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Hepatocellular Mass Lesions – weighty mattersJOHN HART, M.D.SURGICAL PATHOLOGY & HEPATOLOGY

UNIVERSITY OF CHICAGO MEDICAL CENTERjohn.hart@uchospitals.edu

Source: GLOBOCAN 2008 v2.0 http://globalcancermap.com/

Mass Lesions of the LiverCIRRHOTIC LIVER

• Focal fibrosis

• Macroregenerative nodule

• Dysplastic nodule

• Hepatocellular carcinoma (HCC)

• Cholangiocarcinoma

• (metastatic tumor)

NORMAL LIVER

• Metastatic tumor

• Focal nodular hyperplasia

• Hepatocellular adenoma

• Hepatocellular carcinoma

• Cholangiocarcinoma

• Combined HCC/cholangioCa

• Other (cystic) biliary tumors

• Angiomyolipoma

• Epithelioid hemangioendothelioma

• Other mesenchymal tumors

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Hepatocellular Carcinoma in Cirrhosis• High risk:

– Alcoholic steatohepatitis

– Hereditary hemochromatosis

– Chronic HCV hepatitis

– Chronic HBV hepatitis

• Intermediate risk:

– Non-alcoholic steatohepatitis

– Autoimmune hepatitis

– Alpha-1-antitrypsin deficiency

• Low risk:

– Wilson disease

– Primary biliary cirrhosis

– Primary sclerosing cholangitis

Diagnostic algorithm for HCC by the American Association for the Study of Liver Diseases (AASLD)

practice guidelines on the management of HCC in 2010 (Adopted from Bruix J et al).

72 year old male with alcoholic cirrhosis

and an increased serum AFP

2.0 cm mass with atypical imaging characteristics

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reticulin stain

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Hepatocellular Carcinoma – pseudoacinar type

Hepatocellular Carcinoma – pseudoacinar type

Hepatocellular Carcinoma – clear cell type

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Mass Lesions of the LiverCIRRHOTIC LIVER

• Focal fibrosis

• Macroregenerative nodule

• Dysplastic nodule

• Hepatocellular carcinoma

• Cholangiocarcinoma

• (metastatic tumor)

NORMAL LIVER

• Metastatic tumor

• Focal nodular hyperplasia

• Hepatocellular adenoma

• Hepatocellular carcinoma

• Cholangiocarcinoma

• Combined HCC/cholangioCa

• Other (cystic) biliary tumors

• Angiomyolipoma

• Epithelioid hemangioendothelioma

• Other mesenchymal tumors

Focal Nodular HyperplasiaClinical Features

• Presentation:

– Asymptomatic if < 10 cm (majority)

– Abdominal pain, palpable mass

– Serum AFP level is NOT elevated

• Predisposing factors: None identified

• OCP may cause increase in size

• Central scar by CT or MRI:

– Also seen in fibrolamellar carcinoma

– Only present in larger lesions

• Can be multiple

• No malignant potential

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Focal Nodular HyperplasiaHistologic Features

• Irregular pattern of thin fibrous septa – “focal cirrhosis”

• Arteries & proliferating bile ductules in the fibrous septa

• No true portal tracts

• Central scar with large myxomatous vessel

• Normal hepatocytes and trabecular pattern

• Thin fibrous septa at interface with surrounding liver,

which is histologically normal

central scar with aberrant vessel

“focal cirrhosis “ pattern

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bile ductular proliferation in fibrous septa

• 100 consult needle biopsy cases

• 81 Female, mean age = 36

• Asymptomatic (70%), abdominal pain

• Original diagnoses:

– 34 FNH / Suggestive / Possible/ FNH vs FLC

– 26 No diagnosis

– 20 Descriptive (centering on fibrosis)

– 10 cirrhosis or regenerative nodule

– 3 hepatic adenoma

– 7 miscellaneous diagnoses

Human Pathology 2005; 36:1210

Human Pathology 2005; 36:1210-16.Diagnostic Features:

Ductular reaction – focal (50%) or prominent (50%)

Fibrosis – thick septa (67%) or thin septa (33%)

Abnormal arteries (98%)

Cholate stasis (94%)

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36 y.o. F with incidental 3 cm mass in a normal liver

normal liver

“cirrhotic” appearing liver

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Focal nodular hyperplasiaimmunohistologic markers

• CK7– Highlights proliferating ductules

– Biliary metaplasia of some hepatocytes

• CD34– Patchy sinusoidal endothelial reactivity

– No diagnostic utility

• Glutamine synthetase– Characteristic “map-like” reactivity

– Very distinctive in almost all cases

Bioulac-Sage P et al. Over-expression of glutamine synthetase in focal nodular

hyperplasia: a novel easy diagnostic tool in surgical pathology. Liver Int 2009; 29:459-65.

glutamine synthetase – normal liver

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Focal nodular hyperplasia

Glutamine synthetase

Focal nodular hyperplasia

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Glutamine synthetase

Glutamine SynthetaseCONDITION STAINING PATTERN

Normal Distinct zone 3 perivenular cuff

Cirrhosis Patchy & weak periseptal

Focal nodular hyperplasia Strong map-like (geographic)

Hepatocellular adenoma Perivenular or weak & patchy or strong diffuse*

Hepatocellular carcinoma Perivenular or weak & patchy or strong diffuse*

Joseph NM, Ferrell LD, Jain D, Torbenson MS, Wu TT, Yeh MM, Kakar S.

Modern Pathol 2014; 27(1):62-72.

*beta-catenin activated

hepatocellular adenoma

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glutamine synthetase in hepatocellular adenoma

focal nodular hyperplasia

glutamine synthetase in focal nodular hyperplasia

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glutamine synthetase immunostain

cirrhotic liver for comparison with FNH

HCA vs. FNHHepatocellular Adenoma

• Abd. pain due to hemorrhage or/rupture

• Induced by oral contraceptives

• Usually > 10 cm; can be multiple

• Normal serum AFP

• Normal surrounding liver

• Uniform surface or hemorrhage/necrosis

• Interspersed thin walled vessels

• No fibrous septa

• No central scar with aberrant vessel

• Rare reports of malignant change

Focal Nodular Hyperplasia

• Asymptomatic

• Not induced by oral contraceptives

• Usually < 10 cm; can be multiple

• Normal serum AFP

• Normal surrounding liver

• Central scar; no hemorrhage/necrosis

• No interspersed thin walled vessels

• Fibrous septa with bile ductules

• +/- central scar with aberrant vessel

• no risk of malignant change

Hepatocellular Adenoma (HCA)Clinical Features

• Presentation:

– Asymptomatic if < 10 cm

– Abdominal pain

– Rupture with hemorrhage (SHH pathway activation)

– Serum AFP level is NOT elevated

• Predisposing factors:

– OCP in women, anabolic steroids in men

– May regress if drug is withdrawn

• Radiographic findings:

– Can be multiple

– Distinctive characteristics still being elucidated

• Rare examples of malignant transformation

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Hepatocellular Adenoma (HCA)Histologic Features

• No portal tracts or fibrous septa

• Scattered thin walled vessels

• Normal trabecular growth pattern (reticulin)

• No mitotic figures

• Mild cytologic atypia in scattered cells

• Steatosis is common within the adenoma

• Mild inflammation in some cases

• Hemorrhage and necrosis can occur

• Merges imperceptibly with surrounding liver, which is histologically normal

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reticulin stain

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Hepatocellular adenoma

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Hepatocellular adenoma

reticulin stain

Clinical

features

Histologic

features

Glutamine

synthetase

Liver

Fatty

Acid

Binding

Protein

β-catenin

C-reactive

protein

or

Serum

Amyloid A

HNF1-α

mutated

(40-50%)

No specific

features;

Hepatic

Adenomatosis

Diffuse

steatosis

Perivenular or

Weak & PatchyLost

Membranous

reactivityNegative

β-catenin

exon-3

mutated

(10-15%)

Large size;

malignant

transformation

Cytologic

atypia,

pseudoglands,

cholestasis

Diffusely

positive

Diffusely

positive

Focal

nuclear

reactivity

Negative

Inflam

JAK/STAT

activation

(35-45%)

Obese

Alcohol

Peliosis,

abortive fibrous

septa with

ductules,

inflammation

Perivenular

or

Weak & Patchy

Diffusely

positive

Membranous

reactivityPositive

Unclassified

10%None None

Perivenular

or

Weak & Patchy

Diffusely

positive

Membranous

reactivityNegative

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HCA Normal

Liver Fatty Acid Binding Protein

HCA Normal

HFA mutated HCA (40-50%):

Obese women on OCP

No malignant potential

Loss of LFABP by immuno

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• 35 year old female presents with abdominal pain

• CT scan reveals a 6.5 cm liver mass; no central scar

• No history of chronic liver disease

• Serum AFP = < 5

• Resection performed

Clinical HistoryCase Courtesy of Dr. Benjamin Yan,

Medical College of Wisconsin

C12-1323

Inflammatory (telangiectatic) HCA

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reticulin stain

Peliosis

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inflammation

Abortive fibrous septa with ductules

HCA, inflammatory (telangiectatic) subtype

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Serum amyloid A (or C-reactive protein)

Inflammatory (telangiectatic) HCA

• Occurs primarily in young obese females on OCP

• Histologic features:

– Abortive fibrous septa with proliferating ductules (72%)

– Chronic inflammation in fibrous septa

– Peliosis (60%) and steatosis (53%)

• Can have beta-catenin exon 7/8 mutations:– Negligible risk of malignant transformation

– Diffuse (but often weak) GS expression

– No beta catenin nuclear reactivity

Paradis V et al. Hepatology 2007; 46:140-6.

Clinical

features

Histologic

features

Glutamine

synthetase

Liver

Fatty

Acid

Binding

Protein

β-catenin

C-reactive

protein

or

Serum

Amyloid A

HNF1-α

mutated

(40-50%)

No specific

features;

Hepatic

Adenomatosis

Diffuse

steatosis

Perivenular or

Weak & PatchyLost

Membranous

reactivityNegative

β-catenin

exon-3

mutated

(10-15%)

Large size;

malignant

transformation

Cytologic

atypia,

pseudoglands,

cholestasis

Diffusely

positive

Diffusely

positive

Focal

nuclear

reactivity

Negative

Inflam

JAK/STAT

activation

(35-45%)

Obese

Alcohol

Peliosis,

abortive fibrous

septa with

ductules,

inflammation

Perivenular

or

Weak & Patchy

Diffusely

positive

Membranous

reactivityPositive

Unclassified

10%None None

Perivenular

or

Weak & Patchy

Diffusely

positive

Membranous

reactivityNegative

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Clinical History

• 50 year old obese male with a 14 cm liver mass

• No history of chronic liver disease

• Serum AFP level is normal

• Liver biopsy of mass is performed

S03-13926

S03-24118

DiagnosisNeedle biopsy, liver mass:

– Hepatocellular neoplasm. See comment.

Comment: The differential diagnosis in this case is between well differentiated HCC and HCA. Given the gender of the patient and the size of the mass well differentiated HCC is strongly favored, but firm diagnosis will require examination of the resection specimen.

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β-catenin

β-catenin

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glutamine synthetase – diffuse strong

Clinical

features

Histologic

features

Glutamine

synthetase

Liver

Fatty

Acid

Binding

Protein

β-catenin

C-reactive

protein

or

Serum

Amyloid A

HNF1-α

mutated

(40-50%)

No specific

features;

Hepatic

Adenomatosis

Diffuse

steatosis

Perivenular or

Weak & PatchyLost

Membranous

reactivityNegative

β-catenin

exon-3

mutated

(10-15%)

Large size;

malignant

transformation

Cytologic

atypia,

pseudoglands,

cholestasis

Diffusely

positive

Diffusely

positive

Focal

nuclear

reactivity

Negative

Inflam

JAK/STAT

activation

(35-45%)

Obese

Alcohol

Peliosis,

abortive fibrous

septa with

ductules,

inflammation

Perivenular

or

Weak & Patchy

Diffusely

positive

Membranous

reactivityPositive

Unclassified

10%None None

Perivenular

or

Weak & Patchy

Diffusely

positive

Membranous

reactivityNegative

HCA vs HCC• Worrisome features in an HCA:

– Large size (> 5 cm)

– Male gender

– Prominent nuclear pleomorphism

– β-catenin nuclear reactivity

– Diffuse glutamine synthetase reactivity

• Features for HCC:– Elevated serum AFP

– Mitoses, numerous isolated arterioles

– Loss of reticulin or clearly thickened trabeculae

– Stromal production by tumor cells

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Hepatocellular Carcinoma Origin in “Normal Liver”

• Clinical Features:

– Abdominal pain and/or mass

– Constitutional symptoms

– Serum AFP elevated in only 1/3 of patients

– Search for occult chronic liver disease

• Histologic Features:

– No special histologic features (except for distinctive variants)

– Foci of dysplasia in surrounding liver

HCC in non-cirrhotic liver

Hepatocellular Carcinoma (HCC)Immunohistologic Profile

• pCEA – canalicular staining

• CD10 – canalicular staining

• HepPar1 – granular cytoplasmic staining

• MOC31 – no staining

• Cam 5.2 – cytoplasmic staining

• CD34 – increased in endothelial cells

• TTF-1 – cytoplasmic staining (Dako antibody)

• CK7, CK20, CK19 – negative???

• In situ hybridization for albumin mRNA (Mayo)

• [AFP – cytoplasmic staining]

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Bile production by tumor cells is diagnostic of hepatocellular origin

HepPar1• aka “hepatocyte”; “hepatocyte antigen”

• Developed at the University of Pittsburgh

• Staining characteristics:

– Reactive in > 80% of HCC

– Non-reactive in some poorly differentiated HCC

– Can be patchy (20%)

– Coarse cytoplasmic reactivity

– Can also be reactive in some gastric, pancreatic, gallbladder, and lung adenocarcinomas

• Also reactive in benign hepatocytes, FNH, adenoma, MRN, dysplastic nodule

HepPar-1 normal liver

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70 y.o. male with a 10 cm mass in non-cirrhotic liver

HepPar-1

• 35 year old male with an 18 cm liver mass

• No history of chronic liver disease

• Non-cirrhotic liver

• Normal serum AFP level

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HepPar-1

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Synaptophysin

metastatic well differentiated neuroendocrine tumor

C15-1240 65 y.o. M with a 4 cm liver massNo history of liver diseaseSerum AFP level is normal

Normal liverTumor

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HepPar-1

PAX-8

metastatic renal cell carcinoma

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HepPar-1 False Positive Staining• Lung adenocarcinoma (~10%)

• Esophageal adenocarcinoma (~20%)

• Pancreatic adenocarcinoma (~10%)

• Duodenal (small bowel) adenocarcinoma (~25%)

• Liver (hepatocellular) carcinoma (~80%)

• Stomach (gastric) adenocarcinoma (> 40%)

• Gallbladder adenocarcinoma (~30%)

HepPar-1 False Positive Staining• Stomach (gastric) adenocarcinoma (> 40%)

• Lung adenocarcinoma (~10%)

• Pancreatic adenocarcinoma (~10%)

• Gallbladder adenocarcinoma (~30%)

• Esophageal adenocarcinoma (~20%)

• Duodenal (small bowel) adenocarcinoma (~25%)

• Liver (hepatocellular) carcinoma (~80%)

• 87 year old female undergoing cholecystectomy

• Liver mass in a non-cirrhotic liver

• No history of malignancy

C07-11895

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HepPar-1

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p63

gallbladder adenosquamous carcinoma

HepPar-1 – False Negative Staining– Negative in poorly differentiated HCC

– Quite patchy reactivity in many cases

HCC – Microarray AnalysisSY Xiao, Univ. Texas

Non-HCC HCC

Cytochrome P450 7A1

Cytochrome P450 3A3Cytochrome P450 2E1

Cytochrome P450 1A1Cytochrome P450 1b1

Cytochrome P450 51

CD10 43x

Atlas Human 1.2II Atlas Human 1.2II

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Canalicular CD10 in Normal Liver

Well differentiated HCC

pCEA CD10

72 y.o. male with an 8 cm mass in non-cirrhotic liver

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HepPar-1

CD 10

Glypican-3

• Cell surface heparin sulfate proteoglycan

• Oncofetal antigen expressed in embryonic kidney and liver

• Staining characteristics:

– Cytoplasmic reactivity; can be patchy

– Up-regulated in about 80% of HCC

– High rate of reactivity in poorly differentiated HCCs

– Also reactive in a small number of high grade DNs

– No reactivity in adenoma and FNH (& well diff HCC)

– Also reactive in Wilm’s tumor, melanoma and some ovarian carcinomas

• Small number of studies with small sample numbers

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Glypican-3

Glypican-3HepPar-1

TTF-1Poorly diff. HCC

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HepPar-1

Arg-1

UREA CYCLE

HepPar-1 Arg-1

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HepPar-1 Arginase-1

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Immunohistologic Stains for HCC

• Cam 5.2

• pCEA or CD10

• HepPar-1 or Arginase-1

• Glypican-3

• MOC-31 or mCEA (negative)

Immunohistologic Stains

for Masses in Non-Cirrhotic Liver

• Immunostains are not necessary in every case

• Polygonal cell tumors in the HCC differential diagnosis:

– Neuroendocrine (carcinoid) tumor - synaptophysin

– Melanoma – S-100, HMB-45, SOX10

– Hepatoid adenocarcinoma – Arginase-1, CDX2

– Angiomyolipoma, epithelioid type – HMB45

– Adrenocortical carcinoma – inhibin, calretinin

– Renal cell carcinoma – PAX-8

• In situ hybridization for albumin mRNA for poorly diff. tumors

• Much less useful stains: CD34, AFP, CK7, CK20