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Liver Pathology
Tuesday, March 4, 2008 , 7:30 PM
Convention Center 102/104/106
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Moderator:
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ELIZABETH M. BRUNT
Washington University School of Medicine
St. Louis, MO
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Disclosure:
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The speakers have indicated they have nothing to disclose.
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Clinical histories are displayed below.
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for Text and References
Submitted by: Andrew Clouston
The patient was a 40 year old dentist with a history of alcoholic liver disease and decompensated cirrhosis. He was transplanted and the section is from the explant. Apart from some acquired red cell spurring requiring 2 transfusions in the preceding 12 months, there was no history of recurrent transfusions or iron supplementation. Testing for HFE mutations was performed at a later time.
Case 1 - Figure 1
Low power view showing established cirrhosis.
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Case 1 - Figure 2
Medium power view showing pigment in hepatocytes
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Case 1 - Figure 3
Medium power view showing an area of nodular dropout, indicating that active parechymal refashioning is ongoing in this liver. The lost nodule is replaced by a ductular reaction. Small clusters of hepatocytes remain focally.
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Case 1 - Figure 6
Perls stain showing iron accumulation in bile ducts and ductules.
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Case 1 - Figure 7
PAS stain after diastase digestion showing globules of alpha-1-antitrypsin. The patient was PiMZ. The globules were irregularly distributed.
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for Text and References
Submitted by: Christine Janney - Saint Louis University, Saint Louis, MO
The patient, a 36 year old woman, was referred to our center for evaluation and possible resection of a painful large hepatic mass, located in the posterior right lobe. She first noted right upper quadrant abdominal pain 2 months earlier; at that time an ultrasound study demonstrated a predominantly cystic area measuring 6 .3cm in the right lobe of the liver. A subsequent CT scan was initially interpreted as a subcapsular hematoma of the liver. The pain was well-controlled with nonprescription pain medications. One week prior to referral, the pain became worse, and the patient went to an outside hospital. Repeat ultrasound showed that the heterogeneous, cystic and solid lesion now measured at least 11 cm. The repeat CT scan and an MRI were interpreted as showing an encapsulated, predominantly solid mass with cystic, blood-containing regions, c/w an adenoma with hemorrhage, which was thought responsible for the previous subcapsular hematoma. She was referred to St. Louis University Medical Center for resection.
In addition to RUQ pain, the patient complained of fever spiking to 102 degrees F, chills, nausea, vomiting and a 5 pound weight loss over the prior 2 weeks. Past medical history was significant for 2 cesarean sections, post partum depression, and oral contraceptive use. She did not smoke or drink alcohol. Her last menstrual period was 2 weeks prior to referral.
On physical examination, the patient had hepatomegaly and was tender to right upper quadrant palpation. The physical exam was otherwise within normal limits. Laboratory values on admission included a white blood cell count of 14,000, hemoglobin 11, hematocrit 33, platelets 121, platelets 121,000 and albumin 2.9. All other laboratory values were normal.
Following preoperative assessment and review of radiographic studies, the patient underwent a right hepatectomy and resection of adherent diaphragm with prosthetic repair. The patient did well postoperatively and was discharged on postoperative day 5.
Case 2 - Slide 1
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Case 2 - Figure 4
(higher power view of Figure 3) Mass effect adjacent to liver lesion, with portal expansion, edema, ductular proliferation, and mixed inflammation.
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Case 2 - Figure 5
Liver mass with cystic area and hemorrhage.
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Case 2 - Figure 6
Medium power view of lesion with characteristic biphasic pattern.
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for Text and References
Submitted by: Hala R. Makhlouf - Armed Forces Institute of Pathology, Washington, DC
This 28 year old woman presented with a solitary liver mass. She had a history of calcified hepatic nodules, believed to be calcified hemangioma, since childhood (age 4). There was a history of contraceptive steroid use. Imaging studies demonstrated a 15 cm circumscribed multi-lobulated lesion arising from segments IV, V and VI of liver. Serum alpha-fetoprotein was normal. Serology for hepatitis A, B, and C was negative. A trisegmentectomy (segments IVB, V, VI) with a wedge resection of a separate focal nodular hyperplasia from segment VII was performed.
Case 3 - Slide 1
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for Text and References
Submitted by: Cheryl M. Coffin - Primary Children's Medical Center, University of Utah, Salt Lake City, Utah
A 14-year old girl was found to have a mass in the liver. She underwent an extended right hepatic lobectomy. She was alive and well twenty years after initial diagnosis.
Case 4 - Slide 1
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Case 4 - Figure 1
At low power, the embryonal sarcoma of the liver contains extensive areas of myxoid degeneration and coagulative necrosis surrounded by a proliferation of atypical spindled and polygonal cells.
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Case 4 - Figure 2
The tumor cells form sheets and vague fascicles and display nuclear pleomorphism and hyperchromasia.
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Case 4 - Figure 3
Strands of tumor cells are dispersed in a loose myxoid background.
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Case 4 - Figure 4
The pleomorphic hyperchromatic tumor cells show frequent and atypical mitoses.
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Case 4 - Figure 5
In a more cellular areas, variations in cytomorphology are notable, with ovoid, epithelioid, and spindled tumor cells.
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Case 4 - Figure 6
PAS-positive intracellular and extracellular hyaline globules are present focally.
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Case 4 - Figure 7 - A1ACT
Strong diffuse cytoplasmic reactivity for alpha-1 anti-chymotrypsin is present in tumor cells.
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Case 4 - Figure 8 - p53
Diffuse nuclear p53 reactivity is present in tumor cells and may reflect a mis-sense mutation of p53.
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