Rish Pai - FSP Biopsy Interpretation of Liver Tumors -Biopsy... · 2019-07-05 · 1xfohl plqlpdo wr plog qxfohdu dw\sld 5hwlfxolq /lplwhg uhwlfxolq orvv uhodwlyho\ wklq sodwhv 0rghudwho\

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©2017 MFMER | slide-1

Biopsy interpretation of liver tumorsRish K. Pai MD, PhDProfessor of Laboratory Medicine & PathologyMayo Clinic ArizonaFlorida Society of Pathology Summer [email protected]


Liver mass biopsies: Diagnostic issues

• Cirrhotics versus non-cirrhotics

• Malignant tumor in the liver• How to approach these biopsies and confirm or exclude HCC• Subtypes of HCC and mixed tumors• Well-differentiated HCC

• Recognize and correctly classify benign lesions• Recognize lesional tissue• Hepatocellular adenoma• Focal nodular hyperplasia


Liver mass biopsies: Upfront work

•Have standard protocols for a biopsy of a liver mass

• If multiple cores are taken, separate into differentblocks

• If a big core, divide and separate into two blocks

•Cut unstained slides upfront to avoid wasting tissue

•Don’t use up all the tissue:• Reserve tissue for molecular testing

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Cirrhotic liver• Hepatocellular carcinoma

• Cholangiocarcinoma

• Mixed HCC/Cholangiocarcinoma

• Macroregenerative nodule(only on explant)

• Dysplastic nodule (only onexplant)

Non-Cirrhotic liver• < 50 y:

• Hepatocellular adenoma

• Focal nodular hyperplasia

• Hepatocellular carcinoma

• Other primary tumors

• Metastases

• > 50 y:• Metastases

• Hepatocellular carcinoma

• Cholangiocarcinoma

• Focal nodular hyperplasia

• Other primary tumors

Classification of liver tumors: Context!


A note on Dysplastic nodules

• Dysplastic nodule is only diagnosed in the setting ofknown cirrhosis – very rare to diagnose on needlebiopsy (only safely diagnose on explants/resections).

• Dysplastic nodule:• Foci of small cell change (increased N:C ratio)• Focal loss of reticulin• Increased arteries within the lesion


Screening for HCC: Imaging for pathologists

• Ultrasound for cirrhotic patients every 6 months• 94% sensitivity for HCC (only 63% for early HCC)

• CT or MRI is then performed to further classify and determine extent of disease

• HCCs have increased arteries compared to surrounding liver: Brighter inarterial phase and darker in portal venous phase

Arterial phase Equillibrium Portal venous phase

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Cirrhotic liver: Screening for HCC• LI-RADS system (also known as OPTN classification)

Adv Anat Pathol. 2015 Sep;22(5) 314-22.


Title

• Text


• Extended Toronto Criteria (for those patients beyond Milan criteria: single tumor ≤ 5cm, 2-3 tumors none >3cm, no vascular invasion and/or extrahepatic spread)

• Tumor confined to liver• No radiologic evidence of biliary or venous thrombus• No cancer-related symptoms• Biopsy of the largest tumor is not poorly differentiated

• Patients meeting this extended criteria did as well as those withinMilan criteria

Cirrhotic liver: HCC

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• Macrotrabecular pattern of growth is also associated withpoor prognosis

Grading Hepatocellular carcinomaGrade Global assessment Criteria

1 Well differentiated • Tumor cells resemble normal liver• Hepatocellular adenoma or dysplastic

nodule may have to be distinguished

• Cytoplasm: ranges from abundant and eosinophilic to moderate and basophilic

• Nuclei: minimal to mild nuclear atypia• Reticulin: Limited reticulin loss, relatively thin

plates2 Moderately

differentiated• Clearly malignant. • Morphology still suggests hepatocellular

differentiation.

• Cytoplasm: ranges from abundant and eosinophilic to moderate and basophilic

• Nuclei: moderate nuclear atypia; occasional multinucleated tumor cells are acceptable

• Reticulin: More prominent loss3 Poorly differentiated • Clearly malignant.

• Morphology is not specific for hepatocellular differentiation

• Cytoplasm: ranges from moderate to scant, usually basophilic

• Nuclei: marked nuclear pleomorphism, may include anaplastic giant cells

• Reticulin: Variable

• 68 year old cirrhotic male with an atypical liver mass by imaging.

Case 1:


Masses in Cirrhotic liver: Approach• Hepatocellular? Gland forming? Both? Not sure?

Histology Hepatocyte markers

Glypican-3 Reticulin Others

Hepatocellular Maybe (high-grade tumors)

Maybe (high and low-grade tumors)

Maybe (low-grade tumors)

Not usually

Gland forming Not usually No No Sometimes

Both Yes Yes No Yes (CK7, CK19, MOC-31)

Not sure Yes Yes No Yes (CK7, CK19, others)

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• Abnormal architecture: thickened trabecularcords

• Increased N:C ratio

• Nuclear atypia (interpret with caution)

• Increased arteries within the lesion

• Abundant pseudoacinar structures

Histologic features of HCC

Moderately differentiated hepatocellular carcinoma

Growth patterns in HCCMacrotrabecular pattern

Pseudoacinar pattern

Trabecular pattern

Solid pattern

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Bile formation in a malignant tumor = HCC

• 68 yo cirrhotic male with a 2.5 cm lesion withwashout but no arterial enhancement.

Case 2:

Cirrhotic background

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•Clearly hepatocellular

•Favor neoplastic (probably HCC)• Increased N:C ratio• Pseudoacinar structures• Nuclear atypia (least useful)• Arteriolization

•How to prove malignancy?

Case 2:


Marker HCC G1 HCC G2 HCC G3 Caveat

Reticulin (loss or thickened cords)

++(may be focal)

+++ +++Steatosis can distort reticulin, can be difficult to interpret

CD34+++

(sinusoidal expression)

+++(sinusoidal expression)

+++(sinusoidal expression)

May be positive in dysplastic nodules and adenomas

Glypican 3++

(62%)+++

(80%)+++

(85%)Positive in some AdenoCA and germ cell tumors

Glutamine synthetase(Diffuse)

++(60%)

N/A N/ADiffuse GS can be seen in some HCA, dysplastic nodules, AdenoCA

HSP70(nuclear)

++(60%)

N/A N/AHigh background, occasionally dysplasticnodules and AdenoCA

Modern Pathology (2016) 29, 283–292

Markers of hepatocellular malignancy

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HSP70 Glypican-3

CD34Glutamine synthetase

Reticulin: Thickened cords, fragmentation

Normal reticulin


• 68 yo cirrhotic male with a 2.5 cm lesion withwashout but no arterial enhancement.

• Diagnosis: Well-differentiated hepatocellularcarcinoma (based on reticulin stain)

Case 2:

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Mild steatosis Moderate steatosis Severe steatosis


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*

* Non-Cirrhotic liver

Morphologic variants of HCC

Gastroenterol Clin North Am. 2017 Jun;46(2):365-391.

Steatohepatitic HCC• Occurs mainly in patients with underlying NASH• 50% of tumor must have steatohepatitic features• No affect on prognosis.

Clear cell HCC• Clear cells filled

with glycogen• Better prognosis

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Cirrhotic-like HCC• Difficult to identify

grossly and radiologically

• HCC grows in a small nodular pattern


• 65 yo cirrhotic male with an atypical liver mass during HCC screening.

Case 3:

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Cholangiocarcinoma

HCC area? Solid cholangio?


• Hepatocellular? Gland forming? Both? Not sure?Histology Hepatocyte

markersGlypican-3 Reticulin Others




Not usually

Gland forming Not usually No No Sometimes



Masses in Cirrhotic liver: Approach


Marker HCC G1 HCC G2 HCC G3 Caveat

Hep-par1 (HSA)+++

(100%)+++

(98%)++

(64%)Positive in some

AdenoCA

Arginase-1+++

(100%)+++

(100%)+++

(97%)Positive in some

AdenoCA

CD10 or pCEA+++

(canalicular)(92%)

+++(canalicular)

(88%)

+(canalicular)

(54%)

Membranous and cytoplasmic reactivity

in many tumors

BSEP+++

(canalicular)(92%)

+++(canalicular)

(95%)

+(canalicular)

(45%)Not well characterized

Arch Pathol Lab Med. 2015;139:1028–1034;

Markers of Hepatocyte differentiation

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Marker HCC Cholangiocarcinoma

CK7 +/- +++

CK19 +/- +++

Hep-Par1/HSA +++ -

Arginase1 ++++ -

pCEA or CD10 Canalicular Variable but no canalicular

Glypican-3 ++ +/-

MOC-31 - ++

HCC versus Cholangiocarcinoma


CK7: Hepatoid area CK7: Cholangio area

CD10: Normal liver

CD10

Hep-par1/HSA Arginase1

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Glypican-3: Hepatoid area

Glypican-3: Cholangio area


• 65 yo cirrhotic male with an atypical liver mass duringHCC screening.

• Diagnosis: Combined hepatocellular carcinoma andcholangiocarcinoma (cHCC-CCA)

Case 3:


• Combined HCC/Cholangiocarcinoma (cHCC-CCA)• Primary liver cancer with distinct HCC and CCA components• Must occurring within the same tumor nodule.• H&E based diagnosis with IHC support; no cutoff %• Higher frequency after transarterial chemoembolization

• Intermediate cell carcinoma• Primary liver cancer containing intermediate cells only• H&E and IHC based diagnosis (very rare)

• Other variants such as combined HCC/Cholangiocarcinoma with stem cell features and cholangiolocarcinoma are no longer recognized as distinct entities

• Cholangiolocarcinoma is recognized as a subtype of intrahepaticcholangiocarcinoma

Brunt et al. Hepatology. 2018

Combined HCC-cholangiocarcinomacHCC-CCA

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• Hepatocellular? Gland forming? Both? Not sure?


Glypican-3 Reticulin Others




Not usually

Gland forming Not usually No No Yes (CK7 mainly)



Masses in Cirrhotic liver: Approach


• Hepatoid/heptocellular? Gland forming? Can’t tell?


Glypican-3 Cytokeratins Other markers

Hepatoid/hepatocellular Yes Yes (interpret with caution)

Maybe No (but depends on history)

Gland forming No No Yes (CK7, CK20) Yes: Usually CDX2, SATB2, TTF1 (others depend on history)

Can’t tell Yes Maybe Yes (Cam5.2, CK7, others)

Not yet, unstainedslides, do IHC in phases

Malignant masses in Non-cirrhotic liver


• 53 yo female with a liver mass. Liver is non-cirrhotic

Case 4:

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• Hepatoid/hepatocellular? Gland forming? Can’t tell?Histology Hepatocyte

markersGlypican-3 Cytokeratins Other markers

Hepatoid/ hepatocellular

Yes Yes (interpret with caution)

Maybe No (but depends on history)

Gland forming No No Yes (CK7, CK20) Yes: Usually CDX2, SATB2, TTF1 (others depend on history)

Can’t tell Yes Maybe Yes (Cam5.2, CK7, others)

Not yet, unstainedslides, do IHC in phases

Malignant masses in Non-cirrhotic liver


CK7 Hep-par1

Glypican-3 Arginase-1


• Cholangiocarcinoma?

• Metastatic hepatoid carcinoma?

• Combined HCC-cholangiocarcinoma?

• Variant of hepatocellular carcinoma?

Diagnosis?

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Mod Pathol. 2013 Jun;26(6):782-91.

Scirrhous Hepatocellular Carcinoma

CK7 CD68

Fibrolamellar Carcinoma(DNAJB1-PRKACA Fusion)

Normal liver

Abnormal

Case 5: 40 yo female with a liver mass

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Features• Sinusoidal dilatation• Portal tract-like structures

with inflammation, multiple arteries and rare bile ductules (no true bile ducts)

• No fibrous bands or larger arteries


Reticulin: Normal trabecular thickness


Differential Fibrous bands with large arteries

Isolated “naked” small arteries

Bile ductules

Trabecular thickness

Well-differentiated Hepatocellular carcinoma

Not usually Yes No Abnormal

Hepatocellularadenoma

No Yes Sometimes Normal

Focal nodular hyperplasia

Yes Rarely Yes Normal

Low-grade” hepatocellular masses in Non-cirrhotic liver

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• Increasing incidence since widespread use of oralcontraceptives

• Other risk factors: anabolic steroids, glycogen storagedisease, FAP, MODY3

• F>>>M

• Low-risk of malignant transformation

• Symptoms: pain, bleed, infarct, rupture

• Treatment: Avoid OCP and pregnancy; surgery

Hepatocellular adenomas (HCA)


• Morphologic and molecular subtypes• HNF1a mutated HCA

• Biallelic mutations in HNF1A (90% somatic, 10% germline)

• Inflammatory HCA• Constitutive activation of Stat3 due to mutations in pro-inflammatory

pathways• May also develop CTNNB1 mutations and progress to HCC

• b-catenin mutated HCA• 3 different mutation types occur in CTNNB1 (weakly active, mod active, and

highly active)• High risk of malignant transformation to HCC

• HCA-unclassified

Hepatocellular adenomas (HCA)


HNF1α mutated HCA

InflammatoryHCA

β-catenin mutated HCA

Unclassified HCA

β-catenin mutated Inflammatory HCA

~35%

~40%

~15%

~10%

Hepatocellular adenomas (HCA): Subtypes

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Hepatocellular adenomas: subtypesSubtype Histologic features LFABP CRP/SAA Glutamine

Synthetaseβ-catenin

H-HCA • Steatosis Loss Patchy Perivenular Membranous

IHCA • Inflamed portal-tractlike structures with arteries

• Ductular reaction• Sinusoidal dilatation

Retained Diffuselypositive

Perivenular Membranous

β-IHCA • Inflamed portal-tractlike structures with arteries

• Ductular reaction• Sinusoidal dilatation

Retained Diffuselypositive

Diffuse or “Starry sky”

Rare positive nuclei, may be membranous

β-HCA • Atypia Retained Patchy Diffuse or “starry sky”

Rare positive nuclei

U-HCA • Variable Retained Patchy Perivenular Membranous

Features• Sinusoidal dilatation• Portal tract-like

structures with inflammation, multiplearteries and rare bileductules (no true bile ducts)

• No fibrous bands orlarger arteries

Favor inflammatory HCA

C-reactive protein

LFABP

Glutamine synthetase

Beta-catenin

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• 40 yo female with a liver mass

• Diagnosis: Inflammatory hepatocellular adenoma (nofeatures suggestive of beta-catenin mutation)

Case 5:


Does classification matter?

• Subtypes have different risk of malignant degeneration (β-HCA and β-IHCA) and associations.

• But…… classification hasn’t changed treatment guidelines

• Treatment algorithm:• Resect > 5cm to prevent bleeding and malignancy• Resect “adenomas” in men• Resect those growing after withdrawal of oral

contraceptives


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Case 6: 28 yo female with multiple liver nodules



CRP Glutamine synthetase

Beta catenin LFABP

Inflammatory HCA

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CRP Glutamine synthetase

Beta catenin LFABP

HNF1α inactivated HCA

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HNF1α inactivated HCA Inflammatory HCA


• Multiple HCAs – usually greater than 10 visualized by MRI• May have many micro-nodules (usually identified by

IHC)

• Any subtype may occur but usually H-HCA and IHCA

• Risk of malignant transformation depends on HCA subtype

• When innumerable, liver transplantation may beconsidered

Hepatic adenomatosis

• 53 year old non-cirrhotic male with a liver mass

Case 7:

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Mostly preserved?Focal fragmentation


Glutamine synthetase Glypican-3

HSP-70Beta-Catenin

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• 53 year old non-cirrhotic male with a liver mass.

• Diagnosis?• Beta-catenin mutated HCA in a male?• Well differentiated hepatocellular neoplasm of uncertain

malignant potential/Atypical hepatocellular neoplasm?• Well-differentiated HCC?

Case 7:


• Well differentiated hepatocellular neoplasm of uncertain malignantpotential/Atypical hepatocellular neoplasm

• On resection: try to classify definitively as either HCA or HCC

Hum Pathol. 2014 Mar;45(3):658-60.

Case 7:

Case 7: Resection – Well-diff HCC

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• 60 yo male with a history of colorectal carcinoma with 5liver lesions

Case 8:

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CK7: Highlights ductules

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Differential Fibrous bands with large arteries

Isolated “naked” small arteries

Bile ductules

Trabecular thickness

Well-differentiated Hepatocellular carcinoma

Not usually Yes No Abnormal

Hepatocellularadenoma

No Yes Sometimes Normal


Yes Rarely Yes Normal

Low-grade” hepatocellular masses in Non-cirrhotic liver


Modern Pathology (2014) 27, 62–72

FNH versus Inflammatory HCA


Liver international. 2009.

Glutamine synthetase in FNH

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Pseudo map-like Map-like

FNH versus Inflammatory HCA

Glutamine synthetase


Glutamine synthetase: Geographic/map-like pattern

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• 60 yo male with a history of colorectal carcinoma with 5liver lesions

• Diagnosis: Focal nodular hyperplasia

Case 8


• FNH nodules are thought to develop as localized overgrowth ofliver parenchyma resulting from an anomalous arterial branch.

• Cavernous hemangiomas occur in a significant % of patients with FNH

• Usually > 5cm, those < 3cm may not have a central scar

• OCS may promote growth

• Rarely cause symptoms

• Manage conservatively and only resect the rare symptomatic FNH or a lesion where the imaging is not typical



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• Cirrhotics versus non-cirrhotics

• Malignant tumor in the liver• How to approach these biopsies and confirm or exclude HCC• Subtypes of HCC and mixed tumors• Well-differentiated HCC

• Recognize and correctly classify benign lesions• Recognize lesional tissue• Hepatocellular adenoma• Focal nodular hyperplasia

Liver mass biopsies: Diagnostic issues


Questions & Discussion

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Documents

Rish Pai - FSP Biopsy Interpretation of Liver Tumors -Biopsy... · 2019-07-05 · 1xfohl plqlpdo wr plog qxfohdu dw\sld 5hwlfxolq /lplwhg uhwlfxolq orvv uhodwlyho\ wklq sodwhv 0rghudwho\