mass was found.
Case 12 - Figure 1 - Proliferation of spindled and stellate cells, low power
|
Case 12 - Figure 2 - Spindled and stellate cells with ill-defined cell borders and rare multinucleated giant cell, high power
|
Case 12 - Figure 3 - Epithelioid cells, low power
|
Case 12 - Figure 4 - Epithelioid atypical cells containing hyaline globules (arrow) within the cytoplasm and stroma, PAS stain with diastase, high power
|
References
- Craig J, Peters R, Edmondson H: Benign tumors and tumor-like conditions. In Hartmann W, Sobin L (eds): Tumors of the Liver and Intrahepatic Bile Ducts. Washington, D.C., Armed Forces Institute of Pathology, 1989, pp 8-98.
- Hamazaki K, Mimura H, Orita K, et al: Surgical treatment for hepatocellular carcinoma (HCC) 3 cm or less than 3 cm in diameter. Hepato-Gastroenterology 6:485-588, 1992.
- Ishak K, Anthony P, L S: Histological Typing of Tumours of the Liver, 2nd ed. Berlin ,, Springer-Verlag, 1994.
- Ljung B, Ferrell L: Fine needle aspiration biopsy of the liver: Diagnostic problems. In Ferrell L (ed): Diagnostic Problems in Liver Pathology. Pathology: State of the Art Reviews. Philadelphia, Hanley & Belfus, Inc, 1994, pp 161-184.
- Schoenthaler R, Phillips T, Castro J, et al: Carcinoma of the extrahepatic bile ducts: The University of California at San Francisco experience. Annals of Surgery 219:267-274, 1994.
- Torii A, Harada A, Nonami T, et al: Tumor localization as a prognostic factor in hepatocellular carcinoma. Hepato-Gastroenterology 41:16-19, 1994.
- Wanless I, Callea F, Craig J, et al: Terminology of nodular lesions of the liver. Hepatology 25:983-993, 1995.
TABLE 1: Classification of Primary Liver Tumors and Tumor-like Lesions From World Health Organization
Epithelial tumors or tumor-like lesions
Benign |
| | Large regenerative nodule |
| | Low-grade dysplastic nodule |
| | High-grade (borderline) dysplastic nodule |
| | Hepatocellular adenoma |
| | Focal nodular hyperplasia |
| | Bile duct adenoma |
| | Bile duct hamartoma |
| | Biliary cystadenoma |
| | Intraductal biliary papillomatosis |
| | Congenital biliary cysts |
| | Focal fatty change |
| Malignant |
| | Hepatocellular carcinoma, including fibrolamellar variant |
| | Combined hepatocellular and cholangiolar carcinoma |
| | Cholangiocarcinoma, peripheral, hilar, and extrahepatic type |
| | Biliary cystadenocarcinoma |
| | Intraductal papillary adenocarcinoma |
Nonepithelial tumors or tumor-like lesions
Benign |
| | Hemangioma |
| | Angiomyolipoma |
| | Infantile hemangioendothelioma |
| | Mesenchymal hamartoma |
| | Localized fibrous tumor |
| | Solitary necrotic nodule |
| | Inflammatory pseudotumor |
| | Infectious cysts |
| | Other rare benign tumors |
| Malignant |
| | Epithelioid hemangioendothelioma |
| | Angiosarcoma |
| | Undifferentiated sarcoma (embryonal sarcoma) |
| | Lymphoma and other hematopoietic tumors |
| | Kaposi's sarcoma |
| | Other malignant tumors |
|
|
|
|
