Difference between revisions of "Liver neoplasms"

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Liver neoplasms (view source)

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===Malignant lesions of the liver===
===Malignant lesions of the liver===
*[[Hepatocellular carcinoma]] (HCC) - most common malignant liver primary in adults.
*[[Hepatocellular carcinoma]] (HCC) - most common malignant liver primary in adults.
*Hepatoblastoma - malignant liver primary in children.  
*[[Hepatoblastoma]] - malignant liver primary in children.  
*Intrahepatic cholangiocarcinoma (ICC).<ref name=pmid19212669>{{Cite journal  | last1 = Shirakawa | first1 = H. | last2 = Kuronuma | first2 = T. | last3 = Nishimura | first3 = Y. | last4 = Hasebe | first4 = T. | last5 = Nakano | first5 = M. | last6 = Gotohda | first6 = N. | last7 = Takahashi | first7 = S. | last8 = Nakagohri | first8 = T. | last9 = Konishi | first9 = M. | title = Glypican-3 is a useful diagnostic marker for a component of hepatocellular carcinoma in human liver cancer. | journal = Int J Oncol | volume = 34 | issue = 3 | pages = 649-56 | month = Mar | year = 2009 | doi =  | PMID = 19212669 | url = http://www.spandidos-publications.com/serveFile/ijo_34_3_649_PDF.pdf?type=article&article_id=ijo_34_3_649&item=PDF}}</ref>
*Intrahepatic [[cholangiocarcinoma]] (ICC).<ref name=pmid19212669>{{Cite journal  | last1 = Shirakawa | first1 = H. | last2 = Kuronuma | first2 = T. | last3 = Nishimura | first3 = Y. | last4 = Hasebe | first4 = T. | last5 = Nakano | first5 = M. | last6 = Gotohda | first6 = N. | last7 = Takahashi | first7 = S. | last8 = Nakagohri | first8 = T. | last9 = Konishi | first9 = M. | title = Glypican-3 is a useful diagnostic marker for a component of hepatocellular carcinoma in human liver cancer. | journal = Int J Oncol | volume = 34 | issue = 3 | pages = 649-56 | month = Mar | year = 2009 | doi =  | PMID = 19212669 | url = http://www.spandidos-publications.com/serveFile/ijo_34_3_649_PDF.pdf?type=article&article_id=ijo_34_3_649&item=PDF}}</ref>
*Combined hepatocellular carcinoma and intrahepatic cholangiocarcinoma (CHC).
*Combined hepatocellular carcinoma and intrahepatic cholangiocarcinoma (CHC).


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*[[Metastasis]].
*[[Metastasis]].
*[[Cholangiocarcinoma]].
*[[Cholangiocarcinoma]].
*[[Hemangioma]].
*[[Liver hemangioma]].


===Tabular comparison===
===Tabular comparison===
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! Images
! Images
|-
|-
| Hepatic [[hemangioma]]
| [[Hepatic hemangioma]]
| similar to normal liver parenchyma, red (hemorrhagic), well-circumscribed
| similar to normal liver parenchyma, red (hemorrhagic), well-circumscribed
| spaces lined by benign endothelial cells
| spaces lined by benign endothelial cells
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| multiple, white lesions
| multiple, white lesions
| variable, usu. tubular (glandular) with pseudostratified hyperchromatic nuclei
| variable, usu. tubular (glandular) with pseudostratified hyperchromatic nuclei
| CK7-, [[CK20]]-, HepPar-1-, CK19-
| CK7-, [[CK20]]+ (colorectal), HepPar-1-, [[CK19]]-
| [[colorectal carcinoma]] most common
| [[colorectal carcinoma]] most common
| [[Image:Secondary_tumor_deposits_in_the_liver_from_a_primary_cancer_of_the_pancreas.jpg | thumb| center| 150px| Metastases. (WC)]]
| [[Image:Secondary_tumor_deposits_in_the_liver_from_a_primary_cancer_of_the_pancreas.jpg | thumb| center| 150px| Metastases. (WC)]]
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=Benign hepatic neoplasms=
=Benign hepatic neoplasms=
==Bile duct hamartoma==
A. [[File:1 BDH 1 680x512px.tif|Trichrome shows fibrous spaces with dilated ducts (20X).]]
B. [[File:2 BDH 1 680x512px.tif|Bizarre, ramifying tubules with dilatations (100X).]]
<br>
C. [[File:3 BDH 1 680x512px.tif|Bland epithelial linings (400X).]]
D. [[File:4 BDH 1 680x512px.tif|Surrounding tract with tortuous bile ducts & inflammation, likely secondary to hamartomas (200X).]]
Bile duct hamartomas. A. Trichrome shows fibrous spaces with dilated ducts. B. Bizarre, ramifying tubules with dilatations. C. Bland epithelial linings. D. Surrounding tract with tortuous bile ducts & inflammation, likely secondary to hamartomas.
==Bile duct adenoma==
==Bile duct adenoma==
:''Should '''not''' be confused with [[bile duct hamartoma]].''
:''Should '''not''' be confused with [[bile duct hamartoma]].''
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Features:
Features:
*Cystic spaces lined by a mucinous epithelium (simple columnar epithelium with a clear cytoplasm).
*Cystic spaces lined by a mucinous epithelium (simple columnar epithelium with a clear cytoplasm).
*Surrounding dense ovarian like stroma.
DDX:
[[Biliary Intraductal Papillary Neoplasm]]
*no surrounding ovarian stroma
*Intraductal - connects with the biliary tree lumen.


Note:
Note:
*Similar to [[pancreatic mucinous cystadenoma]].
*Similar to [[pancreatic mucinous cystadenoma]].
==Cavernous hemangioma==
A. [[File:1 CAV 1 680x512px.tif|Fibrous foci with increased spaces, hepatocyte focus with nonspecific fibrotic bridge (40X).]]
B. [[File:2 CAV 1 680x512px.tif|Cavernous hemangioma with flat, non-atypical endothelium (200X).]]
<br>
C. [[File:3 CAV 1 680x512px.tif|Tortuous bile ducts/ductules, not to be considered generalized in presence of mass (200X).]]
D. [[File:4 CAV 1 680x512px.tif|Tortuous bile ductsductules, not to be considered generalized in presence of mass (200X).]]
Cavernous hemangioma. A. Fibrous foci with increased spaces, hepatocyte focus with nonspecific fibrotic bridge. B. Cavernous hemangioma with flat, non-atypical endothelium. C. Tortuous bile ductules, not to be considered generalized in presence of mass. D. Tortuous bile ducts, not to be considered generalized in presence of mass.


=Malignant hepatic neoplasms=
=Malignant hepatic neoplasms=
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*Abbreviated ''HCC''.
*Abbreviated ''HCC''.
{{Main|Hepatocellular carcinoma}}
{{Main|Hepatocellular carcinoma}}
==Biliary Intraductal Papillary Neoplasm<ref>{{Cite journal  | Masayuki Ohtsuka, Hiroaki Shimizu, Atsushi Kato, et al., “Intraductal Papillary Neoplasms of the Bile Duct,” International Journal of Hepatology, vol. 2014, Article ID 459091, 10 pages, 2014. doi:10.1155/2014/459091}}</ref>==
===General===
*Rare
*Highest incidence in Far Eastern countries
*Association with hepatolithiasis and clonorchiasis
*Between 50 and 70 years of age
*Slight male predominance
*Intermittent abdominal pain
*Acute cholangitis
*Jaundice
*Biliary counterpart of [[pancreatic intraductal papillary mucinous neoplasm]]
*Biliary counterpart of [[intracholecystic papillary neoplasm]] (gall bladder)
*Construct consumes some cases of biliary cystadenoma/cystadenocarcinoma, biliary papilloma/papillomatosis, intraductal growth type of cholangiocarcinoma and papillary carcinoma of the extrahepatic bile duct.
===Radiology===
*Bile duct dilatation
*Intraductal masses
===Gross===
*Singular, or occasionally multiple, polypoid masses extending into the lumen of a dilated bile duct
*Or multilocular well-defined cystic mass containing mucinous fluid
*Granular or papillary mucosa
*Communication with bile duct may be difficult to confirm
===Microscopic===
*Papillary or villous growth within the lumen of an intra or extrahepatic bile duct
*Papillary fronds with fine vascular cores
*Epithelium types
**Pancreatobiliary
**Intestinal - marked mucin secretion
**Gastric
**Oncocytic types
*Dysplasia
**High or low grade
**Marked variation in histologic grade between different regions of individual tumors
*Common association with invasive cholangiocarcinoma
**Tubular adenocarcinoma
**Mucinous (colloid) carcinoma (often in association with the intestinal type).
====DDX====
*[[Biliary Mucinous Cystic Neoplasm]]
***Epithelium is surrounded by a distinct ovarian-like stroma.
====Photos====
<gallery>
Image:BileDuct IntraductalPapillaryNeoplasm LP CTR.jpg|Bile Ducts - Intraductal Papillary Neoplasm - Low power (SKB)
Image:BileDuct IntraductalPapillaryNeoplasm MP CTR.jpg|Bile Ducts - Intraductal Papillary Neoplasm - Medium power (SKB)
Image:BileDuct IntraductalPapillaryNeoplasm HP CTR.jpg|Bile Ducts - Intraductal Papillary Neoplasm - High power (SKB)
Image:BileDucts IntraductalPapillaryNeoplasm NonMucinousType LP PA.jpg|Bile Ducts - Intraductal Papillary Neoplasm - Low power (SKB)
Image:BileDucts IntraductalPapillaryNeoplasm OncocyticType HP PA.jpg|Bile Ducts - Intraductal Papillary Neoplasm - High power (SKB)
Image:BileDucts IntraductalPapillaryNeoplasm NonMucinousType HP2 PA.jpg|Bile Ducts - Intraductal Papillary Neoplasm - High power (SKB)
</gallery>
A. [[File:1 papillary cbd aca 1 680x512px.tif| Intraductal papillary neoplasm of common bile duct with associated invasive carcinoma.]]
B. [[File:2 papillary cbd aca 1 680x512px.tif| Intraductal papillary neoplasm of common bile duct with associated invasive carcinoma.]]
<br>
C. [[File:3 papillary cbd aca 1 680x512px.tif| Intraductal papillary neoplasm of common bile duct with associated invasive carcinoma.]]
D. [[File:4 papillary cbd aca 1 680x512px.tif| Intraductal papillary neoplasm of common bile duct with associated invasive carcinoma.]]
<br>
E. [[File:5 papillary cbd aca 1 680x512px.tif| Intraductal papillary neoplasm of common bile duct with associated invasive carcinoma.]]
F. [[File:6 papillary cbd aca 1 680x512px.tif| Intraductal papillary neoplasm of common bile duct with associated invasive carcinoma.]]
Intraductal papillary neoplasm of common bile duct with associated invasive carcinoma. A. The papillary tumor comprises mostly variably dilated acini. B. Tumor also shows areas of micropapillae. C. Some areas within the non-invasive tumor showed necrosis, with the black pyknotic nuclei amid red debris. D. Definite invasion was established low power by glands headed in perpendicular directions. E. Embedded in fibroblastic response are non-acinar walls and isolated epithelial groups. F. Also embedded in fibroblastic response are flat glands with nuclei showing loss of polarity (lack of respect for lateral intercellular borders shown by variable orientation to base of gland).
Notes -
*Reflect on the known marked variation in histologic grade between different regions of individual tumors when rendering an opinion on a small biopsy specimen.
*Consider the possibility of an invasive component and submit tissue generously.
See also:
PubCan [http://www.pubcan.org/printicdotopo.php?id=5755]


==Cholangiocarcinoma==
==Cholangiocarcinoma==
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==Hepatic metastasis==
==Hepatic metastasis==
{{Main|Metastasis}}
{{Main|Liver metastasis}}
*[[AKA]] ''liver metastases''.
*[[AKA]] ''liver metastases''.
*[[AKA]] ''metastatic liver disease''.
*[[AKA]] ''metastatic liver disease''.
===General===
==Hematopoietic tumors==
*Metastases are very common - often from the gastrointestinal tract, e.g. [[colorectal cancer]]. 
A [[File:1 MM 1 Covenant 680x512px.tif|One liver core was normal (Row 1 Left 40X).]]
**Most liver masses in are not biopsied... as a primary lesion is evident.<ref>OA. 29 November 2009.</ref>
<br>
*Dependent on the extent of disease, [[CRC]] metastatic to the liver may be curable with a liver resection.
B [[File:2 MM 1 Covenant 680x512px.tif|A triad with a proliferated bile ductule, otherwise normal (Row 1 Right 400X).]]
**Peritoneal disease, i.e. a malignant peritoneal nodule, in the context of liver metastases does poorly, and is considered a contraindication to liver resection.<ref name=pmid8511077>{{Cite journal  | last1 = Elias | first1 = D. | last2 = Rougier | first2 = P. | last3 = Mankarios | first3 = H. | last4 = Fahrat | first4 = F. | last5 = Lasser | first5 = P. | title = [Resectable liver metastases and synchronous extra-hepatic sites of colorectal origin. Surgical indications]. | journal = Presse Med | volume = 22 | issue = 11 | pages = 515-20 | month = Mar | year = 1993 | doi =  | PMID = 8511077 }}
<br>
</ref>
C [[File:3 MM 1 Covenant 680x512px.tif|The other core showed a mass of tumor mashed against normal liver (Row 2 Left 40X).]]
*It is important to consider [[germ cell tumour]]s in the DDx as these may be curable with chemotherapy.
<br>
*Clear cell variant of HCC may be misdiagnosed as metastatic [[clear cell carcinoma]].
D [[File:4 MM 1 Covenant 680x512px.tif|Tumor cells showed round to ovoid nuclei without pattern and with grey cytoplasm that proved to be CD138 positive (Row 2 Right 400X).]]
*Interhepatic cholangiocarcinoma is an adenocarcinoma - it may look like a metastatic lesion.
<br>
<br>
Further reading:
Plasmacytoma appearing as a tumor mass. A. One liver core was normal. B. A triad with a proliferated bile ductule, otherwise normal. C. The other core showed a mass of tumor mashed against normal liver. D. Tumor cells showed round to ovoid nuclei without pattern and with grey cytoplasm that proved to be CD138 positive.
*{{Cite journal  | last1 = Anders | first1 = RA. | last2 = Kamel | first2 = IR. | title = Biopsy considerations in the diagnosis of hepatic masses. | journal = Clin Gastroenterol Hepatol | volume = 5 | issue = 5 | pages = 541-4 | month = May | year = 2007 | doi = 10.1016/j.cgh.2007.02.028 | PMID = 17478344 }}


===Gross pathology/radiology===
A. [[File:1 B cell lym liver 1 680x512px.tif|Apparent inflamed fibrous tract with lobular inflammatory collections in adjacent liver (Row 1 Left 40X).]]
*Multifocal or solitary.
<br>
**Classically multifocal.
B. [[File:2 B cell lym liver 1 680x512px.tif|Apparent inflamed fibrous band between two relatively hepatocyte regions (Row 1 Right 40X).]]
<br>
C. [[File:3 B cell lym liver 1 680x512px.tif|Apparent piecemeal necrosis with bile ductular proliferation (Row 2 Left 200X).]]
<br>
D. [[File:4 B cell lym liver 1 680x512px.tif|Apparent portal inflammation with unaffected interlobular bile duct (Row 2 Right 200X).]]
<br>
E. [[File:5 B cell lym liver 1 680x512px.tif|Apparent lobular infiltrate with small masse.]]
<br>
F. [[File:6 B cell lym liver 1 680x512px.tif|Proof is at high power. All cells are similar to macrophages but are too closely crowded to be macrophages. The monomorphism (one type of cell) should inspire immunohistochemical stains, which showed the patient had a B cell lymphoma.]]
<br>
B cell lymphoma mimicking hepatitis with fibrosis. A. Apparent inflamed fibrous tract with lobular inflammatory collections in adjacent liver. B. Apparent inflamed fibrous band between two relatively hepatocyte regions. C. Apparent piecemeal necrosis with bile ductular proliferation. D. Apparent portal inflammation with unaffected interlobular bile duct. E. Apparent lobular inflammation with collections a bit too large for usual lobular inflammation.  F. Proof is at high power. All cells are similar to macrophages but are too closely crowded to be macrophages. The monomorphism (one type of cell) should inspire immunohistochemical stains, which showed the patient had a B cell lymphoma.


<gallery>
[[File:5 02965636298621 sl 1.png|Malignant B cell lymphoma, NOS, in a 63 year old man’s liver]]
Image: Secondary_tumor_deposits_in_the_liver_from_a_primary_cancer_of_the_pancreas.jpg |Hepatic metastases (pancreas). (WC)
[[File:5 02965636298621 sl 2.png|Malignant B cell lymphoma, NOS, in a 63 year old man’s liver]]
</gallery>
[[File:5 02965636298621 sl 3.png|Malignant B cell lymphoma, NOS, in a 63 year old man’s liver]]
 
[[File:5 02965636298621 sl 4.png|Malignant B cell lymphoma, NOS, in a 63 year old man’s liver]]
===Microscopic===
[[File:5 02965636298621 sl 31.png|Malignant B cell lymphoma, NOS, in a 63 year old man’s liver]]
Features:
[[File:5 02965636298621 sl 6.png|Malignant B cell lymphoma, NOS, in a 63 year old man’s liver]]
*Histologic features are dependent on primary and degree of differentiation.
<br>
The classic liver metastasis ([[colorectal carcinoma]]):
Malignant B cell lymphoma, NOS, in a 63 year old man’s liver. No other specimens were available for further classification. A. Tumor expands a triad and occupies parenchymal regions. B. Bounding a bile duct, modestly sized round to reniform lymphoid cells, many without nucleoli, accompany small round lymphocytes. Some of the larger cells have clefts (arrows). C. CD3 stain shows many of the lymphoid cells are intercalated reactive T cells. D. Ki67 shows less than half the tumor cells, mostly the larger ones, are in proliferative phase, arguing against the notion of a high grade B cell lymphoma. E. CD79A establishes B cell phenotype (CD20 was also positive). F. That the tumor cells are BCL2 positive evinces B cell neoplasia. The cells were CD10, BCL6, and cyclin D1 negative, militating against mantle cell lymphoma and CLL, with no follicular origin identified.
*Gland forming columnar shaped cells with pseudostratified hyperchromatic cigar-shaped nuclei.
 
DDx:
*[[Cholangiocarcinoma]].
*[[Hepatocellular carcinoma]], pseudoglandular.<ref name=pmid2440554>{{Cite journal  | last1 = Kondo | first1 = Y. | last2 = Nakajima | first2 = T. | title = Pseudoglandular hepatocellular carcinoma. A morphogenetic study. | journal = Cancer | volume = 60 | issue = 5 | pages = 1032-7 | month = Sep | year = 1987 | doi =  | PMID = 2440554 }}</ref>
 
====Image====
<gallery>
Image:Adenocarcinoma_liver_metastasis.jpg | Liver metastasis - adenocarcinoma. (WC/Nephron)
</gallery>
 
===IHC===
*Metastases are typically negative for ''HepPar-1''.
**HepPar-1 (hepatocytes paraffin antibody 1) - labels hepatocellular mitochondria.<ref name=pmid12502967>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.</ref>
 
Note:
*If a primary is already established by pathology and the clinical impression is a metastasis, it isn't necessary to do IHC if the morphology of the lesion in the liver is compatible with the established primary.
===Sign out===
<pre>
LIVER, PORTION OF SEGMENTS 2 AND 3, RESECTION:
- METASTATIC ADENOCARCINOMA.
-- RESECTION MARGIN CLEARANCE 2 MM.
- LIVER STEATOSIS, MILD.
</pre>
 
====Micro====
The section show liver parenchyma with an invasive adenocarcinoma. The adenocarcinoma
has well formed glands with dirty necrosis.  The nuclei are appear crowded and
have an ellipsoid shape.  Focally, zones of necrosis are present. See background liver.


BACKGROUND LIVER (BASED ON H&E ONLY)<br>
[[File:4 89735893919405 sl 1.png| High grade B cell lymphoma involving liver]]
Fibrosis: not identified.<br>
[[File:4 89735893919405 sl 2.png| High grade B cell lymphoma involving liver]]
Fibrous septa: absent.<br>
[[File:4 89735893919405 sl 3.png| High grade B cell lymphoma involving liver]]
Septa with curved contours: absent.<br>
[[File:4 89735893919405 sl 4.png| High grade B cell lymphoma involving liver]]
Large droplet steatosis (% of hepatocytes): mild (20%).<br>
[[File:4 89735893919405 sl 5.png| High grade B cell lymphoma involving liver]]<br>
Ballooning of hepatocytes: not identified.<br>
High grade B cell lymphoma involving liver in a 77 year old woman. A. A band of cancer abuts fibrotic liver with steatosis. B. Cancer cells show primitive, round to ovoid, variably sized, dark nucleoli and an aberrant mitoses. Cytoplasm is scant. C. Cancer cells are CD79a positive. D. Most cancer cell nuclei were positive for Ki-67, overall about 80%. E. A minority of cancer cells are CD10 positive.
Mallory-Denk bodies: not identified.<br>
Portal inflammation: present, mild.<br>
Interface activity: not identified.<br>
Lobular necroinflammation: not identified.<br>
Ducts: present in normal numbers.<br>
Duct injury: not identified.<br>
Ductular reaction: not identified.<br>
Cholestasis: present peritumoural, otherwise absent.<br>
Terminal hepatic venules: present.<br>
Ground glass cells with routine stains: not identified.


=See also=
=See also=
Mitchell
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