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Liver Pathology
Thursday, March 25, 7:30 PM
Salon 1
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 Liver Cases
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Moderator:
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KENNETH BATTS
Abbott Northwestern Hospital and Virginia Piper Cancer Institute
Minneapolis, MN
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Disclosure:
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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.
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Panelists:
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JASON DANIELS, Abbott Northwestern Hospital and Virginia Piper Cancer Institute, Minneapolis, MN
LISA M. YERIAN, Cleveland Clinic, Cleveland, OH
MICHAEL S. TORBENSON, Johns Hopkins University School of Medicine, Baltimore, MD
IAN R. WANLESS, Dalhousie University, Halifax, Nova Scotia, Canada
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Clinical histories are displayed below.
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for Text and References
Submitted by: Lisa M. Yerian - Cleveland Clinic, Cleveland, OH
The patient is a 38 year old male with a history of ulcerative colitis and primary sclerosing cholangitis who underwent living related donor transplantation from his uncle. The patient received a left lobe liver graft with end-to-side portocaval shunt, splenic artery ligation, and a Roux-en-Y hepaticojejunostomy. He tolerated the procedure. On post-operative days 1 and 2, the patient was awake and alert, hemodynamically stable, and was extubated. The patient's lactate level, transaminases and bilirubin were all decreasing. Postoperative ultrasounds showed a patent liver vasculature with elevated portal venous velocities, main hepatic artery resistive index was 0.81 – 0.88 and normal direction of flow. Urine output was good, and hemoglobin and hematocrit were stable. On POD 2, creatinine slightly increased. On POD 3 the patient became lethargic and slow to follow commands. An ultrasound showed a large new fluid collection medial to the spleen, possibly representing a fluid-filled stomach. CT revealed a diffusely hypodense liver, patent vessels, and a patent left portal vein to IVC shunt. There was a small amount of right subphrenic fluid, and the patient was returned to the OR for exploratory laparotomy and abdominal washout. No bile leak or abscess was identified. A biopsy was taken, and abdominal fluid cultures were sent. On POD 4, the bilirubin increased and the patient was hemodynamically stable but became hypertensive, tachycardic, and unresponsive. INR remained elevated, and creatinine increased. An US showed splenomegaly and patent hepatic vasculature, with main hepatic artery resistive index 0.49-0.53. On POD 5 the patient was re-listed as status 1 for re-liver transplantation secondary to allograft failure, and on POD 7 he underwent orthotopic liver transplantation.
Case 1 - Slide 1
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Case 1 - Slide 2
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Case 1 - Slide 3
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for Text and References
Submitted by: Jason Daniels - Abbott Northwestern Hospital and Virginia Piper Cancer Institute, Minneapolis, MN
A 69-year-old female presents with obstructive jaundice. Her past medical history is unremarkable with no known liver disease.
Recent laboratory values are as follows:
AST (SGPT): 141 (10-42 IU/L)
ALT (SGOT): 212 (10-40 IU/L)
Alkaline Phosphatase: 571 (34-104 IU/L)
Total protein: 7.4 (6.0-8.0 g/dL)
Albumin: 4.3 (3.5-5.0 g/dL)
Total bilirubin: 4.9 (<1.6 mg/dL)
Platelets: 256,000/mm3 (140,000-440,000/mm3).
She underwent an endoscopic ultrasound which demonstrated a normal pancreas and distal bile duct. The pancreatic parenchyma appeared normal. In the liver there was a left lobe and porta hepatis mass. An ERCP demonstrated a narrowing of the common bile duct at the right duct. The left duct was completely obliterated. A cholangiogram revealed a normal CBD with complete obstruction of the left hepatic duct and stenosis involving the bifurcation extending 3 to 4 cm to the right biliary system.
A CT scan revealed a 10 x 8.5 x 8.5 cm hypervascular central mass arising from the medial left hepatic lobe. The focus was primarily in segment 4B. Clinically it appeared to be hepatocellular carcinoma (HCC). Serum tumor markers include: AFP: 3.2 ng/ml, CA 19-9: 19 (0-36 U/ml), and CEA: 1.0 ng/ml. A biopsy was obtained (see microscopic images).
She then underwent a left trisegmentectomy with radical bile duct excision. The tumor was found to be invading into the bile duct. She was reconstructed with a Roux-en-Y hepaticojejunostomy.
for Text and References
Submitted by: Michael S. Torbenson - Johns Hopkins University School of Medicine, Baltimore, MD
A 62 year old female with a high CA125 underwent exploratory laparotomy to rule out ovarian cancer. The surgeon found no evidence for cancer but did see a pedunculated lesion of the liver that was near but not connected to the faliciform ligament. The liver was otherwise grossly unremarkable. The lesion was biopsied.
Case 3 - Figure 1
H&E, original magnification 20X. A low power view of the mass lesion shows scattered small islands of hepatocytes surrounded by abundant extracellar material.
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Case 3 - Figure 2
H&E, original magnification 40X. A medium power view shows the extracellular material involves the portal tracts. The hepatic artery and bile duct can be seen in the remnant of a portal tract.
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Case 3 - Figure 3
H&E, original magnification 40X. A medium power view shows the extracellular material involves the central veins. This central vein is nearly obliterated.
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Case 3 - Figure 4
H&E, original magnification 100X. A high power view shows the extracellular material as it abuts the islands of hepatocytes. The hepatocytes show no atypia.
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Case 3 - Figure 5
original magnification 100X. H&E. A high power view shows the extracellular material. There are scattered cells throughout the extracellular material but these cells show no atypia. No mitotic figures were observed.
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Case 3 - Figure 6
H&E, original magnification 16X. A high power view shows the extracellular material has a basophilic and somewhat fibrillar appearance.
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Case 3 - Figure 7
original magnification 100X. Miller's Elastic stain. An elastic stain shows the extracellular material is primarily composed of elastic fibers. Both VVG and Movat stains will also work equally well to highlight the elastic fibers in these cases.
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Submitted by: Ian R. Wanless - Dalhousie University, Halifax, Nova Scotia, Canada
A 60 year old man had a segmental liver resection for a focal lesion. The submitted material is from the grossly visible liver lesion. There was a known history of primary endocrine carcinoma in the pancreas.
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