Wednesday, August 31, 2016

President's Message August 2016

Dear Friends and Colleagues:

The Hans Popper Society is growing and thriving! Many thanks to all of you who participate in the society by attending the companion meeting, the reception, and by doing such great work on the various committees. Also, many thanks to all of you who have recently joined the society—Welcome! The mission of the Hans Popper Society is to increase knowledge about the normal and diseased liver, with a special emphasis on the role of liver pathology in clinical care.  For those of you who are new to the society, I thought it might be worthwhile to take the next few President Messages and familiarize everyone with the structure of the Hans Popper Society.     

The Hans Popper Society is operated through the executive board. The executive board is chaired by the president and is composed of the president, vice president, ex president, and secretary-treasurer. The secretary-treasurer serves for three years and can be renewed, while the other members each serve for two years in each role, starting in the vice president role and moving to president and then ex president (so 6 years in total).  The secretary-treasurer and the vice president are nominated by the executive board and final approval/disproval obtained at the annual business meeting.

The function of the executive board is to administer the society in accordance with the society by-laws and SOPs.  Most of this involves (1) appointing, overseeing, and directing the various activities of the committees and (2) planning the USCAP companion meeting and reception (the latter which began last year).  The executive committee meets on a regular basis by phone conference (usually bimonthly) and has an annual face-to-face meeting at the USCAP.  

That sums up the executive board—we’ll proceed on to other offices and committees in the next message.

Please don’t forget to mark your calendars for the Hans Popper Reception in San Antonio (Saturday night).

Regards,
Michael Torbenson, MD
President, Hans Popper Hepatopathology Society

Tuesday, August 30, 2016

Interesting Case August 2016

Clinical History


A 43 year old woman with a previous history of ductal breast carcinoma, status post chemo -radiation and surgical therapy, was found to have a liver lesion detected on surveillance imaging. 

Imaging Findings


Abdominal MRI demonstrated a 3.1 cm lesion in the right lobe of the liver. The lesion showed prompt arterial enhancement and gradual washout.  Fine needle aspiration (FNA) and needle core biopsy was performed. FNA disproved metastatic disease and prompted a partial hepatectomy. 

Photomicrographs



Figure 1. Gross photograph of the right hepatectomy specimen

Figure 2. H&E (400X)

Figure 3. TFE-3 immunohistochemistry (400X)

Figure 4. HMB45 immunohistochemistry (400X)

Liver Biopsy Findings 


The liver biopsy showed an infiltrative neoplastic process with a solid to vaguely organoid growth pattern. The tumor was composed of large plump cells showing an epithelioid and plasmacytoid appearance. The tumor cells had abundant eosinophilic cytoplasm with low nuclear to cytoplasmic ratios and frequent multinucleated giant cells. Mitotic figures were rare. Necrosis was not detected. The background liver exhibited no features of chronic hepatitis or cirrhosis. 

Immunohistochemistry showed that the tumor cells were reactive with antibodies to TFE-3 (Fig 3), HMB-45 (Fig 4), cathepsin K, and MITF. The tumor cells were negative for AE1/3, CAM 5.2, ER, PR, S100, Melan A, arginase 1, INI-1, CD31, E-cadherin, SMA, desmin, and inhibin. The electron microscopy study failed to reveal intracytoplasmic crystals. The FISH assay for rearrangement of TFE-3 locus gene at Xp11.2 was negative. 

Diagnosis 


Perivascular epithelioid cell neoplasm (“PEComa”)

Major Learning Points


1. The presence of an organoid growth pattern and epithelioid or plasmacytoid cells should raise the possibility of PEComa.
2. PEComa is a unique tumor composed of histologically and immunohistochemically distinct perivascular epithelioid cells with coexpression of both melanocytic and smooth muscle markers. 
3. The presence of HMB-45-positive myoid cells is diagnostic.

Discussion

Perivascular epithelioid cell neoplasm (PEComa) belongs to a family of tumors composed of histologically and immunohistochemically distinctive perivascular epithelioid cells.  This group includes renal and extra-renal angiomyolipoma, lymphangiomatosis, clear cell “sugar” tumor of the lung, myelomelanocytic tumor, and abdominopelvic sarcoma of perivascular epithelioid cells. PEComa of the liver is exceedingly rare. PEComas have been predominantly described in women with the average age of 46. Since PEComa is associated with tuberous sclerosis (6-10%), overactive mTOR pathway is possibly contributing to tumorigenesis.   

Grossly the tumor occurs as a yellow to gray mass, which may reach up to 20 cm in size. Microscopically, PEComas are composed of clear to slightly eosinophilic cells that grow in distinctive nested or sometimes sheet-like patterns. The cells organize in a radial fashion around blood vessels. The blood vessel types range from thin spider web-like capillary networks to dilated, hyalinized, thick-walled arterioles. Both epithelioid and myoid elements are prominent, with the epithelioid cells typically occupying the more immediate perivascular space and the spindle-shaped myoid cells farther away. Multinucleated giant cells are characteristic. Many cells may demonstrate cytoplasmic distention with glycogen or lipid. PEComas are generally considered benign neoplasms, if they lack malignant morphologic features. Tumors that are “symplastic” or large in size are considered uncertain in terms of malignant potential. The dimorphic cellular composition of this tumor makes fine needle aspiration and core biopsy diagnosis difficult as it was witnessed in our case. Higher grade and cellularity correspond to higher malignant potential. If more than two “worrisome” histologic features are identified, the tumor is considered malignant.

The immunohistochemical features to distinguish PEComas from other neoplasms is the unique coexpression of both melanocytic and smooth muscle markers. The most important diagnostic criterion, according to WHO classification of tumors, is the presence of HMB-45-positive myoid cells. PEComas with a predominant component of clear cells also show extensive TFE-3 and cathepsin K positivity, but they are not typically associated with tuberous sclerosis complex mutations.

The chief histologic differential diagnosis in our case included metastatic mammary carcinoma, alveolar soft part sarcoma and malignant melanoma. Review of the previous mastectomy, the negative immunohistochemistry for breast markers and the unusual morphology largely ruled out a metastatic breast carcinoma. The organoid growth pattern with loosely cohesive epithelioid cells raised the possibility of alveolar soft part sarcoma. This, however, was excluded by electron microscopy and the lack of TFE-3 gene Xp11 rearrangement. Lack of malignant features such as frequent mitotic figures and necrosis helped excluded metastatic malignant melanoma. Currently, the only curative option for liver PEComa is surgical excision with wide margins. Adjuvant therapy has no defined role in the treatment of metastatic disease. Rapamycin, an inhibitor of mTOR pathway, may be beneficial for patients with metastatic disease.

References


Enzinger & Weiss’s. Soft tissue Tumors. Ch. 36. Perivascular epithelioid cell family of tumors. 5th ed. 2008. Mosby Inc, Elsevier. Philadelphia.
Colden C, Walsh NJ, Kruse EJ: Perivascular Epithelioid Cell Tumor of the Liver. The American surgeon 2015, 81:e345-6.
Tsui WM, Colombari R, Portmann BC, Bonetti F, Thung SN, Ferrell LD, Nakanuma Y, Snover DC, Bioulac-Sage P, Dhillon AP: Hepatic angiomyolipoma: a clinicopathologic study of 30 cases and delineation of unusual morphologic variants. The American journal of surgical pathology 1999, 23:34-48
Agaram NP, Sung YS, Zhang L, Chen CL, Chen HW, Singer S, Dickson MA, Berger MF, Antonescu CR: Dichotomy of Genetic Abnormalities in PEComas With Therapeutic Implications. The American journal of surgical pathology 2015, 39:813-25.
Kenerson H, Folpe AL, Takayama TK, Yeung RS: Activation of the mTOR pathway in sporadic angiomyolipomas and other perivascular epithelioid cell neoplasms. Human pathology 2007, 38:1361-71.

This case was submitted by:

Natalia I. Rush, MD, Resident, Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN 
Jingmei Lin, MD PhD, Assistant Professor, Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN

Interesting Case August 2016

Clinical History


A 43 year old woman with a previous history of ductal breast carcinoma, status post chemo -radiation and surgical therapy, was found to have a liver lesion detected on surveillance imaging. 

Imaging Findings


Abdominal MRI demonstrated a 3.1 cm lesion in the right lobe of the liver. The lesion showed prompt arterial enhancement and gradual washout.  Fine needle aspiration (FNA) and needle core biopsy was performed. FNA disproved metastatic disease and prompted a partial hepatectomy. 

Photomicrographs



Figure 1. Gross photograph of the right hepatectomy specimen

Figure 2. H&E (400X)

Figure 3. TFE-3 immunohistochemistry (400X)

Figure 4. HMB45 immunohistochemistry (400X)

Liver Biopsy Findings 


The liver biopsy showed an infiltrative neoplastic process with a solid to vaguely organoid growth pattern. The tumor was composed of large plump cells showing an epithelioid and plasmacytoid appearance. The tumor cells had abundant eosinophilic cytoplasm with low nuclear to cytoplasmic ratios and frequent multinucleated giant cells. Mitotic figures were rare. Necrosis was not detected. The background liver exhibited no features of chronic hepatitis or cirrhosis. 

Immunohistochemistry showed that the tumor cells were reactive with antibodies to TFE-3 (Fig 3), HMB-45 (Fig 4), cathepsin K, and MITF. The tumor cells were negative for AE1/3, CAM 5.2, ER, PR, S100, Melan A, arginase 1, INI-1, CD31, E-cadherin, SMA, desmin, and inhibin. The electron microscopy study failed to reveal intracytoplasmic crystals. The FISH assay for rearrangement of TFE-3 locus gene at Xp11.2 was negative. 

Diagnosis 


Perivascular epithelioid cell neoplasm (“PEComa”)

Major Learning Points

1. The presence of an organoid growth pattern and epithelioid or plasmacytoid cells should raise the possibility of PEComa.
2. PEComa is a unique tumor composed of histologically and immunohistochemically distinct perivascular epithelioid cells with coexpression of both melanocytic and smooth muscle markers. 
3. The presence of HMB-45-positive myoid cells is diagnostic.

Discussion

Perivascular epithelioid cell neoplasm (PEComa) belongs to a family of tumors composed of histologically and immunohistochemically distinctive perivascular epithelioid cells.  This group includes renal and extra-renal angiomyolipoma, lymphangiomatosis, clear cell “sugar” tumor of the lung, myelomelanocytic tumor, and abdominopelvic sarcoma of perivascular epithelioid cells. PEComa of the liver is exceedingly rare. PEComas have been predominantly described in women with the average age of 46. Since PEComa is associated with tuberous sclerosis (6-10%), overactive mTOR pathway is possibly contributing to tumorigenesis.   

Grossly the tumor occurs as a yellow to gray mass, which may reach up to 20 cm in size. Microscopically, PEComas are composed of clear to slightly eosinophilic cells that grow in distinctive nested or sometimes sheet-like patterns. The cells organize in a radial fashion around blood vessels. The blood vessel types range from thin spider web-like capillary networks to dilated, hyalinized, thick-walled arterioles. Both epithelioid and myoid elements are prominent, with the epithelioid cells typically occupying the more immediate perivascular space and the spindle-shaped myoid cells farther away. Multinucleated giant cells are characteristic. Many cells may demonstrate cytoplasmic distention with glycogen or lipid. PEComas are generally considered benign neoplasms, if they lack malignant morphologic features. Tumors that are “symplastic” or large in size are considered uncertain in terms of malignant potential. The dimorphic cellular composition of this tumor makes fine needle aspiration and core biopsy diagnosis difficult as it was witnessed in our case. Higher grade and cellularity correspond to higher malignant potential. If more than two “worrisome” histologic features are identified, the tumor is considered malignant.

The immunohistochemical features to distinguish PEComas from other neoplasms is the unique coexpression of both melanocytic and smooth muscle markers. The most important diagnostic criterion, according to WHO classification of tumors, is the presence of HMB-45-positive myoid cells. PEComas with a predominant component of clear cells also show extensive TFE-3 and cathepsin K positivity, but they are not typically associated with tuberous sclerosis complex mutations.

The chief histologic differential diagnosis in our case included metastatic mammary carcinoma, alveolar soft part sarcoma and malignant melanoma. Review of the previous mastectomy, the negative immunohistochemistry for breast markers and the unusual morphology largely ruled out a metastatic breast carcinoma. The organoid growth pattern with loosely cohesive epithelioid cells raised the possibility of alveolar soft part sarcoma. This, however, was excluded by electron microscopy and the lack of TFE-3 gene Xp11 rearrangement. Lack of malignant features such as frequent mitotic figures and necrosis helped excluded metastatic malignant melanoma. Currently, the only curative option for liver PEComa is surgical excision with wide margins. Adjuvant therapy has no defined role in the treatment of metastatic disease. Rapamycin, an inhibitor of mTOR pathway, may be beneficial for patients with metastatic disease.

References


Enzinger & Weiss’s. Soft tissue Tumors. Ch. 36. Perivascular epithelioid cell family of tumors. 5th ed. 2008. Mosby Inc, Elsevier. Philadelphia.
Colden C, Walsh NJ, Kruse EJ: Perivascular Epithelioid Cell Tumor of the Liver. The American surgeon 2015, 81:e345-6.
Tsui WM, Colombari R, Portmann BC, Bonetti F, Thung SN, Ferrell LD, Nakanuma Y, Snover DC, Bioulac-Sage P, Dhillon AP: Hepatic angiomyolipoma: a clinicopathologic study of 30 cases and delineation of unusual morphologic variants. The American journal of surgical pathology 1999, 23:34-48
Agaram NP, Sung YS, Zhang L, Chen CL, Chen HW, Singer S, Dickson MA, Berger MF, Antonescu CR: Dichotomy of Genetic Abnormalities in PEComas With Therapeutic Implications. The American journal of surgical pathology 2015, 39:813-25.
Kenerson H, Folpe AL, Takayama TK, Yeung RS: Activation of the mTOR pathway in sporadic angiomyolipomas and other perivascular epithelioid cell neoplasms. Human pathology 2007, 38:1361-71.

This case was submitted by:

Natalia I. Rush, MD, Resident, Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN 
Jingmei Lin, MD PhD, Assistant Professor, Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN

Interesting Case August 2016

Clinical History


A 43 year old woman with a previous history of ductal breast carcinoma, status post chemo -radiation and surgical therapy, was found to have a liver lesion detected on surveillance imaging. 

Imaging Findings


Abdominal MRI demonstrated a 3.1 cm lesion in the right lobe of the liver. The lesion showed prompt arterial enhancement and gradual washout.  Fine needle aspiration (FNA) and needle core biopsy was performed. FNA disproved metastatic disease and prompted a partial hepatectomy. 

Photomicrographs



Figure 1. Gross photograph of the right hepatectomy specimen

Figure 2. H&E (400X)

Figure 3. TFE-3 immunohistochemistry (400X)

Figure 4. HMB45 immunohistochemistry (400X)

Liver Biopsy Findings 


The liver biopsy showed an infiltrative neoplastic process with a solid to vaguely organoid growth pattern. The tumor was composed of large plump cells showing an epithelioid and plasmacytoid appearance. The tumor cells had abundant eosinophilic cytoplasm with low nuclear to cytoplasmic ratios and frequent multinucleated giant cells. Mitotic figures were rare. Necrosis was not detected. The background liver exhibited no features of chronic hepatitis or cirrhosis. 

Immunohistochemistry showed that the tumor cells were reactive with antibodies to TFE-3 (Fig 3), HMB-45 (Fig 4), cathepsin K, and MITF. The tumor cells were negative for AE1/3, CAM 5.2, ER, PR, S100, Melan A, arginase 1, INI-1, CD31, E-cadherin, SMA, desmin, and inhibin. The electron microscopy study failed to reveal intracytoplasmic crystals. The FISH assay for rearrangement of TFE-3 locus gene at Xp11.2 was negative. 

Diagnosis 


Perivascular epithelioid cell neoplasm (“PEComa”)

Major Learning Points

1. The presence of an organoid growth pattern and epithelioid or plasmacytoid cells should raise the possibility of PEComa.
2. PEComa is a unique tumor composed of histologically and immunohistochemically distinct perivascular epithelioid cells with coexpression of both melanocytic and smooth muscle markers. 
3. The presence of HMB-45-positive myoid cells is diagnostic.

Discussion

Perivascular epithelioid cell neoplasm (PEComa) belongs to a family of tumors composed of histologically and immunohistochemically distinctive perivascular epithelioid cells.  This group includes renal and extra-renal angiomyolipoma, lymphangiomatosis, clear cell “sugar” tumor of the lung, myelomelanocytic tumor, and abdominopelvic sarcoma of perivascular epithelioid cells. PEComa of the liver is exceedingly rare. PEComas have been predominantly described in women with the average age of 46. Since PEComa is associated with tuberous sclerosis (6-10%), overactive mTOR pathway is possibly contributing to tumorigenesis.   

Grossly the tumor occurs as a yellow to gray mass, which may reach up to 20 cm in size. Microscopically, PEComas are composed of clear to slightly eosinophilic cells that grow in distinctive nested or sometimes sheet-like patterns. The cells organize in a radial fashion around blood vessels. The blood vessel types range from thin spider web-like capillary networks to dilated, hyalinized, thick-walled arterioles. Both epithelioid and myoid elements are prominent, with the epithelioid cells typically occupying the more immediate perivascular space and the spindle-shaped myoid cells farther away. Multinucleated giant cells are characteristic. Many cells may demonstrate cytoplasmic distention with glycogen or lipid. PEComas are generally considered benign neoplasms, if they lack malignant morphologic features. Tumors that are “symplastic” or large in size are considered uncertain in terms of malignant potential. The dimorphic cellular composition of this tumor makes fine needle aspiration and core biopsy diagnosis difficult as it was witnessed in our case. Higher grade and cellularity correspond to higher malignant potential. If more than two “worrisome” histologic features are identified, the tumor is considered malignant.

The immunohistochemical features to distinguish PEComas from other neoplasms is the unique coexpression of both melanocytic and smooth muscle markers. The most important diagnostic criterion, according to WHO classification of tumors, is the presence of HMB-45-positive myoid cells. PEComas with a predominant component of clear cells also show extensive TFE-3 and cathepsin K positivity, but they are not typically associated with tuberous sclerosis complex mutations.

The chief histologic differential diagnosis in our case included metastatic mammary carcinoma, alveolar soft part sarcoma and malignant melanoma. Review of the previous mastectomy, the negative immunohistochemistry for breast markers and the unusual morphology largely ruled out a metastatic breast carcinoma. The organoid growth pattern with loosely cohesive epithelioid cells raised the possibility of alveolar soft part sarcoma. This, however, was excluded by electron microscopy and the lack of TFE-3 gene Xp11 rearrangement. Lack of malignant features such as frequent mitotic figures and necrosis helped excluded metastatic malignant melanoma. Currently, the only curative option for liver PEComa is surgical excision with wide margins. Adjuvant therapy has no defined role in the treatment of metastatic disease. Rapamycin, an inhibitor of mTOR pathway, may be beneficial for patients with metastatic disease.

References


Enzinger & Weiss’s. Soft tissue Tumors. Ch. 36. Perivascular epithelioid cell family of tumors. 5th ed. 2008. Mosby Inc, Elsevier. Philadelphia.
Colden C, Walsh NJ, Kruse EJ: Perivascular Epithelioid Cell Tumor of the Liver. The American surgeon 2015, 81:e345-6.
Tsui WM, Colombari R, Portmann BC, Bonetti F, Thung SN, Ferrell LD, Nakanuma Y, Snover DC, Bioulac-Sage P, Dhillon AP: Hepatic angiomyolipoma: a clinicopathologic study of 30 cases and delineation of unusual morphologic variants. The American journal of surgical pathology 1999, 23:34-48
Agaram NP, Sung YS, Zhang L, Chen CL, Chen HW, Singer S, Dickson MA, Berger MF, Antonescu CR: Dichotomy of Genetic Abnormalities in PEComas With Therapeutic Implications. The American journal of surgical pathology 2015, 39:813-25.
Kenerson H, Folpe AL, Takayama TK, Yeung RS: Activation of the mTOR pathway in sporadic angiomyolipomas and other perivascular epithelioid cell neoplasms. Human pathology 2007, 38:1361-71.

This case was submitted by:

Natalia I. Rush, MD, Resident, Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN 
Jingmei Lin, MD PhD, Assistant Professor, Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN

Wednesday, August 3, 2016

Journal Watch May-June 2016

Hepatology, May-June 2016


Delaunay Jean-Louis et al. Hepatology 2016;63:1620-1631.

Progressive familial intrahepatic cholestasis type 3 (PIFIC 3) is caused by variations in the ABCB4 gene which encodes an ATP binding cassette (ABC) transporter protein (also called MDR3). ABCB4 is expressed on the hepatocytic bile canalicular membrane where it mediates secretion of phosphatidylcholine (PC). ABCB4 defects result in low levels of biliary PC with resultant biliary epithelial damage. These investigators evaluated the biologic consequences of 12 ABCB4 variants in 9 patients with PIFIC3. Using site-directed mutagenesis and cell line expression models, the cellular localization of expression and biologic activity of the ABCB4 variants was evaluated. The authors classified the ABCB4 variations into 5 categories based on severity of disease, impact on protein maturity, activity, or stability (i.e., clinical and biological relevance). This proof-of-principle study provides clues for genetically based therapeutic strategies; each category of protein defect suggests a specific therapeutic strategy. This study also demonstrates the possibility of restoring normal cellular function by pharmacological methods.

Schwimmer JB. Hepatology 2016;63:1718-1725.

This is a good review of the advances made and remaining challenges in pediatric NAFLD.

Marchesini G et al. Hepatology 2016;63:2032-2043.

This is a great review which covers aspects ranging from hepatic lipid metabolism, the impacts of the genetic background, diet and physical activity on fatty liver disease.

American Journal of Surgical Pathology, May-June 2016


Fujikura, K, et al.  Am J Surg Pathol. 2016 May;40(5):689-96. 

Bile salt export pump (BSEP) and multidrug-resistance protein 3 (MDR3), both members of the ATP-binding cassette transporter family involved in bile acid homeostasis, are specifically expressed in hepatocytes.  The purpose of this study was to further evaluate the utility of these immunohistochemical markers in retrospective cohorts of select malignancies.  The first cohort consisted of hepatocellular carcinomas (HCCs, n = 54), intrahepatic cholangiocarcinomas (ICCs, n = 34), combined hepatocellular-cholangiocarcinomas (CHCs, n = 23), and hepatoid carcinomas predominantly of gastric origin (n = 27).  For HCCs, BSEP and MDR3 showed similar sensitivities to ARG1 and HepPar-1 in well to moderately differentiated malignancies (all ≥ 94%), but lower sensitivities in poorly differentiated malignancies (e.g. MDR3 = 67% vs. ARG1 = 100%).  No ICCs or hepatoid carcinomas stained for BSEP or MDR3 whereas 9% of ICCs were positive for ARG1 and 44% of hepatoid carcinomas were immunoreactive for HepPar-1.  In CHCs where cholangiocellular areas were sometimes positive for ARG1 (26%) or HepPar-1 (52%), none of these same areas stained for BSEP or MDR3.  The second cohort consisted of primary liver cases originally diagnosed as poorly differentiated carcinoma, NOS (n = 8) due to inconclusive morphologic and immunohistochemical evidence to categorize as HCC or ICC.  In 2 of these cases, either BSEP or MDR3 was positive, suggesting the diagnoses as HCCs.  In conclusion, BSEP and MDR3 appear to be promising adjunctive markers for differentiating HCCs from ICCs and HCCs from hepatoid carcinomas originating from other organs.  

Shibahara, J, et al. Am J Surg Pathol. 2016 May;40(5):608-16.

These authors question the validity of grouping HCC containing “stem/progenitor-like” cells into the category of combined hepatocellular-cholangiocarcinoma (CHC) as presented in the WHO Classification of Tumours of the Digestive System (4th ed).  This retrospective case series from a single institution compares clinicopathologic characteristics and prognosis among the typical subtype of CHC with stem cell features [referred to as HCC with reactive ductule-like components (HCC-RD) in this manuscript], classical CHC, and conventional HCC.  Tumors were classified solely on H&E morphology: HCC-RD (n = 46), classical CHC (n = 38), and conventional HCC (n = 483).  Compared to HCC, HCC-RD patients were more often younger (60.3 vs. 64.5 yrs age), female (52.2% vs. 20.5%) and had higher serum AFP (106 vs. 19 ng/mL) and CA19-9 (40.0% vs. 16.9%) levels.  HCC-RD frequently showed clear cell features, interstitial fibrosis, and intratumoral neutrophils compared with HCC.  Both disease free survival and overall survival were similar between HCC-RD and HCC, but worse for CHC compared with HCC (p ≤ 0.032, up to 60 month follow up).  Therefore, despite differences in morphology and some clinical features, the authors propose that based on prognosis, HCC-RD should be considered as an HCC variant rather than a subtype of CHC.  Meanwhile, differences in morphology and prognosis were confirmed for classical CHC.

Journal of Hepatology, May-June 2016



NAFLD is the most common liver disorder in Western countries and includes two pathologically distinct entities: non-alcoholic fatty liver (NAFL) and non-alcoholic steatohepatitis (NASH). The evidence based Clinical Practice Guidelines is developed from data retrieved by an extensive PubMed search up to April 2015 and include guidelines for NAFLD prevalence, pathogenesis, diagnostic algorithm, and management including pediatric NAFLD. Recent advances in genetic association, non-invasive assessment, and clinical management are also included. The document is intended for both practical use and advancing research.  It should also help improve patient care and awareness of the importance of NAFLD.

American Journal of Clinical Pathology, May-Jun 2016


Sasaki M, Nitta T et al. Am J Clinic Pathol 2016; 145 (6): 815-825.

Using exosome sequencing and next generation sequencing, recent studies have revealed frequent alterations in several new genes including the three chromatin-remodeling genes (BAP1, ARID1A, and PBRM) in cholangiocarcinomas. The authors investigated the inactivating mutation of ARID1A gene by immunohistochemistry in 13 cHC-CCs, 49 ICCs, 17 IPNBs, 72 EHCC, and 43 GBCs, and correlated with clinical characteristics, KRAS mutation status and survival. Loss of ARID1A expression was found in 14% of biliary carcinomas but 0% of IPNBs. Biliary carcinomas with loss of ARID1A expression were mass forming or flat infiltrating types and histologically tubular adenocarcinomas with abound fibrous stroma. Loss of ARID1A expression was not correlated with staging and patient survival. Interestingly, no biliary carcinomas harbored both ARID1A and KRAS mutations. The study suggests inactivating mutation of ARID1A may be involved in a novel pathway of biliary carcinogenesis, which is different from KRAS pathway in IPNB and BilIN.

Modern Pathology, May-Jun 2016


Rush N., et al. Modern Pathology 2016; 29: 489–499

Hepatic arterial buffer response is defined as increased hepatic arterial flow secondary to reduced portal flow which has been demonstrated experimentally and surgically. In this report, the pathologic change of hepatic arterial buffer response in 21 patients (12 male and 9 female) with extrahepatic portal vein thrombosis was evaluated. In addition, CD34 staining, outer diameters, luminal diameters and wall thickness of hepatic arteries cut in cross-section and outer diameters of cross-sectioned paired bile ducts were compared with age- and gender-matched controls. Measurements of 280 and 193 arteries from patients and controls demonstrated statistically significant arterial dilatation and arterial wall thinning in patients with extra-hepatic portal vein thrombosis (P<0.05). Diffuse and obvious changes, and portal vein absence or attenuation were seen only in the patient group, although subtle and/or focal dilatation of central veins, portal veins and sinusoids, focal trabecular thinning/thickening and mild ductular reaction were common findings in both groups. Capillarization of sinusoids was not seen on CD34 stain. Two patients showed significant ductular reaction, one of who developed biliary strictures on follow-up. In summary, hepatic arterial dilatation and wall thinning in non-cirrhotic patients with portal vein thrombosis provide histopathologic evidence of hepatic arterial buffer response in the human liver. Diffuse sinusoidal dilatation or absence or attenuation of portal veins is highly suggestive of extrahepatic portal vein thrombosis. Periportal shunt vessels, hypervascular portal tracts, muscularized portal veins, large thick-walled or dilated arteries are rare, but can aid diagnosis. Normal or near-normal biopsies do not rule out portal vein thrombosis.

Rondell P Graham RP, Modern Pathology 2016; 29: 607–615

Rare hepatic adenoma associated with synchronous or metachronous fibrolamellar carcinoma has not been well studied. Four hepatic adenomas co-occurring with or preceding a diagnosis of fibrolamellar carcinoma from three patients were included in this study. Histologically, three of the adenomas showed the typical morphology of HNF1-α inactivated adenomas, and one showed a myxoid phenomenon. Fluorescence in situ Hybridization (FISH) analysis showed negative PRKACA rearrangements in all adenomas. All adenomas displayed complete loss or significant reduction of liver fatty acid binding protein (LFABP) expression immunohistochemically. Interestingly, the fibrolamellar carcinomas in each case also showed loss of LFABP expression. One of the fibrolamellar carcinomas was negative for PRKACA rearrangements by FISH, whereas the others were positive. An additional cohort of 19 fibrolamellar carcinomas was studied (n=19) to investigate if LFBAP loss is typical of fibrolamellar carcinomas in general. All 19 fibrolamellar carcinomas showed the expected PRKACA rearrangements and the loss of LFABP immunohistologically. To validate this observation, mass spectrometry-based proteomics was performed on tumor-normal pairs of six fibrolamellar carcinomas and showed an average 10-fold reduction in LFABP protein levels in tumors. In conclusion, hepatic adenomas co-occurring with fibrolamellar carcinomas show LFABP loss and are negative for PRKACA rearrangements. LFABP loss, a unique feature of fibrolamellar carcinoma, leads to HNF1-α inactivation that is an important event in pathogenesis.

Journal of Gastroenterology and Hepatology, May-Jun 2016


Adams LA, et al. J Gastroenterol Hepatol. 2016 May;31(5):1016-24

Diabetes at time of liver transplantation is well known to be associated with reduced post-transplant survival. In this study, additional metabolic conditions (obesity and hypertension) were accessed for prognostic impact on post-transplantation survival. A multi-center cohort included 617 adult subjects who underwent liver transplantation between 2003 and 2009. After a median follow-up of 5.8 years (range 0–10.5), 112 (18.2%) patients died. Diabetes was associated with reduced post-transplant survival (hazard ratio 1.89, 95% confidence interval [CI] 1.25–2.86, P = 0.003), whereas obesity, hypertension, dyslipidemia, and the metabolic syndrome itself were not (P>0.3 for all). Patients with concomitant diabetes and obesity had lower survival (adjusted Hazard Ratio [aHR] 2.40, 95%CI 1.32–4.38, P = 0.004), whereas obese non-diabetic or diabetic non-obese patients had similar survival compared with non-diabetic, non-obese individuals. The presence of hypertension or dyslipidemia did not impact on survival in patients with diabetes (P>0.1 for both). Obese diabetic patients had longer intensive care and hospital stays than those of non-obese diabetic or obese, non-diabetic (P<0.05). The impact of concomitant obesity and diabetes on survival was greater in subjects aged 50+ years (52.6% 5-year survival, aHR 3.04, 95% CI 1.54–5.98) or those transplanted with hepatocellular carcinoma (34.1% 5-year survival, aHR 3.35, 95% CI 1.31–5.57). Diabetes without obesity was not associated with an increased mortality rate in these sub-groups. In summary, concomitant diabetes and obesity, but not each condition in the absence of the other, is associated with reduced post-liver transplant survival. The impact of diabetes and obesity is greater in older patients and those with hepatocellular carcinoma. 

Gastroenterology, May –June 2016


Newsome PN, Gastroenterology. 2016;150(5):1073-6.

Ratziu V, et al; GOLDEN-505 Investigator Study Group. Gastroenterology. 2016;150(5):1147-1159.

This is an editorial and accompanying study published in the same issue reporting the efficacy of GFT505 in NASH in a phase II study.  GFT505 is a dual peroxisome proliferator-activated receptor (PPAR)-α and -δ agonist that has been reported to lower liver lipids and lower expression of proinflammatory and profibrotic genes in NASH. The antifibrotic effect of GFT505 may be mediated by PPAR-δ agonism. The study involved 274 noncirrhotic biopsy-proven NASH cases who received oral elafibranor (GFT505) or placebo for one year. The primary end point of the study was to reduce any component of NAS to 0 without increase in fibrosis. This end point was not met in the study.
However, the efficacy of elafibranor vs. placebo for cases with NAS >4 was demonstrated in post hoc analysis. Resolution of NASH defined by disappearance of ballooning without progression of fibrosis was achieved in higher number of patients compared to placebo.  The efficacy in NAS ≥ 4 and F1-3 fibrosis (22% resolution vs 13%; p=0.026) was higher than cases with NAS ≥ 4 and F2/3 (15% resolution vs 9% in placebo; p=0.002), suggesting lower response with advanced fibrosis. There were no cardiovascular events or deaths with elafibranor, but decrease in renal function was observed in 7 patients and will need monitoring in future studies.

Human Pathology, May-June 2016


Yeh MM, et al; Nonalcoholic Steatohepatitis Clinical Research Network. Hum Pathol. 201 ;52:28-37.

This study from the NASH Clinical Research Network Database comprised 157 cases: 94 definite NASH, 40 borderline NASH, 23 not NASH. Acidophil bodies (AB) were counted, and expressed as an acidophil body index (ABI) defined as mean AB count per mm2 was calculated. ABI was 0.04 in definite NASH and 0.02 in borderline as well as not NASH cases (p=0.02). Higher ABI was associated with greater lobular inflammation and hepatocellular ballooning, while no association was observed with steatosis or fibrosis stage. 

Gut, May-June 2016


Xiao X, et al. Gut 2016;65:1035-1041. 

The Milan criteria are commonly used to determine liver transplantation in patients with hepatocellular carcinoma.  These stringent criteria have been challenged by alternative expanded criteria including the Valencia, UCSF, University Clinic of Navarra, and Hangzhou criteria.  In this study, the authors compare the outcomes of 6012 patients with hepatocellular carcinoma using these various criteria.  The authors showed that those patients meeting Milan criteria had better outcomes than those exceeding Milan criteria.  However, of the 3286 patients exceeding Milan criteria, 2255 patients did not have tumor recurrence during the 5-year follow-up.  The modified Hangzhou criteria (tumor burden ≤8 cm regardless of AFP and differentiation, or tumor burden >8 cm but AFP ≤100 ng/mL and well-moderate differentiation) had 1-, 3-, and 5-year tumor free survival rates comparable to the Milan criteria. 

American Journal of Gastroenterology, May-Jun 2016


Nelson JE, et al. Am J Gastroenterol 2016;111:852-863. 
The authors study 190 adults with biopsy proven NAFLD.  Vitamin D deficiency was present in 55% of patients was associated with a definitive histologic diagnosis of NASH, increased lobular inflammation, more ballooning degeneration, and presence of fibrosis. RNA sequencing identified differentially expressed genes involving in the MAPK and NF-kB pathways between vitamin D deficient and non-deficient subjects.  The authors suggest that dietary and lifestyle modifications to increase vitamin D levels in deficient NAFLD patients may be beneficial.
http://www.ncbi.nlm.nih.gov/pubmed/27002799

Histopathology May-June 2016


Zen Y, Britton D, Mitra V, Pike I, Heaton N & Quaglia A.  Histopathology 2016;68:796–809.
Using a conventional liquid chromatography-tandem mass spectrometry (LC-MS/MS) protocol, proteomics evaluations frozen large bile ducts inpatients with IgG4 sclerosing cholangitis (ISC) and Primary sclerosing cholangitis (PSC) were found to have differential expressions of proteins that appear to relate to the pathogeneses of these diseases. Of 11 activated pathways in ISC > PSC, 3 were found to include B cell- or immunoglobulin- related pathways, while the 2 activated pathways in PSC > ISC related to extracellular matrix remodelling.

Richard Colling, Clare Verrill, Eve Fryer, Christiana Kartsonaki, Lai M Wang, Roger Chapman, Naayil Rajabally,  & Kenneth Fleming.  Histopathology. 2016;68(6):819-24

The authors in this paper present a semi-quantitative gardening of G1-G3 for basement membrane thickening and its diagnostic accuracy for Primary sclerosing cholangitis (PSC). They found that G3 BMT was 95% specific for PSC but with low sensitivity of 16% among 128 patients studied.

Quaglia A, Alves VA, Balabaud C, Bhathal PS, Bioulac-Sage P, Crawford JM, Dhillon AP, Ferrell L, Guido M, Hytiroglou P0, Nakanuma Y, Paradis V, Snover DC, Theise ND, Thung SN, Tsui WM, van Leeuwen DJ; International Liver Pathology Study Group. Histopathology. 2016;68(7):953-67

Clinicopathological concepts on acute and chronic liver disease have evolved rapidly during the last few years, with advances in general and specific treatment options and improved patient outcomes. The old paradigm of 'irreversibility' of cirrhosis had been challenged in major ways, and the validity of the usage of the term 'cirrhosis' has come into question. This paper addresses aetiology-based clinicopathological concepts and features that may deserve attention because they may determine disease outcome and, specifically, patterns of regression and remodelling. A variety of therapeutic interventions may influence remaining disease features after elimination of damaging agents (virus, alcohol, etc.), and determine the final clinical outcome including the risk of hepatocellular carcinoma (HCC). New concepts create new responsibilities and opportunities for the pathologist to contribute to the understanding of liver pathology and communicate this with clinical colleagues and researchers.

Ma C, Brunt EM. Histopathology. 2016;68(7):996-1003

The aim of this study was to evaluate the frequency of terminal hepatic venules (THV) injury resembling sinusoidal obstruction syndrome (SOS) in the setting of haematopoietic stem cell transplant (HSCT) recipients. A total of sixty-three consecutive biopsies from allogeneic HSCT recipients were scored for injured THVs. Forty-nine (78%) biopsies had injured THVs, and 10 (16%) were diagnosed with SOS (mean ± standard deviation of injured THVs/biopsy: 90 ± 9%). Biopsies diagnosed with other diseases also had injured THVs (36 ± 33%). Biopsies from patients with cyclophosphamide plus fractionated total body irradiation conditioning and biopsies taken within 100 days post-HSCT had significantly more occluded THVs (respectively: 40 ± 38%, P = 0.0188; and 35 ± 35%, P = 0.0076) than those with other conditioning regimens or in biopsies taken >100 days post-HSCT. All biopsies taken at any time in the 6-year post-HSCT period had similar amounts of THV phlebosclerosis (23 ± 25%). The authors found a high incidence of THV injuries resembling SOS in post-HSCT liver biopsies. THV injuries were detectable for several years post-HSCT, and were concurrent with other diagnoses. Our results also suggest that SOS may be underdiagnosed.

Liver transplantation, May-Jun 2016


Venturi C, Reding R, Quinones JA, Sokal E, Rahier J, Bueno J, Sempoux C. Liver Transpl. 2016;22(6):822-9
The authors performed anti-smooth muscle actin (ASMA) immunostain and picrosirius red stain on 162 liver transplant biopsies of 54 patients performed at 6 months, 3 years, and 7 years. They demonstrate by computer morphometric analysis that biopsies with ASMA expression (surrogate for activated stellate cells) of 8% of biopsy surface area or greater at 6 months, was an independent risk factor for significant fibrosis at 7-years.

Erard-Poinsot D, Guillaud O, Hervieu V, Thimonier E, Vallin M, Chambon-Augoyard C, Boillot O, Scoazec JY,Dumortier J. Liver Transpl. 2016;22(6):773-84

Alcoholic liver disease (ALD) is a major indication for liver transplantation (LT), but up to 20% of patients experience severe alcoholic relapse. The aims of this study were to evaluate the impact of severe alcoholic relapse on the graft (based on histological examination) and to identify predictive factors associated with recurrent alcoholic cirrhosis (RAC). From 1990 to 2010, 369 patients underwent LT for ALD at Edouard Herriot Hospital (Lyon, France) and survived more than 1 year. All patients who presented severe alcoholic relapse and histological follow-up were included. Liver biopsies were performed at 1 and 5 years and at every 5 years after LT, and when clinically indicated. The median follow-up after LT was 11 years (range, 3-18 years). Severe alcoholic relapse was observed in 73 (20%) of the 369 patients, from whom 56 patients with histological evaluation were included. RAC was diagnosed in 18 (32%) of the 56 patients included, which represents 5% of the 369 patients transplanted for ALD. The median delay between LT and RAC was 6 years (range, 3-10 years) and 4.5 years (range, 2-8 years) after severe alcoholic relapse. The median cumulated years of alcohol use before RAC was 3.5 years (range, 2-7 years). The cumulative risk for F4 fibrosis was 15% at 3 years, 32% at 5 years, and 54% at 10 years after severe alcoholic relapse. A young age at LT (≤50 years old) and an early onset of heavy drinking (within the first 3 years after LT) were associated with RAC. In conclusion, severe alcoholic relapse usually occurs in the first years after LT and is responsible for accelerated severe graft injury. 

Harper AM1, Edwards E, Washburn WK, Heimbach J.  Liver Transpl. 2016;22(6):757-64

A review of 4,500 explant pathology findings documented online using the OPTN explant pathology form confirmed the usefulness of this form as information such as Extrahepatic spread, poor tumor differentiation, microvascular invasion, macrovascular invasion, and confirmation of pre-transplant Milan staging were found to have significant prediction for tumor recurrence in the post-transplant period.

Hejlova I, Honsova E, Sticova E, Lanska V, Hucl T, Spicak J, Jirsa M, Trunecka P. Liver Transpl. 2016;22(5):644-55

Steatosis occurs frequently after liver transplantation (LT). We aimed to determine the prevalence of steatosis in adult LT recipients, to determine the effects of significant (>33%; grades 2-3) steatosis on patient survival, and to identify risk factors for the development of significant steatosis and its effect on fibrosis progression. We retrospectively examined 2360 posttransplant biopsies of 548 LT recipients. Survival was compared between patients with significant steatosis and those with grades 0-1 steatosis. Patients with significant steatosis were compared to controls without steatosis (grade 0) for clinical and laboratory factors and fibrosis progression. Steatosis was found in 309 (56.4%) patients, including 93 (17.0%) patients with significant steatosis. Steatohepatitis (nonalcoholic fatty liver disease activity score ≥ 5) was diagnosed in 57 (10.4%) patients. The prevalence of steatosis increased from 30.3% at 1 year to 47.6% at 10 years after LT (P < 0.001). Survival times did not differ between groups (P = 0.29). On multivariate analysis of pretransplant factors and initial immunosuppression (IS), alcohol-induced cirrhosis (P < 0.001) and high body mass index (BMI; P = 0.002) were associated with the development of significant steatosis, whereas increased levels of alkaline phosphatase (P = 0.01) and mycophenolate mofetil given initially (P = 0.009) appeared to protect against significant steatosis. On multivariate analysis of posttransplant factors, high BMI (P < 0.001), serum triglycerides (P < 0.001), alcohol consumption (P = 0.005), and type 2 diabetes mellitus (P = 0.048) were associated with significant steatosis, whereas high creatinine (P = 0.02) appeared to protect against significant steatosis. Significant steatosis was not associated with a higher fibrosis stage (P = 0.62). Posttransplant steatosis affects 56.4% of LT recipients, and the prevalence increases with time after LT. Recipient factors and types of IS affect the risk for significant steatosis, which is not associated with a higher fibrosis stage or worse patient survival.

Prepared by:
Editor, Daniela Allende, Cleveland Clinic
Rish Pai, MD, PhD; Mayo Clinic Arizona
Sanjay Kakar, MD; University of California, San Francisco
Cindy Guy, MD; Duke University
Wenqing Cao, MD; New York University
Jingmei Lin, MD, PhD; Indiana University
Oyedele Adeyi, MD; University of Toronto
Eric Yee, MD; University of Oklahoma

Wednesday, June 1, 2016

President's Message May 2016

Dear Friends and Colleagues:
Michael Torbenson, MD

It is a great honor to serve as the president of the Hans Popper Society! It's a particular pleasure to work with all of the great people who work so hard to make the Society run smoothly, including all of the committee members and the general members who are committed to promoting and growing the field of liver pathology. A special thanks to Dr. Isabel Fiel, our past president. 

The field of liver pathology is going to change considerably over our careers. New imaging methods and new drugs are altering and will continue to alter the way medicine is practiced. Our roles in patient care will change but I do not believe our roles will diminish because new ones will emerge. As one example, currently the primary role for the liver biopsy in tumor management is diagnosis, but in the future I believe pathologists will play additional key roles in patient management by providing histology-based information on prognosis and treatment options.

In this time of change, the Society will benefit us all through its education mission and will benefit patients as our collective ongoing research activities promote improved understanding and management of liver disease. 

Regards,
Michael Torbenson, MD
President, Hans Popper Hepatopathology Society

Sunday, May 29, 2016

Interesting Case April 2016

Clinical History

A 65 year old woman was found to have abnormal liver tests during a follow up visit for monoclonal gammopathy of uncertain significance (MGUS), IgG kappa. High transaminase levels prompted a needle core biopsy of the liver.

Lab Values

ALT and AST >200 U/L
Antimitochondrial antibody (AMA) was negative.

Photomicrographs

Figures 1A (H&E) and 1B (CD68)
Figures 2A (H&E) and 2B (CD68)
Figures 3A (Ig kappa)  and 3B (PAS-D)
Figure 4 (H&E)
Figures 5A (H&E)  and 5B (Rhodanine)

Liver Biopsy Findings

The liver biopsy shows extensive sinusoidal infiltration by bland appearing plump eosinophilic cells with somewhat retractile or granular cytoplasm (Figures 1A and 2A). These cells are positive for CD68 confirming they are histiocytes (Figures 1B and 2B). The histiocytes contain crystalline immunoglobulin kappa highlighted on the Ig kappa and PAS-D stains (Figures 3A and 3B, respectively). Ig lambda was negative.
In a single portal tract there is mild inflammation associated with bile duct injury (Figure 4). One periportal area is positive for focal copper accumulation on the Rhodanine stain (Figures 5A and 5B, respectively). There were no histologic features of a concomitant clonal plasma cell or lymphoproliferative process.

Diagnosis

Crystal-storing histiocytosis (immunoglobulin variant).
Focal mild portal inflammation with associated bile duct injury.

Major Learning Points

Crystal-storing histiocytosis (CSH) is a subtle histologic diagnosis when it involves the liver.
A systematic approach to liver biopsy evaluation will help avoid missing sinusoidal infiltrates.
The published literature on CSH reveals that most cases are due to plasma cell proliferative disorders (such as multiple myeloma and MGUS) with rare cases due to other causes such as i) Charcot Leyden crystals, ii) clofazimine, iii) marked polyclonal plasma cell rich inflammation and iv) hereditary cystinosis. 
It is important to evaluate the biopsy which shows CSH for a simultaneous clonal lymphoproliferative or plasma cell proliferative process. If an initial work up is negative, the patient should have periodic follow up as the diagnosis of CSH can precede the diagnosis of a plasma cell proliferative disorder.


Discussion

Crystal-storing histiocytosis (CSH) is rare. In the liver, the diagnosis is subtle because the sinusoidal location of eosinophilic histiocytes blends in with the adjacent eosinophilic hepatocytes. CSH can be due to a number of causes, but >90% of cases are due to plasma cell proliferative disorders including multiple myeloma, lymphoplasmacytic lymphoma and MGUS. Often times these underlying disorders are known to the clinical service, however, it is useful to include this association in the pathology report for clinicians who may not be aware. Furthermore, in situations in which a plasma cell proliferative disorder has not yet been established, pointing out this association in the pathology report may facilitate further clinical evaluation. It is also worth noting that a recently characterized subset of cases of CSH may be due to clofazimine, Charcot-Leyden crystals, rheumatoid arthritis, marked polyclonal plasma cell inflammation or hereditary cystinosis. These should also be included in the differential diagnosis for cases where no history is present.

CSH typically presents as either a generalized disease with multi-organ involvement or a localized process. The liver is involved in about half the cases of generalized disease. There are no recognized histologic differences between localized and generalized cases. This distinction is made based on clinical information and review of specimens from multiple sites.

Histologically, cases of CSH are characterized by an abundance of eosinophilic histiocytes with plump cytoplasm containing birefringent crystalline material. In the liver, the histiocytes most often show a sinusoidal pattern of distribution, but mass-like lesions can occur. The histiocytes show the typical immunophenotype with CD68 and CD163 expression. If the crystals are composed of immunoglobulin, they may be clonal or polyclonal and composed of light chains or rarely heavy chains. Immunoglobulin crystals are often needle shaped but in the authors’ experience, other shapes can be seen. The mechanism for crystal formation is poorly understood.

CSH should be distinguished from Langerhans cell histiocytosis, Gaucher’s disease and other lysosomal storage diseases and infection. Langerhans cell histiocytosis is often accompanied by a prominent eosinophilic infiltrate and the neoplastic cells display grooved nuclei. Lysosomal storage diseases are characterized by foamy rather than birefringent cytoplasm and immunoglobulin immunohistochemistry is negative. Electron microscopy and enzyme assays may be helpful in confirming and refining the diagnosis of a lysosomal storage disease. Finally, infections can be excluded based on histochemical stains (such as AFB and GMS) together with clinical information and blood tests.

This case is unusual in that there is focal bile duct injury with associated periportal copper accumulation. The very focal nature of these findings is insufficient for a diagnosis of primary biliary cirrhosis and the patient’s AMA is negative.

In conclusion, CSH is a rare, histologically subtle disorder which may affect the liver. Importantly, most cases are due to an underlying plasma cell proliferative disorder. 

This case was contributed by:
Rondell P Graham, MBBS, Gastrointestinal/Liver Pathology Fellow, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
and
Vashal Chandan,  MBBS, Assistant Professor of Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN

Reference:
S Dogan et al. Head and Neck Pathol 2012;6:111-120.

Monday, March 28, 2016

Journal Watch January - February 2016

Histopathology Jan-Feb 2016


Low expression of B-cell-associated protein 31 in human primary hepatocellular carcinoma correlates with poor prognosis. 
Tan, N, et al. Histopathology 2016, 68, 221–229.

Based on the hypothesis that endoplasmic reticulum (ER) stress was associated with hepatocellular carcinogenesis, and that BAP31 regulates the export of secreted membrane proteins from the ER to the downstream secretory pathway, the authors investigated BAP31 as potential correlate of tumor biology, and hence prognosis. The study utilized paraffin-embedded tissue microarrays on a training, and a validation, cohort of HCC patients. The outcome indicates poor survival and higher tumor recurrence rate post-operatively correlated with low expression of BAP31 in tumor cells. Tumors that expressed this protein had a mean overall survival of 46.3 months versus 33.6 months in low expressor (p=0.021) among the validation cohort.  Also mean time to recurrence of 36.8 versus 26. 5 months was found in the validation cohort in high versus low expressing tumors respectively, although this did not reach statistical significance (p= 0.13). How BAP31 expression correlates with other measures of tumor biology was also analyzed.


Liver transplantation Jan-Feb 2016


Contribution of alloantigens to hepatic ischemia/reperfusion injury: Roles of natural killer cells and innate immune recognition of nonself. 
Kimura S, et al. Liver Transpl. 2016;22(1):80-90

Overactivation of the nuclear factor (erythroid-derived 2)-like 2-antioxidant response element pathway in hepatocytes decreases hepatic ischemia/reperfusion injury in mice. 
Lee LY, et al. Liver Transpl. 2016;22(1):91-102.

Subnormothermic ex vivo liver perfusion is a safe alternative to cold static storage for preserving standard criteria grafts. 
Spetzler VN, et al. Liver Transpl. 2016;22(1):111-9

The January 2016 issue of Liver Transplantation published three articles around ischemia-reperfusion and preservation injury of transplanted grafts.  A role for alloantigens and Natural Killer Cells is proposed by the Pittsburgh group (Kimura S et al), because depleting NK cells reduced significantly reperfusion injury. A second paper proposed mediating the antioxidant response influenced reperfusion injury in a mouse model. Lee LY et al demonstrated that “Over-activation of the Nuclear Factor (Erythroid-Derived 2)–Like 2–Antioxidant Response Element Pathway in Hepatocytes Decreases Hepatic Ischemia/Reperfusion Injury in Mice”. A third paper utilized an ex vivo warm preservation method at just subnormothermic temperature to demonstrate superior outcome to the traditional cold storage of standard criteria cadaveric organs in humans.  This paper by Spetzler VN et al from Toronto, Canada  demonstrated histologically and biochemically that parenchymal, endothelial, and biliary epithelial cells were better preserved using subnormothermic ex vivo than cold preservation.

Excellent outcomes of liver transplantation using severely steatotic grafts from brain-dead donors. 
Wong, T et al. Liver Transpl 2016;22:226-236

This paper challenges the traditional view that steatosis was a contraindication to organ acceptance for transplantation. Between 1991 and 2013 19 patients received grafts with more than 60% macrovesicular steatosis. Compared with a control of 354 recipients of less steatotic grafts, the short-term and long-term outcomes were not clinically or statistically significant. The outcome parameters measured are primary non-function; post-operative hospital stay duration; early allograft dysfunction; 30-day mortality and 1-year and 3-year overall survival rates.

Gut, Jan-Feb 2016


Stratification of hepatocellular carcinoma risk in primary biliary cirrhosis: a multicenter international study. 
Trivedi PJ, et al; Global PBC Study Group. Gut. 2016 Feb;65(2):321-9.

Hepatocellular carcinoma is a rare event in patients with primary biliary cirrhosis/cholangitis.  In this study of 4565 patients with PBC, 123 developed HCC (incidence rate of 3.4 cases/1000 patient-years).  The authors attempt to define the risk factors for the development of HCC in this cohort.  In univariate analysis male sex, elevated aspartate aminotransferase, thrombocytopenia, advanced biochemical disease, and hepatic decompensation were significantly associated with HCC development.  Advanced fibrosis (stage III/IV according to Batts and Ludwig) was also predictive but many patients did not have a baseline liver biopsy.  The strongest predictor of HCC development was lack of biochemical response (measured by Paris-I criteria) to ursodeoxycholic acid.  Lack of response to urso predicted development of HCC in patients with all stages of disease.  On multivariate analysis lack of biochemical response was the most significant factor predictive of HCC (hazard ratio 3.44).

Modern Pathology, Jan-Feb 2016


Inflammatory hepatocellular adenomas developed in the setting of chronic liver disease and cirrhosis.
Calderaro J; et al. Modern Pathology, 2016;26(1):43-50.

Hepatocellular adenoma, a heterogeneous entity, often occurs in non-fibrotic livers. The most common subtype of hepatocellular adenoma is inflammatory adenoma that harbors somatic mutations of genes involving in interleukin-6 pathway leading to elevated C-reactive protein and serum amyloid A expression. In this study, 10 benign hepatocellular neoplasms from three patients with cirrhosis were assessed using immunohistochemistry and molecular methods, including PCR and sequencing for CTNNB1, HNF1A, IL6ST, GNAS, STAT3, and TERT (promoter) mutations. A group of 32 cirrhotic livers that were caused by various etiologies was used as controls. The etiologies of cirrhosis of the three study patients included metabolic syndrome and/or alcohol liver disease. Two of them had a single tumor, and one developed more than 30 lesions. Microscopic examination revealed well-differentiated neoplasms that shared morphological features of inflammatory adenoma including inflammatory infiltrates, sinusoidal dilatation, and dystrophic vessels. Sequencing analysis demonstrated somatic mutations of IL6ST (n=8), STAT3 (n=1) and GNAS (n=1), the typical hotspots in IL-6/JAK/STAT pathway. Additionally, two lesions were immunoreactive for serum amyloid A and/or C-reactive protein. In summary, the findings support the existence of rare inflammatory type hepatocellular adenoma in patients with cirrhosis.

Gastroenterology, Jan-Feb 2016


Time to Replace Assessment of Liver Histology With MR-Based Imaging Tests to Assess Efficacy of Interventions for Nonalcoholic Fatty Liver Disease. 
Byrne C, Targher G. Gastroenterology. 2016;150(1):7-10.

This commentary is likely a response to the views expressed by Drs. Kleiner and Bedossa in the previous issue regarding histologic end points for NASH trials (covered in previous J watch).  The authors argue that the FDA requirement of improvement of the histologically derived NAFLD Activity Score by 2 points for drug approval for NASH should be changed. The authors believe liver fat content is an early marker of disease, and should be used for evaluation of treatment. This is also relevant as patients with steatosis have increased risk of cardiovascular disease and it is also important to ensure that therapy for NAFLD prevents harm beyond the liver as well. The authors also cite a few small studies that show that there is no difference in disease progression in simple steatosis vs. steatohepatitis.

End Points Must Be Clinically Meaningful for Drug Development in Nonalcoholic Fatty Liver Disease.
Sanyal AJ, et al. Gastroenterology. 2016;150(1):7-10.

In a competing opinion, these authors state that there is no compelling evidence that improvement of steatosis will lead to “clinically meaningful benefit,” as intended by the FDA. Hence improvement in steatosis alone by MR or other techniques does not meet regulatory standards to be accepted as the surrogate for drug approval for NASH.

Am J Pathology, Jan-Feb 2016


Diet-Induced Obesity Enhances Progression of Hepatocellular Carcinoma through Tenascin-C/Toll-Like Receptor 4 Signaling
Benbow JH et al. Am J Pathol 2016 Jan;186(1):145-158.

Tenascin-C is an extracellular matrix protein known to play a role in fibrogenesis and tumorigenesis. The authors developed a diet-induced obesity HCC mouse model and used it along with other tools to determine the cellular mechanism by which TnC signaling is involved in the promotion of inflammation, hepatocyte epithelial-to-mesenchymal transition (EMT), hepatocyte migration and carcinogenesis. Patients’ plasma TnC levels were also measured; obese patients with cirrhosis alone and in combination with HCC showed significant increases compared to healthy volunteers and patients with less severe liver injury. The authors conclude that hepatic stellate cell-derived TnC is elevated in obesity-associated HCC and that TnC can initiate an inflammatory response and EMT through TLR4 signaling. TnC is potentially a candidate as an early HCC biomarker and may also be a therapeutic target.

Serum miR-30e and miR-223 as Novel Noninvasive Biomarkers for Hepatocellular Carcinoma
Bhattacharya S et al. Am J Pathol 2016 Feb;186(2):242-247.

Limited noninvasive biomarkers for HCC detection are available, but early detection is key for improving outcomes. MiRNAs are single stranded, noncoding RNAs which regulate gene silencing by targeting mRNA directly for degradation or by inhibiting translation. 70 serum samples were utilized for miRNA-specific qRT-PCR. The authors found that miR-30e and miR-223 were expressed in significantly lower levels in the sera of HCC patients compared with healthy volunteers and chronic liver disease patients. These miRNAs may be candidates for useful HCC biomarkers.

Hepatology Jan-Feb 2016

Circulating Tumor Cells are Associated with Poor Overall Survival in Patients with Cholangiocarcinoma
Yang JD et al. Hepatology 2016;63:148-158.

The incidence of intrahepatic cholangiocarcinoma (iCCA) appears to be increasing and the prognosis remains dismal due to late detection. As a tumor proliferates, some tumor cells are released into the bloodstream to generate circulating tumor cells (CTCs). CTCs can be detected by tools such as the CellSearch System which uses EpCAM antibody-coated magnetic beads. These authors prospectively studied 88 iCCA patients and found that CTCs were associated with more aggressive tumor characteristics (including more extensive tumor burden, larger tumor size, multifocal disease, lymph node involvement and metastatic disease) and independently associated with survival after adjusting for known predictors of survival. The detection of CTCs could be useful for patient management decisions and as a predictor of recurrent disease s/p resection or as a predictor of unresectability.

Risk Stratification in Autoimmune Cholestatic Liver Diseases: Opportunities for Clinicians and Trialists
Trivedi PJ et al. Hepatology 2016;63:644-659.

Renewed interest in and understanding of the mechanistic and biologic pathways involved in primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) have spurned the desire for additional therapies beyond ursodeoxycholic acid. The newer therapies would be aimed at both slowing the disease progression and improving quality of life. Also, there is now a better understanding of disease heterogeneity and therefore an opportunity to provide patients with a more individualized assessment. These factors have led to a new approach to patient care that focuses on risk stratification. This article reviews the applicability and validity of risk stratification in autoimmune cholestatic liver disease.

Clinical Gastroenterology and Hepatology Jan-Feb 2016


The Epidemiology of Liver Disease Unique to Pregnancy in a US Community: A Population-Based Study
Allen AM, Kim WR et al.  Clin Gastroenterol Hepatol. 2016;14:287-294.

The epidemiology of liver diseases of pregnancy (LDoP) including intrahepatic cholestasis of pregnancy (ICP), acute fatty liver of pregnancy (AFLP), HEELP (hemolysis, elevated liver enzyme, and low platelets), hyperemesis gravidarum (HG) and preeclampsia (PE) with liver dysfunction, in the US population is largely unknown. This first population based study of LDoP in the US identified 247 subjects with LDoP from 35,101 pregnancies in 21,857 subjects in Olmsted County, Minnesota between 1996 and 2010 using the Rochester Epidemiology Project database.  The overall incidence of LDoP was 0.77% of pregnancies, lower than that reported from Europe or US tertiary referral centers. PE with liver dysfunction was the most common (0.4%) followed by HELLP (0.23%) and ICP (0.1%), whereas HG with liver dysfunction (0.05%) and AFLP (one patient) were very rare. The overall fetal motility rate was 4% in patients with PE, 3% in patients HELLP, and 100% in the one case with AFLP. In the median of 7 years follow-up, the recurrence rate in subsequent pregnancies was 64% in HG, 63% in ICP and 17% in HELLP. Subsequent hepatobiliary diseases and other medical conditions were not common in the study.


Journal of Hepatology Jan-Feb 2016


Morphophenotypic changes in human multistep hepatocarcinogenesis with translational implications.
Sciarra A, Tommaso LD et al. Journal of Hepatology 2016; 64:87-93. 

The multistep Human hepatocarcinogenesis from low to high grade dysplastic nodules (LGDN and HGDN), to early and progressed hepatocellular carcinoma (eHCC and pHCC) is still controversial. The authors studied the morphophenotypic changes (vascular profile, ductular reaction/stromal invasion) and overexpression of five biomarkers (GPC3, HSP70, GS, CHC and EZH2), in a series of 100 resected nodules (13 LGDN, 16 HGDN, 42 eHCC and 29 pHCC). The data suggested that the earliest alteration was the vascular remodeling of the nodules, detectable in LGDN, but did not linearly develop in the sequence. As the disease progresses, there is significantly increased biomarker overexpression and decreased DR. The mean value of cumulative semi-quantitative score (CK7/CD34/5 biomarkers) was significantly different among the four diagnostic categories. For diagnosis, using traditional 3M panel (HPS70, GS and GPC3), eHCC was detected in 52% of the cases. When applying 4M panel (HPS70, GS, GPC3, and CHC) and 5M panel, eHCC was documented in 76% and 93% of the cases respectively. The study support the multistep nature of hepatocarcinogenesis. Additional biomarkers may increase the sensitivity and specificity of diagnosing eHCC.

FibroGENE: A gene-based model for staging liver fibrosis.
Eslam M, Hashem AM et al. Journal of Hepatology 2016; 64:390-398. 

Several non-invasive methods based on panels of serum markers, or the measurement of liver stiffness by elastograph have been established and widely used as surrogate measures. But the concerns about reproducibility and over- or under-estimation of fibrosis stage in these methods, particularly for non- CHC (chronic hepatitis C) diseases such as CHB and NAFLD, are problematic. The recent findings from the study group indicated that single-nucleotide polymorphisms (rs12979860) in the intronic region of the interferon-k4 (IFNL4) gene modulate liver inflammation and fibrosis, in an etiology independent manner. The authors in the current study sought to incorporate the invariant genetic marker of liver fibrosis risk to algorithms for fibrosis prediction, in combination with routinely available clinical and laboratory data. After analysis of two cohorts 3234 patients with liver fibrosis of different etiologies, data suggest that the novel non-invasive decision tree model (FibroGENE-DT) reliably estimates the risk of fast fibrosis progression, significant fibrosis and cirrhosis. FibroGENE-DT also performs well in NAFLD and CHB with AUROCs (area under the receiver operating characteristic curve) of 0.791, and 0.726, respectively. In addition, FibroGENE-DT excludes cirrhosis with a negative predictive value (NPV) of > 0.96 in CHC, CHB and NAFLD. FibroGENE-DT model may be an effective clinical tool for prediction of fibrosis risk in chronic liver diseases and assessment of liver fibrosis stage to aid clinical decision making.

Prepared by:
Rish Pai, MD, PhD; Mayo Clinic Arizona
Sanjay Kakar, MD; University of California, San Francisco
Cindy Guy, MD; Duke University
Wenqing Cao, MD; New York University
Jingmei Lin, MD, PhD; Indiana University
Oyedele Adeyi, MD; University of Toronto

Journals Reviewed
American Journal of Surgical Pathology, Modern Pathology, Histopathology, Human Pathology, American Journal of Clinical Pathology, Journal of Pathology, Archives of Pathology and Laboratory Medicine, Advances in Anatomic Pathology, Hepatology, Journal of Hepatology, Liver Transplantation, Gastroenterology, Gut, Clinical Gastroenterology and Hepatology, Journal of Gastroenterology and Hepatology, American Journal of Gastroenterology