Liver neoplasms

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This article examines liver neoplasms and pre-malignant lesions of the liver. In North America, most malignant liver lesions are metastases.

This article focuses on primary malignancies of the liver, neoplastic liver lesions, and biliary malignancies. It only briefly discusses metastatic lesions. An introduction to liver pathology is in the liver article. Medical liver disease is dealt with in the medical liver disease article.

Overview

Dysplasic lesions of the liver

Types:[1]

  • "Large cell dysplasia" (AKA large cell change) - not considered a precursor for HCC, not considered a dysplasia.[2]
  • Small cell dysplasia.
  • Low grade dysplasia.
  • High grade dysplasia.

Neoplastic lesions

  • Hepatic adenoma.

Malignant lesions of the liver

  • Hepatocellular carcinoma (HCC) - most common malignant liver primary in adults.
  • Hepatoblastoma - malignant liver primary in children.
  • Intrahepatic cholangiocarcinoma (ICC).[3]
  • Combined hepatocellular carcinoma and intrahepatic cholangiocarcinoma (CHC).

Tabular comparison

Features of HCC & its precursors - generated from DCHH[4] and STC:

Features SCD Low-grade dysplasia High-grade dysplasia HCC
Plate thickness <3 cells <=2 cells <=3 cells, usu. >2 cells >3 cells
Reticulin (stain) intact chicken wire intact chicken wire intact chicken wire damaged chicken wire
Nuclear changes nuc. enlargement,
hyperchromasia		 +/- atypia (???) marked atypia +/- incr. NCR,
+/-irreg. nuc. contour
Cytoplasmic change hyperchromasia, decr. as
cell size preserved		 none (???) +/- basophilia variable (lighter vs. hyperchromasia)
Portal tracts ? loss of portal tracts loss of portal tracts loss of portal tracts
Management follow ??? follow ablate ablate/surgery

Abbreviations:

  • SCD = small cell dysplasia.

Notes:

  • Large cell dysplasia:
    • Cell size ~ 2x normal, NC ratio ~ normal.
  • SCD:
    • Cell size ~ 1/2x normal, NC ratio - increased.

Small liver cell dysplasia

  • Abbreviated SLCD.
  • AKA small cell dysplasia.

General

  • Considered a precursor to HCC.
    • Frequently found in livers with HCC - when compared to livers without HCC.[5]

Microscopy

Features:[6]

  • Cells similar in size to normal hepatocytes.
    • Name derived from the fact that there is also an entity that was called large cell dysplasia (AKA large cell change).
  • Increased NC ratio - "more blue".
  • Mild nuclear and cytoplasmic hyperchromatism.

Notes:

  • Normal hepatic architecture (main differentiator from HCC).
  • Remember "... blue is bad".

Micrograph:

Low grade dysplasia

Microscopy

  • Uniform cells - "noticeably different from normal".[7]
    • Changes in nuclear size, irregular nuclear contour and/or changes in cytoplasm staining.
  • Loss of portal tracts.
  • Irregular margin.

Notes:

  • DCHH describes LGD as: "normal hepatocytes in plates [of normal thickness]".[4]

DDx:

High grade dysplasia

  • "Bader" version of low grade dyplasia.

Features - in addition to those of low grade dysplasia:[4]

  • Liver plate >2 cells thick.
  • Significant nuclear atypia.
  • Basophilic cytoplasm.

Micrograph:

Hepatic neoplasms

In North America, the most common malignant liver tumour is metastases.

Hepatic adenoma

  • AKA hepatocellular adenoma, abbreviated HCA.

General

  • Grow under the influence of sex hormones.
    • Associated with OCP use - may regress with discontinuation.
    • May rupture in pregnancy.
  • Usually diagnosed by radiology.

Gross

Features:[8]

  • Often subcapsular location.
  • Well circumscribed, but not encapsulated.

Microscopic

Features:

  • Sheets or cords of cells with mild variation of cell and nuclear size.[9]
  • Cords of cells upto 3 cells thick.[10]
  • Cells may have cytoplasmic clearing due to glycogen or be pale - obvious if seen.
  • Vascular - large arteries, dilated thin-walled veins.

Negatives:

  • No bile ducts.
  • No portal tracts.
  • No cirrhosis! If cirrhosis is present it isn't a hepatic adenoma - important.

Images:

DDx:

  • Well-differentiated HCC.[11]
    • Hepatic adenoma is differentiated from well-differentiated HCC by its architecture; adenomas have cords of cells upto 3 cells thick & have preserved reticulin architecture.

Subclassification

Based on molecular changes:[12][13]

  1. Inflammatory hepatic adenoma.
  2. Hepatocyte nuclear factor 1 alpha-mutated hepatic adenoma.
    • Inactivating mutation.
  3. Beta-catenin-mutated hepatic adenoma
    • Activating mutation.
  4. Unclassified hepatic adenoma.

Note:

  • Beta-catenin is considered an oncogene.

IHC

  • AFP -ve. (???)
  • HNF1alpha +ve/-ve.
  • Beta-catenin +ve/-ve.

Hepatoblastoma

General

  • Most common liver cancer in children.[9][14]
    • Rare in adolescents and adults.
    • Age of diagnosis usu. ~1 year old; most less than 3 years old.
  • Surgical biopsy; core needle biopsy not done as as lesion is vascular.

Associations:

Clinical:

Microscopic

Features:

  • Small round cell tumour.
  • Fetal hepatocytes ~ 1:3 NC ratio, eosinophilic cytoplasm.
  • +/-Mesenchymal component
    • Immature fibrous tissue, osteoid or cartilage.

Images:

Subtypes

  • Six histologic subtypes - that are subdivided into two groups:[17]
    • Epithelial type:
      1. Fetal pattern.
      2. Embryonal and fetal pattern.
      3. Macrotrabecular pattern.
      4. Small cell undifferentiated pattern
    • Mixed epithelial and mesenchymal type:
      1. With teratoid features.
      2. Without teratoid features.

Hepatocellular carcinoma

General

  • Commonly abbreviated HCC.

Clinical

  • Serum AFP elevated - in approx. 50% of patients.[19]
  • Treatments: RFA (radiofrequency ablation), ethanol ablation, liver resection, liver transplant.[20]
  • Mean survival at time of diagnosis ~6 months.[20]

Epidemiology

  • Highest where prevalence of hepatitis B virus (HBV) is high.[21]
  • HCC generally arises in the setting of cirrhosis.
    • HBV commonly leads to HCC without cirrhosis[21] - may be without cirrhosis as it is regressed.

Risk factors:[21][22]

  • Chronic alcoholism.
  • Hepatitis C virus (HCV) - chronic infection.
  • HBV - chronic infection.
  • Aflatoxins (food contaminant - mould).[20]
  • Hereditary tyrosinemia.
  • Hereditary hemochromatosis.

Gross

Features:[23]

  • Unifocal, multifocal or diffusely infiltrative.
    • Tumours are multifocal in approx. 50% of cases;[24][25] some authors have suggested it is upto 75% of cases.[20]
  • Pale in relation to surrounding liver or green (due to bile secretion).

Microscopic

Requirements:[26]

  • Architectural changes.
    • Liver plate more than 3 cells thick - key feature.
    • Loss of reticulin scaffold - incomplete loss is considered significant.
    • CD34+ staining cells, suggesting loss of epithelial cells that form the sinusoids.
    • Loss of structures seen in a normal liver lobule (bile ductules, portal triad).
    • Invasion of the portal tract - useful in well-diff. lesions.[27]

Additional findings:[28]

  • Nuclear changes.
    • Increased NC ratio - key feature if present.
    • Nuclear hyperchromasia.
    • Abnormal nuclear contour.
    • Mitoses.
  • Cytoplasmic changes.
    • Cytoplasmic hyperchromasia, clearing or lighter staining.

Varied architecture - may be:[29]

  • Pseudoglandular - can be confused with adenocarcinoma.
  • Trabecular.
  • Fibrolamellar.
  • Solid.

Notes:

  • HCC with trabecular morphology has some resemblance to normal liver - but has extra cells.
  • Fibrolamellar - better prognosis, classically in young adults.
  • Stroma is usually scant.[30]

ASIDE:

Images:

Fibrolamellar hepatocellular carcinoma

  • Abbreviated fibrolamellar HCC, FL-HCC, and FHCC.
General
  • Rare variant.
  • Classically afflicts younger patients.
    • Mean age at onset ~27 years in one study.[31]
  • Individuals usually do not have the classic risk factors for HCC, i.e. no cirrhosis, no hepatitis.[31]

Clinical:

  • AFP usu. not elevated.[31]
Microscopic

Features:[32]

  • Large polygonal tumours cells with:
    • Graunular eosinophilic cytoplasm.
    • Low NC ratio.[33]
  • Layered dense collagen bundles.

Images:

Sclerosing HCC

Features:

  • Fibrosis. (???)

Notes:

  • Seen in non-cirrhotic livers.

Grading

Edmondson-Steiner grading system:[34][35]

  • Well-differentiated.
    • Some say "it cannot be diagnosed on biopsy,"[36] as it cannot be reliably differentiated from a regenerative nodule.
  • Moderately differentiated.
    • Round, regular nuclei, some hyperchromatism, nucleoli present, increase NC ratio.
  • Poor differentiated.
    • Very prominent nucleoli, pronounced nuclear irregularity.
  • Undifferentiated.
    • Anaplastic giant cells.

Simplified description - based on MacSween:[35]

  • Well-differentiated = cytologically near normal.
  • Moderate = looks like a cancer, small nucleoli.
  • Poor = bad cancer, raisin-like (irregular) nuclear membrane, large nucleoli (~1/3 of nucleus).
  • Undifferentiated = death on a slide, huge cells (3-4x the size of other cells).

IHC

  • CD34 +ve sinusoids; sinusoids in normal liver are CD34 -ve.
  • HepPar-1 +ve; may be neg. in high grade tumours.
  • AFP +ve; may be neg. even if the serum AFP is elevated.
  • CK18 +ve.[37]
  • Glypican-3 +ve (cytoplasmic, granular cytoplasmic or membranous).[3]

Image:

Cholangiocarcinoma

General

  • Malignancy of the biliary tree.
  • May be intrahepatic, i.e. intrahepatic cholangiocarcinoma (abbreviated ICC), or extrahepatic.

Epidemiology

  • Rare - approximately 1/5 the incidence of HCC.[39]
  • More common among asians.

Risks:

Gross

  • Classically one large mass, may have satellite nodules.

Microscopic

Features:[44]

  • Usually an adenocarcinoma, i.e. gland forming with:
    • Cuboidal or columnar mucin producing cells, and
    • A dense fibrous (desmoplastic) stroma.

Notes:

  • Biliary stents lead to reactive changes,[45] these can be confused for malignancy. One must always check whether a biliary stent was in situ at time of biopsy.[46]
  • Usually abundant desmoplasia, ergo hard to get good, i.e. diagnositic, endoluminal brushing specimens.[47]

DDx:

Images:

IHC

Classic IHC pattern:[48]

  • CK7 +ve.
  • CK20 +ve/-ve.
  • HepPar-1 -ve.
  • AFP -ve.[49]

ICC vs. HCC:[50]

  • ICC: CK19 (92.5%), MUC-1 (73.8%) +ve.
  • HCC: HepPar-1 (85.6%), CD34 (87.8%) +ve.

HCC vs. ICC:[51]

  • TTF-1: ~90-100% +ve (cytoplasmic) in HCC vs. ~10% in cholangiocarcinoma.

Angiosarcoma

Main article: Angiosarcoma

General

  • Liver angiosarcomas are associated with vinyl chloride exposure.[52]

Microscopic

Features:

  • Atypical endothelial cells - may be subtle.

Hepatic metastasis

  • AKA liver metastases.

General

  • Metastases are very common - often from the gastrointestinal tract, e.g. colorectal cancer.
    • Most liver masses in are not biopsied... as a primary lesion is evident.[53]
  • Dependent on the extent of disease, CRC metastatic to the liver may be curable with a liver resection.
  • It is important to consider germ cell tumours in the DDx as these may be curable with chemotherapy.
  • Clear cell variant of HCC may be misdiagnosed as metastatic clear cell carcinoma.
  • Interhepatic cholangiocarcinoma is an adenocarcinoma - it may look like a metastatic lesion.


Further reading:

Gross pathology/radiology

  • Multifocal or solitary.

Microscopic

Features:

  • Histologic features are dependent on primary and degree of differentiation.

The classic liver metastasis (colorectal carcinoma):

  • Gland forming columnar shaped cells with pseudostratified hyperchromatic cigar-shaped nuclei.

Image:

IHC

  • Metastases are typically negative for HepPar-1.
    • HepPar-1 (hepatocytes paraffin antibody 1) - labels hepatocellular mitochondria.[54]

See also

References

  1. ↑ STC. S.30-37, 19 Jan 2009.
  2. ↑ Park, YN.; Roncalli, M. (Nov 2006). "Large liver cell dysplasia: a controversial entity.". J Hepatol 45 (5): 734-43. doi:10.1016/j.jhep.2006.08.002. PMID 16982109.
  3. ↑ 3.0 3.1 Shirakawa, H.; Kuronuma, T.; Nishimura, Y.; Hasebe, T.; Nakano, M.; Gotohda, N.; Takahashi, S.; Nakagohri, T. et al. (Mar 2009). "Glypican-3 is a useful diagnostic marker for a component of hepatocellular carcinoma in human liver cancer.". Int J Oncol 34 (3): 649-56. PMID 19212669. http://www.spandidos-publications.com/serveFile/ijo_34_3_649_PDF.pdf?type=article&article_id=ijo_34_3_649&item=PDF.
  4. ↑ 4.0 4.1 4.2 4.3 Tadrous, Paul.J. Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum (1st ed.). Wiley. pp. 170-1. ISBN 978-0470519035.
  5. ↑ Szczepański, W. (1997). "Liver cell dysplasia in liver cirrhosis and hepatocellular carcinoma.". Pol J Pathol 48 (3): 147-57. PMID 9401407.
  6. ↑ STC S.32, 19 Jan 2009.
  7. ↑ STC - 19 Jan 2009. (???)
  8. ↑ STC S.20, 19 Jan 2009.
  9. ↑ 9.0 9.1 Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 923. ISBN 0-7216-0187-1.
  10. ↑ STC S.19, 19 Jan 2009.
  11. ↑ SN. 29 May 2009.
  12. ↑ Katabathina, VS.; Menias, CO.; Shanbhogue, AK.; Jagirdar, J.; Paspulati, RM.; Prasad, SR. (Oct 2011). "Genetics and imaging of hepatocellular adenomas: 2011 update.". Radiographics 31 (6): 1529-43. doi:10.1148/rg.316115527. PMID 21997980.
  13. ↑ Sasaki, M.; Yoneda, N.; Kitamura, S.; Sato, Y.; Nakanuma, Y. (Oct 2011). "Characterization of hepatocellular adenoma based on the phenotypic classification: The Kanazawa experience.". Hepatol Res 41 (10): 982-8. doi:10.1111/j.1872-034X.2011.00851.x. PMID 21883740.
  14. ↑ URL: http://emedicine.medscape.com/article/986802-overview. Accessed on: 29 November 2009.
  15. ↑ DeBaun MR, Tucker MA (March 1998). "Risk of cancer during the first four years of life in children from The Beckwith-Wiedemann Syndrome Registry". J. Pediatr. 132 (3 Pt 1): 398–400. PMID 9544889.
  16. ↑ URL: http://emedicine.medscape.com/article/986802-diagnosis. Accessed on: 11 February 2011.
  17. ↑ URL: http://emedicine.medscape.com/article/986802-diagnosis. Accessed on: 11 February 2011.
  18. ↑ URL: http://www.cap.org/apps/cap.portal?_nfpb=true&cntvwrPtlt_actionOverride=%2Fportlets%2FcontentViewer%2Fshow&_windowLabel=cntvwrPtlt&cntvwrPtlt{actionForm.contentReference}=cap_foundation%2FcaseOfMonth%2FMar10%2Fmar_2010_cotm_diagnosis.html&_state=maximized&_pageLabel=cntvwr#null. Accessed on: 11 February 2011.
  19. ↑ Iacobuzio-Donahue, Christine A.; Montgomery, Elizabeth A. (2005). Gastrointestinal and Liver Pathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 588. ISBN 978-0443066573.
  20. ↑ 20.0 20.1 20.2 20.3 http://emedicine.medscape.com/article/282814-overview
  21. ↑ 21.0 21.1 21.2 Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 924. ISBN 0-7216-0187-1.
  22. ↑ Leong TY, Leong AS (2005). "Epidemiology and carcinogenesis of hepatocellular carcinoma". HPB (Oxford) 7 (1): 5–15. doi:10.1080/13651820410024021. PMC 2023917. PMID 18333156. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2023917/.
  23. ↑ Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 925. ISBN 0-7216-0187-1.
  24. ↑ Yusuf MA, Badar F, Meerza F, et al. (2007). "Survival from hepatocellular carcinoma at a cancer hospital in Pakistan". Asian Pac. J. Cancer Prev. 8 (2): 272–4. PMID 17696722.
  25. ↑ Sharieff S, Burney KA, Ahmad N, Salam A, Siddiqui T (October 2001). "Radiological features of hepatocellular carcinoma in Southern Pakistan". Trop Doct 31 (4): 224–5. PMID 11676064.
  26. ↑ Adapted from STC (19 Jan 2009).
  27. ↑ Kojiro, M.; Wanless, IR.; Alves, V.; Badve, S.; Balabaud, C.; Bedossa, P.; Bhathal, P.; Bioulac-Sage, P. et al. (Feb 2009). "Pathologic diagnosis of early hepatocellular carcinoma: a report of the international consensus group for hepatocellular neoplasia.". Hepatology 49 (2): 658-64. doi:10.1002/hep.22709. PMID 19177576. http://onlinelibrary.wiley.com/doi/10.1002/hep.22709/pdf.
  28. ↑ Adapted from STC (19 Jan 2009).
  29. ↑ Iacobuzio-Donahue, Christine A.; Montgomery, Elizabeth A. (2005). Gastrointestinal and Liver Pathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 590-1. ISBN 978-0443066573.
  30. ↑ Iacobuzio-Donahue, Christine A.; Montgomery, Elizabeth A. (2005). Gastrointestinal and Liver Pathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 591. ISBN 978-0443066573.
  31. ↑ 31.0 31.1 31.2 Stipa, F.; Yoon, SS.; Liau, KH.; Fong, Y.; Jarnagin, WR.; D'Angelica, M.; Abou-Alfa, G.; Blumgart, LH. et al. (Mar 2006). "Outcome of patients with fibrolamellar hepatocellular carcinoma.". Cancer 106 (6): 1331-8. doi:10.1002/cncr.21703. PMID 16475212.
  32. ↑ Iacobuzio-Donahue, Christine A.; Montgomery, Elizabeth A. (2005). Gastrointestinal and Liver Pathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 595-6. ISBN 978-0443066573.
  33. ↑ STC. 6 December 2010.
  34. ↑ Primary carcinoma of the liver: a study of 100 cases among 48,900 necropsies. EDMONDSON HA, STEINER PE. Cancer. 1954 May;7(3):462-503. PMID 13160935.
  35. ↑ 35.0 35.1 Burt, Alastair D.;Portmann, Bernard C.;Ferrell, Linda D. (2006). MacSween's Pathology of the Liver (5th ed.). Churchill Livingstone. pp. 783. ISBN 978-0-443-10012-3.
  36. ↑ AP. 28 May 2009.
  37. ↑ AP. 28 May 2009.
  38. ↑ Goodman, ZD. (Feb 2007). "Neoplasms of the liver.". Mod Pathol 20 Suppl 1: S49-60. doi:10.1038/modpathol.3800682. PMID 17486052.
  39. ↑ Iacobuzio-Donahue, Christine A.; Montgomery, Elizabeth A. (2005). Gastrointestinal and Liver Pathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 608. ISBN 978-0443066573.
  40. ↑ Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 926. ISBN 0-7216-0187-1.
  41. ↑ Park, do H.; Son, HY. (Apr 2008). "Images in clinical medicine. Clonorchis sinensis.". N Engl J Med 358 (16): e18. doi:10.1056/NEJMicm054461. PMID 18420495.
  42. ↑ de Martel C, Plummer M, Franceschi S (March 2010). "Cholangiocarcinoma: Descriptive epidemiology and risk factors". Gastroenterol Clin Biol. doi:10.1016/j.gcb.2010.01.008. PMID 20202771.
  43. ↑ Ananthakrishnan AN, Saeian K (April 2007). "Caroli's disease: identification and treatment strategy". Curr Gastroenterol Rep 9 (2): 151–5. PMID 17418061.
  44. ↑ Iacobuzio-Donahue, Christine A.; Montgomery, Elizabeth A. (2005). Gastrointestinal and Liver Pathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 609. ISBN 978-0443066573.
  45. ↑ Carrasco, CH; Wallace, S; Charnsangavej, C; Richli, W; Wright, KC; Fanning, T; Gianturco, C (Dec 1985). "Expandable biliary endoprosthesis: an experimental study.". AJR Am J Roentgenol 145 (6): 1279-81. PMID 3877438.
  46. ↑ STC. 2 October 2009.
  47. ↑ STC. 6 December 2010.
  48. ↑ Iacobuzio-Donahue, Christine A.; Montgomery, Elizabeth A. (2005). Gastrointestinal and Liver Pathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 609. ISBN 978-0443066573.
  49. ↑ STC. 6 December 2010.
  50. ↑ [Evaluation of immunohistochemical markers for differential diagnosis of hepatocellular carcinoma from intrahepatic cholangiocarcinoma] Dong H, Cong WL, Zhu ZZ, Wang B, Xian ZH, Yu H. Zhonghua Zhong Liu Za Zhi. 2008 Sep;30(9):702-5. Chinese. PMID 19173916.
  51. ↑ Lei JY, Bourne PA, diSant'Agnese PA, Huang J (April 2006). "Cytoplasmic staining of TTF-1 in the differential diagnosis of hepatocellular carcinoma vs cholangiocarcinoma and metastatic carcinoma of the liver". Am. J. Clin. Pathol. 125 (4): 519–25. doi:10.1309/59TN-EFAL-UL5W-J94M. PMID 16627262.
  52. ↑ Mitchell, Richard; Kumar, Vinay; Fausto, Nelson; Abbas, Abul K.; Aster, Jon (2011). Pocket Companion to Robbins & Cotran Pathologic Basis of Disease (8th ed.). Elsevier Saunders. pp. 212. ISBN 978-1416054542.
  53. ↑ OA. 29 November 2009.
  54. ↑ The diagnostic value of hepatocyte paraffin antibody 1 in differentiating hepatocellular neoplasms from nonhepatic tumors: a review. Lamps LW, Folpe AL. Adv Anat Pathol. 2003 Jan;10(1):39-43. Review. PMID 12502967.
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