Thursday, February 23, 2017

Hans Popper Hepatopathology Society Reception 2017

Hans Popper Hepatopathology Society Members,

You are invited to the Hans Popper Hepatopathology Society Reception

Saturday March 4th
6:00-8:00 PM

Hilton Palacio Del Rio, Room H-2093
200 S. Alamo St
San Antonio TX 78205

Telephone number to hotel front desk: 210-222-1400

Looking forward to seeing you!

Wednesday, February 22, 2017

President’s Message February 2017

As promised, this president’s message will continue on a “tour” of the Hans Popper Hepatopathology Society structure. The executive committee has been working very hard on writing and adopting SOPs for each of the offices and committees of the HPHS.  We hope to have these finished very soon, at which point they will be posted on the HPS website, available to anyone who like to view them. The Executive Committee hopes this will help make the HPHS more accessible to all by making it easier to understand all of the “moving parts” of the society and how the committees and offices are interrelated.  SOP is short for standard operating procedure (sometimes also called “standing operating procedure”). SOPs function in societies like the HPHS as a template, describing the duties and roles for each committee and officer. While SOPs tend to be a bit dry to talk about, not nearly as exciting as a liver biopsy, they are important to make sure societies function smoothly and are especially important as societies become larger.  Because the HPHS has grown so successfully over the past years, it’s a great time to put into place more formal SOPs.

In the last message, we reviewed the Executive Committee and its function.  This time we will review the Membership Committee.  Members are the most important element of the HPHS—in fact the mission of the HPHS is to serve its members through educational offerings in the art and science of liver pathology.  Thus, the Membership Committee is of particular importance.  The Committee has a chairperson and 5 members, each who serve for three years.  The start/end times for each are staggered in order to maintain a smooth transition as new members rotate on/off.  The Membership Committee is responsible for reviewing and approving membership applications, including associate members and emeritus members.  Associate membership is extended to individuals still in training programs (residency/fellowship) and lasts for 2 years, renewable as needed.  The Chair of the Committee presents the list of new members at the annual HPHS Business Meeting during the USCAP annual meeting.  The Membership Committee Chair also maintains (working closely with the secretary-treasurer) the full list of all members with their contact information.  Finally, this important committee is also in charge of actively seeking new members for the HPHS—the society grows and thrives by recruiting new members who have an interest in liver pathology.  

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

Hans Popper Hepatopathology Society Reception
Saturday March 4th
Time: 6:00-8:00 PM
Room H-2093
Hilton Palacio Del Rio
200 S. Alamo St
San Antonio TX 78205
Telephone to hotel front desk 210-222-1400

Michael Torbenson, MD
President, Hans Popper Hepatopathology Society

Wednesday, January 25, 2017

Journal Watch November-December 2016

American Journal of Gastroenterology

Vitamin D is not associated with severity in NAFLD: Results of a paired clinical and gene expression profile analysis
Patel YA, Henao R, Moylan CA, Guy CD, Piercy DL, Diehl AM, Abdelmalek MF. Am J Gastroenterol 2016;111:1591-1598.

Vitamin D deficiency is associated with obesity, sedentary lifestyle, and insulin resistance.  Recent studies have implicated vitamin D in the pathogenesis of NAFLD.  The authors of this study correlated vitamin D levels with clinical, histologic, and gene expression differences in patients with NAFLD.  Vitamin D levels decreased with increased BMI but no differences were seen in vitamin D levels between patients with NAFLD and control patients.  There was no association between vitamin D levels and steatosis, lobular inflammation, ballooning, or overall NAS score.  Interestingly, vitamin D levels increased with increasing fibrosis up to stage 3 but were decreased in cirrhotic patients.  When comparing stage 0-1 to stage 3-4 patients, there only minor differences in expression of genes associated with vitamin D metabolism.


Zhou S, Venkatramani R, Gomulia E, Shillingford N, Wang L. Histopathol 2016; Nov;69(5):822-830

The authors studied the diagnostic and prognostic utility of SALL4 in hepatoblastomas (HB). This marker was present in 100% and 41% respectively of embryonal and fetal components of HB, but not in the small cell or mesenchymal components. Also SALL4 expression correlated with poor overall survival and other prognostic indices.
AIMS: To investigate the expression of spalt-like transcription factor 4 (SALL4), a regulator of embryonal development, in three epithelial components of hepatoblastoma (HB) and the relationship between SALL4 expression levels and patients' clinicopathological features.
METHODS AND RESULTS:  A total of 115 specimens from 79 patients with HB were selected for immunostaining of SALL4. Nuclear staining was semi-quantified using the immunoreactive score (IS; range: 0-12). SALL4 expression was seen in all embryonal components (mean IS = 8.58) and in 41% of fetal components (mean IS = 0.78). No SALL4 expression was seen in either small cell undifferentiated or mesenchymal components of HB. Neither chemotherapy nor metastasis altered SALL4 expression significantly. High SALL4 expression levels were associated significantly with decreased overall survival (OS) (P = 0.004), event-free survival (EFS) (P = 0.003) and the presence of metastasis (P = 0.049) on univariate analysis. Multivariate analysis identified SALL4 as an independent prognostic predictor for OS (P = 0.029).
CONCLUSIONS:  SALL4 is useful for subtyping HB, and high SALL4 expression is associated with decreased survival in HB.

Piotti KC, Yantiss RK, Chen Z, Jessurun J. Histopathol 2016; Dec;69(6):937-942

AIMS:  Serum amyloid A is an acute phase reactant that is produced by hepatocytes in response to either inflammatory or neoplastic conditions. Because inflammatory adenomas produce this protein, serum amyloid A immunohistochemistry has been used in the evaluation of hepatocellular neoplasms. However, studies evaluating the expression of this protein in hepatitis are lacking. The aim of this study was to perform serum amyloid A immunostains on medical liver biopsy specimens of patients with common chronic liver diseases and correlate them with disease activity and stage.
METHODS AND RESULTS:  We performed serum amyloid A immunostains on 160 medical liver biopsies, including 100 cases of hepatitis C virus infection at different stages (20 cases of each) and 20 cases each of hepatitis B viral infection, steatohepatitis and autoimmune hepatitis. The extent and location of staining was recorded and correlated with grade, stage and laboratory values (transaminases, bilirubin and viral load). Data were analyzed using the Cochran-Mantel-Haenszel χ2 test for trend. Serum amyloid A staining was present in 130 (81%) cases and was limited to zone 3 perivenular hepatocytes in 66 (41%). Biopsy specimens with less fibrosis and/or mild portal inflammation showed significantly more staining than those with cirrhosis (P < 0.001), or at least moderate inflammatory activity (P < 0.001). There was no significant association between lobular inflammation (P = 0.06), bilirubin levels or viral load and immunohistochemical staining for serum amyloid A.
CONCLUSIONS:  Our results show that liver biopsy specimens with mildly active chronic hepatitis, early fibrosis and normal serum transaminases show more serum amyloid A immunopositivity compared with cases with more inflammatory activity, fibrosis or transaminitis. These findings indicate that serum amyloid A is expressed primarily in the early phases of disease and might influence progression and/or response to treatment.

Shalaby A, Hajhosseiny R, Zen Y, Davenport M, Quaglia A. Histopathol 2016; Dec;69(6):943-949

Aims: Orientation and digital analysis of the biliary remnants in the resected porta hepatis in infants with biliary atresia.
Methods and results:  Samples were orientated intra-operatively then stained with haematoxylin and eosin and immunostained for cytokeratin 7 (CK7). Sections were then digitized and analysed. Most proximal transected surface area was defined as the porta hepatis area (PHA) and the biliary epithelial area was defined as ‘BEA’. Data are quoted as median (range). Non-parametric statistical comparisons were made as appropriate. P < 0.05 was regarded as significant. Thirty-eight infants underwent surgery [median age 53 (16–120) days]. Eight specimens were excluded from the study due to technical reasons, leaving 30 specimens as the study cohort. Median PHA was 70 (30–133) mm2, median BEA 0.57 (0.07–5.5) mm2 (r = 0.51; P < 0.002). The median BEA/PHA ratio was 9.6 × 10−3 (1.9–104 × 10−3). There was a marked correlation of PHA with plasma γ-glutamyl transpeptidase (r = −0.51; P = 0.001). Both total BEA and the BEA/PHA ratio correlated with alkaline phosphatase (r = −0.35; P = 0.03 and r = −0.47; P = 0.005, respectively). Age at surgery correlated inversely with BEA (r = −0.44; P = 0.01) but not PHA (P = 0.1).
Conclusions: Precise quantification of biliary remnants is possible and correlates with biochemical variables. Values for BEA were associated with and declined demonstrably with increasing age at surgery.

Fujikura K, Fukumoto T, Ajiki T, Otani K, Kanzawa M, Akita M, Kido M, Ku Y, Itoh T, Zen Y. Histopathol 2016; Dec;69(6):950-961.

Aims: The aim of this study was to achieve a better definition of intraductal papillary neoplasms of the bile duct (IPNBs).
Methods and results: Biliary tumours that showed predominantly intraductal papillary growth were provisionally classified as IPNBs (n = 25) and papillary cholangiocarcinomas (n = 27). IPNB was defined as a neoplasm that is confined to the epithelium or is regularly arranged in a high-papillary architecture along thin fibrovascular stalks, whereas the term ‘papillary cholangiocarcinoma’ was used for tumours with more complex papillary structures (e.g. irregular papillary branching or mixed with solid–tubular growth). In our consecutive cohort of biliary neoplasms, 5% were classified as IPNBs, and 10% as papillary cholangiocarcinomas. IPNBs differed from papillary cholangiocarcinomas by less advanced invasion, gross mucin overproduction (72% versus 7%), and their prevalent location (84% of IPNBs in intrahepatic/hilar ducts; 70% of papillary cholangiocarcinomas in extrahepatic ducts). Gastric-type and oncocytic-type tumours were only detected in IPNBs. Expression of mucin core proteins and cytokeratin 20 significantly differed between the two groups. KRAS and GNAS were wild-type genotypes in all but one case of KRAS-mutated IPNB. Patients with IPNB had better recurrence-free survival than those with papillary cholangiocarcinoma (P = 0.007). In multivariate analysis, in which several other prognostic factors (e.g. stromal invasion and lymph node metastasis) were applied, the classification of the two papillary tumours was an independent prognostic factor (P = 0.040).
Conclusions: Given the significant contrast in clinicopathological features between IPNBs and papillary cholangiocarcinomas, it may be more appropriate to use the diagnostic term ‘IPNB’ for selected tumours that show regular papillary growth, separately from papillary cholangiocarcinomas.

Chan AW, Yu S, Yu YH, Tong JH, Wang L, Tin EK, Chong CC, Chan SL, Wong GL, Wong VW, Chan HL, Lai PB, To KF. Histopathol 2016; Dec;69(6):971-984.

Aims: Steatosis in hepatocellular carcinoma (HCC) has been recognized for decades and found most commonly in small, well-differentiated HCC. However, the clinicopathological features and pathogenesis of HCC with steatosis is not well characterized. There are few data concerning whether HCC with steatosis should be regarded a distinct histological variant, steatotic HCC.
Methods and results: A retrospective cohort of 516 patients undergoing curative surgery for primary HCC was recruited. The median follow-up was 45.5 (range: 0.2–166.0) months. Steatotic HCC was defined as HCC with significant steatosis (≥5% of tumour cells). Associations with immunohistochemical expression of fatty acid binding protein-1 (FABP1), sonic hedgehog (SHH) and gene polymorphism of patatin-like phospholipase 3 (PNPLA3) were analysed. Steatotic HCC was found in 21.1% of patients and was associated with higher metabolic risks [diabetes mellitus (36.7% versus 18.2%) and hypertension (44.0% versus 28.7%)], underlying fatty liver (60.6% versus 37.8%), steatohepatitis (30.3% versus 13.0%), smaller tumour size, lower frequency of major vessel (1.8% versus 11.3%) and microvascular invasion (20.2% versus 32.4%), earlier tumour stages and lower serum alpha-fetoprotein. It was associated with developing late tumour relapse (hazard ratio 2.15, P = 0.002) independently of underlying cirrhosis and non-anatomical excision. Steatotic HCC did not differ from HCC without significant steatosis in immunohistochemical expression of FABP1 and SHH and PNPLA3 gene polymorphism.
Conclusion: Steatotic HCC is a common histological variant of HCC with distinct association with underlying fatty liver, steatohepatitis and metabolic risks. Despite more favourable baseline tumour features, it was associated with late tumour relapse.

Walter D, Herrmann E, Winkelmann R, Albert JG, Liese J, Schnitzbauer A, Zeuzem S, Hansmann ML, Peveling-Oberhag J, Hartmann S. Histopathol 2016; Dec;69(6):962-970.

Background and aims: CD15 is expressed by various cancer types; among these are intrahepatic and perihilar cholangiocarcinoma (CCA). The aim of this study was to elucidate CD15 expression in distal CCA as well as in dysplastic biliary tissue and to determine its prognostic significance.
Methods and results: Tissue samples from patients with intrahepatic (iCCA, n = 22), perihilar (pCCA, n = 7) and distal CCA (dCCA, n = 15), who underwent surgical resection in the period from 2010 to 2015 were evaluated for CD15 expression. Tissue of synchronous lymph node metastasis (n = 13), CCA-associated dysplasia (n = 20), dysplasia in intraductal biopsies (n = 10) and benign proliferations (n = 12), as well as inflammatory biliary lesions (n = 28) and non-inflammatory bile ducts (n = 23), were evaluated equally for CD15 expression. CD15 was found to be expressed highly in iCCA (81.8%), pCCA (85.7%), dCCA (73.3%), CCA-associated dysplasia (70.0%), dysplasia in intraductal biopsies (100%) and metastatic tissue (84.6%). CD15 expression was negative in 58 of 64 benign bile duct alterations resulting in an overall sensitivity and specificity of CD15 in CCA of 80.7 and 90.6% patients, respectively. CD15 expression was correlated significantly with a decreased overall survival in patients with CD15-positive CCA associated dysplasia (P = 0.003). However, CD15 expression in the invasive tumour component was not correlated with clinical outcome.
Conclusion: CD15 is a sensitive and specific marker for intraepithelial and invasive neoplasias of the bile duct. Therefore, it can be helpful in the delineation of dysplastic and neoplastic biliary cells from non-neoplastic tissue, which frequently causes a diagnostic problem in indeterminate biliary stricture.

Modern Pathology

Hale G, Liu X, Hu J, Xu Z, Che L, Solomon D, Tsokos C, Shafizadeh N, Chen X, Gill R, Kakar S. Mod Pathol 2016; Nov; 29(11):1370-1380.

The study examines the correlation between glutamine synthetase staining patterns and β-catenin mutations in 15 typical hepatocellular adenomas, 5 atypical hepatocellular neoplasms and 60 hepatocellular carcinomas. Glutamine synthetase staining was classified as: (1) diffuse homogeneous: moderate-to-strong cytoplasmic staining in >90% of lesional cells, without a map-like pattern, (2) diffuse heterogeneous: moderate-to-strong staining in 50-90% of lesional cells, without a map-like pattern, and (3) patchy: moderate-to-strong staining in <50% of lesional cells (often perivascular), or weak staining irrespective of the extent, and all other staining patterns (including negative cases). Sanger sequencing of CTNNB1 exon 3 was performed in all cases. Of hepatocellular tumors with diffuse glutamine synthetase staining (homogeneous or heterogeneous), an exon 3 β-catenin mutation was detected in 33% (2/6) of typical hepatocellular adenoma, 75% (3/4) of atypical hepatocellular neoplasm and 17% (8/47) of hepatocellular carcinomas. An exon 3 mutation was also observed in 15% (2/13) of hepatocellular carcinomas with patchy glutamine synthetase staining. The results show a modest correlation between diffuse glutamine synthetase immunostaining and exon 3 β-catenin mutations in hepatocellular adenoma and hepatocellular carcinoma with discrepancy rates >50% in both hepatocellular adenoma and hepatocellular carcinoma. The interpretation of β-catenin activation based on glutamine synthetase staining should be performed with caution, and the undetermined significance of various glutamine synthetase patterns should be highlighted in pathology reports.

Journal of Hepatology

Solà E, Kerbert A, Verspaget HW, et al. J Hepatol 2016; 65:914-920.

Clinical decompensation of cirrhosis is mainly related to a progressive increase in portal hypertension and circulatory dysfunction. Copeptin is the C-terminal fragment of the vasopressin (AVP) precursor and is secreted from neurohypophysis together with AVP. This prospective study included 321 patients and investigated the level of copeptin in disease progression and prognosis of cirrhosis.  The plasma copeptin level showed a significant correlation with plasma AVP level and endogenous vasoactive systems in cirrhotic patients. Compared to the patients with compensated cirrhosis, the patients with decompensation showed significantly higher plasma copeptin levels. Multivariate analysis revealed plasma copeptin was an independent predictor of development of complications of cirrhosis and 3-months mortality. The data suggests that copeptin is reliable marker for disease progression, decompensation and poor prognosis in patients with cirrhosis.

Pais R, Barritt AS 4th, Calmus Y, Scatton O, Runge T, Lebray P, Poynard T, Ratziu V, Conti F. J Hepatol 2016; 65:1245-1257.

NAFLD has become one of the most frequent cause of chronic liver disease, cryptogenic cirrhosis, and hepatocellular carcinoma, and is the second leading cause of liver transplantation (LT) in the United States. In this review article, the authors discuss the multifaceted impact of NAFLD on liver transplantation and how to optimize the outcome of NAFLD patients undergoing LT. Several key points are raised: patients with NAFLD listed for LT are more often removed from the waiting list because of associated comorbidities and older age; the shortage of liver grafts will increase in the future and the use of fatty liver grafts will require optimization of surgical and preservation techniques; patients with NAFLD are at higher risk of cardiovascular morbidity and mortality following LT; NAFLD recurrence is frequent after LT.

American Journal of Surgical Pathology

Russo P1, Magee JC, Anders RA, Bove KE, Chung C, Cummings OW, Finegold MJ, Finn LS, Kim GE, Lovell MA, Magid MS, Melin-Aldana H, Ranganathan S, Shehata BM, Wang LL, White FV, Chen Z, Spino C; Childhood Liver Disease Research Network (ChiLDReN). Am J Surg Pathol 2016; Dec;40(12):1601-1615.

Given variability in data and limitation to single institution cohorts in previous studies, the goal of this project was to better define which histologic features are the strongest predictors of biliary atresia (BA) and identify parameters that may be of prognostic significance.  This study utilized data and slide review from cholestatic infants that were prospectively enrolled in the multicenter ChiLDReN network to determine which histologic features: (1) could distinguish BA from non-BA causes of cholestasis [N=227]; (2) varied with respect to clinical parameters (including age); and (3) correlated with clinical outcome in BA patients after hepatoportoenterostomy (HPE) [N=316].  Except for patient age, central review pathologists were blinded to all clinical information and scored 26 histologic features based on consensus.  Bile plugs in portal tracts and portal tract edema, when seen without bile duct paucity or features of idiopathic neonatal hepatitis (giant cell transformation and extramedullary hematopoiesis), were most associated with BA (diagnostic accuracy 90%).  With regard to clinical outcomes, elevated bilirubin 6 months after HPE was associated with older age, but showed no strong correlation with histologic changes.  Advanced fibrosis (Batts-Ludwig stage ≥3 fibrosis), ductal plate malformation, bile duct injury, older age at HPE, and elevated INR were associated with an increased risk for transplantation.  In contrast to previous literature, this study found that age was not a significant factor in assigning the biopsy to the correct category of disease (BA vs. non-BA), and that there was substantial variability in the range of histologic changes in cases of BA that were clinically well-characterized.  Common causes of misinterpretation of findings in BA cases as non-BA included an overestimation of bile duct paucity and underestimation of portal tract edema as well as known mimickers of BA (cystic fibrosis and α-1 antitrypsin deficiency) in needle biopsies.

Archives of Pathology and Laboratory Medicine

Ainechi S, Lee H. Arch Pathol Lab Med 2016; Nov;140(11):1285-1289.

This resident short review summarizes current terminology and disease concepts for precancerous lesions of the biliary tract.  Normal biliary tract histology, categories and features of biliary neoplasia (biliary intraepithelial neoplasia, intraductal papillary neoplasm of the bile duct, intraductal tubular neoplasm, mucinous cystic neoplasm, differences in immunophenotype), geographic differences in disease incidence and risk factors for biliary neoplasia are discussed in this manuscript.


Happaerts S, Foucault A, Billiard JS, Nguyen B, Vandenbroucke-Menu F. Hepatol 2016; 64(5): 1800-1802.

The authors report a case of a 27 year-old woman with a past medical history of tetralogy of Fallot and Abernathy malformation (congenital extrahepatic portosystemic shunt), who had a 22 cm combined hepatocellular-cholangiocarcinoma (HCC-CC) resected.  Non-neoplastic tissue adjacent to the carcinoma showed FNH-like reaction, consistent with the pre-operative imaging studies which suggested nodular regenerative hyperplasia, FNH, and FNH-like lesions in addition to the carcinoma. Such lesions, including hepatocellular carcinoma (HCC), have been reported in the past, but this is the first report of HCC-CC in the setting of Abernathy malformation. Of particular interest is a 2011 paper referenced by the authors, which describes in detail the various histologic findings seen in Abernathy malformation. These include absence of portal veins in small portal tracts, hypoplastic portal veins in larger portal tracts, lobular unpaired arterioles, hepatic artery hypertrophy, and nodular regenerative hyperplasia, all changes which likely reflect the absence of a portal venous system with compensatory hepatic artery buffer response.

Calderaro J, Rousseau B, Amaddeo G, Mercey M, Charpy C, Costentin C, Luciani A, Zafrani ES, Laurent A, Azoulay D, Lafdil F, Pawlotsky JM. Hepatol 2016; 64(6): 2038-2046.

The authors investigated the PD-L1 status of 217 hepatocellular carcinomas. PD-L1 expression by neoplastic cells was associated with elevated serum AFP, satellite nodules, lymphovascular space invasion, poor differentiation, and CK19 expression. PD-L1 expression by inflammatory cells associated with the tumor was associated with elevated serum AFP, lymphovascular space invasion, poor differentiation, and lymphoepithelial histologic subtype of HCC. No association was seen with B-catenin nuclear staining or with diffuse glutamine synthetase expression.

Rebouissou S, Franconi A, Calderaro J, Letouzé E, Imbeaud S, Pilati C, Nault JC, Couchy G, Laurent A, Balabaud C, Bioulac-Sage P, Zucman-Rossi J. Hepatol 2016; 64(6):2047-2061.

This paper is by the French group which has reported much of the data on hepatocellular adenoma (HA) subtypes. In this study, the authors investigated B-catenin mutation status and B-catenin activity levels on fresh frozen tissue from 220 HAs, 373 HCCs, and 17 borderline HA/HCC lesions. Overall B-catenin activity was higher in HCCs than HAs, and this was related to mutation type. In their HAs, they divided the B-catenin activation into three categories, which was related to specific mutations:
1) Weak activation: S45, K335, and N387 mutations.
2) Moderate activation: T41 mutations.
3) High activation: Exon 3 deletions (most commonly seen in borderline lesions) and D32-S37 mutations.
Tumors with highly active mutations demonstrated strong and homogenous GS staining. Weak mutants demonstrated heterogenous and patchy GS staining. Also, highly active mutants typically showed nuclear B-catenin IHC staining, whereas weakly active mutants did not. Thus, weak mutants would not show typical high risk IHC staining, whereas highly active mutants would. S45, however, is a notable exception which was a mutation seen in both HAs and HCCs. Although this mutation could be seen in malignancy, particularly if duplicated, GS IHC staining would not pick it up. In HCCs with weakly active mutations, the authors demonstrated B-catenin to be activated through additional events, such as loss of heterozygosity (LOH) at 3p or a second B-catenin mutation. Overall, the study is the largest to date correlating B-catenin mutation status with GS IHC staining pattern.

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

Tuesday, November 22, 2016

Journal Watch September-October 2016

Clinical Gastroenterology and Hepatology

Noninvasive Detection of Nonalcoholic Steatohepatitis Using Clinical Markers and Circulating Levels of Lipids and Metabolites
Zhou Y, Oresic M, Leivonen M, et al. Clin Gastroenterol Hepatol. 2016;14:1463-1472.

Clinical factors such as age, sex, liver enzymes, components of the metabolic syndrome, as well as circulating markers of inflammation, fibrosis, apoptosis, and extracellular matrix components are associated with NASH. Genetic factors, especially the I148M variant in patatin-like phospholipase domain containing protein 3 (PNPLA3), also confers susceptibility to NASH. In this study, using mass spectrometry (MS)-based methods, the authors identified a set of lipids and metabolites that significantly associated with NASH in a liver biopsy cohort of 318 patients. They subsequently developed models based on 1) clinical parameters and the PNPLA3 genotype alone (NASH Clin Score); 2) MS-based profiling (NASH Met Score); and 3) all data (NASH ClinLipMet Score). They found that the NASH ClinLipMet Score identified patients with NASH with significantly higher accuracy than the NASH Clin Score or NASH Met Score. A score based on MS (glutamate, isoleucine, glycine, lysophosphatidylcholine 16:0, phosphoethanolamine 40:6) and knowledge of AST, fasting insulin, and PNPLA3 genotype may be a useful tool to improve noninvasive diagnosis of NASH.

Journal of Hepatology

Definition and Risk Factors for Chronicity Following Acute Idiosyncratic Drug-induced Liver Injury
Medina-Caliz I, Robles-Diaz M, Garcia-Muñoz B,et al. J Hepatol. 2016; 65:57-65.

The best definition of DILI chronicity remains a matter of debate. This study prospective, long-term follow-up study analyzed 298 out of 850 patients in the Spanish DILI registry and concluded one year is the best cutoff point to define chronic DILI. In this cohort, 28 patients (8%) were chronic DILI. Risk factors for chronicity include old age, dyslipidemia, and severe DILI.  Compare to acute DILI, chronic DILI group had significantly higher mean values of alanine aminotransferase (ALT), alkaline phosphatase (ALP) and total bilirubin (TB). In addition, elevated ALP and TB in second month from DILI onset may predict chronicity. Main drug classes associated with chronic DILI were statins, and anti-infective.


Prevalence of Sclerosing Cholangitis Detected by Magnetic Resonance Cholangiography in Patients With Long-term Inflammatory Bowel Disease.
Lunder AK, Hov JR, Borthne A, et al. Gastroenterol. 2016;151(4):660-669.

This study examines MRCP findings in 756 patients with IBD 20 years after initial diagnosis to examine the prevalence of primary sclerosing cholangitis (PSC). Findings of PSC were seen on imaging in 26 cases (8.1%), of which only 7 (2.2%). PSC-related findings correlated with extensive colitis, history of colectomy, and persistent symptoms. In asymptomatic cases with PSC-like changes, the MRCP findings increased on follow-up. In this study, prevalence of PSC was 3-fold higher compared to that detected based on symptoms. Subclinical PSC and no biochemical abnormalities were seen in 65% of cases.

Shifting Paradigms: What Is the True Prevalence and Clinical Course of Primary Sclerosing Cholangitis?
Weersma RK, Lindor KD. Gastroenterol. 2016;151(4):590-3.

This is an editorial that accompanies the previous article. The review highlights the important findings of the paper:
-Biochemical abnormalities are not always present in PSC.
-Severe colitis and prior colectomy are risk factors for subclinical PSC.
-The natural history of subclinical PSC detected by MRCP will requires longer follow-up studies; the present data indicates that these cases progress in a subset of cases.

Human Pathology

Arginase-1 is frequently positive in hepatoid adenocarcinomas.
Chandan VS, Shah SS, Torbenson MS, et al. Hum Pathol. 2016; 55:11-6.

The morphology and immunohistochemical findings in hepatoid adenocarcinomas are similar to hepatocellular carcinoma (HCC). This study performed immunohistochemistry for Arginase-1, Hepar-1, Glypican-3, CK7, CK20, CK19, polyclonal carcinoembryonic antigen, ɑ-fetoprotein, CDX2, and TTF-1 in 8 cases, and albumin in situ hybridization in 4 of cases of hepatoid adenocarcinoma. Arginase-1 was positive in 5 (62.5%) cases, 2 of which had diffuse staining. Hepar-1 was positive in all 8 cases; glypican-3, CK7 and AFP were each positive in 4 (50%), CK19 in 3 (37.5%); polyclonal carcinoembryonic antigen (canalicular staining) in 3 (37.5%) and albumin in situ hybridization was positive in 3 (75%); CDX2 in 2 (25%); CK20 in 1 (12.5%); TTF-1 was negative in all cases.  Arginase-1 cannot be used to distinguish HCC from hepatoid adenocarcinoma.

Quantitative fibrosis estimation by image analysis predicts development of decompensation, composite events and defines event-free survival in chronic hepatitis B patients.
Bihari C, Rastogi A, Sen B, et al. Hum Pathol. 2016; 55: 63-71.

Fibrosis quantification was done in 964 cases of chronic hepatitis B by image analysis on Masson's trichrome-stained sections. Median quantitative fibrosis (QF) was F0, 1%; F1, 3.03%; F2, 7.1%; F3, 12.7%; F4, 26.9%. METAVIR stage, liver stiffness measurement, and hepatic vein pressure gradient correlated with QF. After adjusting for stage, QF, albumin and ALT were predictors of outcome.

Hepatocyte differentiation markers in adenocarcinoma of the prostate: hepatocyte paraffin 1 but not arginase-1 is specifically expressed in a subset of prostatic adenocarcinoma.
Giedl J, Büttner-Herold M, Wach S, et al. Hum Pathol. 2016; 55: 101-7.

Prostate adenocarcinoma and hepatocellular carcinoma (HCC) can present with bone metastasis and typically negative for both CK7 and CK20. This study performed immunohistochemistry for arginase-1 and HepPar-1 using tissue microarrays in 557 cases of prostatic adenocarcinoma. Positive staining with HepPar-1 was seen in 64 (11.5%) cases showed with variable expression (1-75%) in tumor cells. HepPar-1 staining in >10% of tumor cells was present in 13 (2.3%) cases. Arginase-1 showed nonspecific cytoplasmic staining in 19 (3.4%), which was different from combined nucleocytoplasmic staining seen in normal liver and HCC. This pattern with Arg-1 was used with one antibody lot, but not the other. Nucleocytoplasmic pattern was seen in Arg-1 only 1 case. In conclusion, HepPar-1 is common in prostatic adenocarcinomas and Arg-1 expression is more reliable for distinction of HCC and prostatic adenocarcinoma.

American Journal of Surgical Pathology

Clearance of Hepatic Spingomyelin by Olipudase Alfa is Associated with Improvement in Lipid Profiles in Acid Spingomyelinase Deficiency
Thurberg BL, Wasserstein MP, Jones SA, et al. Am J Surg Pathol. 2016; 40(9):1232-42.

Acid spingomeylinase deficiency/Niemann-Pick disease (ASMD/NPD) is a lysosomal storage disorder due to abnormal intracellular accumulation of spingomyelin (SM).  In NPD type B, SM accumulation within Kupffer cells and hepatocytes eventually leads to hepatomegaly, a significant cause of morbidity and mortality.  In addition to abnormal LFTs, most patients also have abnormal lipid profiles (high LDL-C, low HDL-C), known risk factors for atherosclerosis and coronary artery disease.  In this study, the investigators demonstrate the effects of escalating doses of olipudase alfa (OA), a recombinant human ASM that has shown promise as enzyme replacement therapy in previous phase 1 trial data.  Histomorphologic (including MetaMorph digital analysis), biochemical and electron microscopic parameters were evaluated after 26 weeks of therapy.  Compared to baseline, 4 out of 5 patients (tissue insufficient for analysis in 1 subject) showed significant reductions in SM by all 3 methods of measurement, and normalization of AST/ALT.  Additionally, all patients showed decreases in LDL-C and increases in HDL-C.  OA continues to show promise but therapy is still investigational and effects on long-term outcomes remain unknown.

Archives of Pathology and Laboratory Medicine

Practical Applications in Immunohistochemistry: Evaluation of Rejection and Infection in Organ Transplantation
Troxell ML, Lanciault C. Arch Pathol Lab Med 2016; 140(9): 910-925.

This review article summarizes applications and limitations of C4d and other infectious organism immunostains in the setting of solid organ transplant.  With regards to the liver and ABO-compatible grafts, recipients with preformed lymphocytotoxic donor-specific antibodies (DSA) are at increased risk for developing antibody-mediated rejection (ABMR).  Microscopic changes suggestive of ABMR include bile ductular reaction, periductal neutrophilic infiltrates, portal edema, fibrin deposition around or within vessels, lobular neutrophils, and sinusoidal injury with parenchymal hemorrhage in severe cases.  When C4d immunohistochemistry is performed to assess for ABMR, staining of portal veins/capillaries and/or sinusoids is considered supportive of ABMR; however, staining of the sinusoids is thought to be more specific.  C4d immunohistochemistry result reporting should indicate if there is positive staining and which compartment stains; more than 50% staining is termed diffuse and has the highest correlation with ABMR.  However, C4d immunohistochemistry must be interpreted in context with histologic changes, DSA titers and the clinical situation, as C4d staining alone is not specific and can be seen in approximately 50% of cases with cellular rejection as well as conditions not related to rejection (chronic hepatitis, vascular injury, biliary injury).  Likewise, when performing immunostains for infectious agents, we are reminded that a negative stain does not exclude infection (organisms can be patchy, false-negative sampling, some antibody clones may react with only a limited range of viral serotypes) and more than one infectious agent may coexist in a case.

American Journal of Pathology

Pathogenesis of Kupffer Cells in Cholestatic Liver Injury
Sato K, Hall C, Glaser S, et al. Am J Pathol 2016; 186: 2238-2247.

This is a detailed review of the pathogenic role of Kupffer cells in chronic liver inflammatory injury, with a focus on chronic cholestatic disease.


Albumin expression distinguishes bile duct adenomas from metastatic adenocarcinoma.
Moy AP, Arora K, Deshpande V. Histopathol. 2016;69(3):423-430

AIMS: Bile duct adenomas may be difficult to distinguish from metastatic carcinomas, particularly well-differentiated pancreatic ductal adenocarcinoma. Prior studies have evaluated the utility of various immunohistochemical markers, although these markers are notable for low sensitivity and/or specificity. The aim of this study was to investigate the utility of albumin and BRAFV600E expression in distinguishing between metastatic pancreatic adenocarcinoma and bile duct adenoma.
METHODS AND RESULTS: We studied 26 bile duct adenomas, three bile duct hamartomas, and 158 pancreatic ductal adenocarcinomas. Branched-chain in-situ hybridization (bISH) for albumin was performed; bISH is based on the branched DNA technology, wherein signal amplification is achieved via a series of sequential steps. Additionally, BRAFV600E immunohistochemistry (IHC) was performed on a subset of cases. Twenty-three of 25 (92%) bile duct adenomas were positive for albumin; 18 (72%) showed diffuse staining, and five showed focal staining (20%), including two challenging examples. Two bile duct hamartomas also stained positively. All pancreatic adenocarcinomas were negative for albumin. Seven of 16 (44%) bile duct adenomas and five of 106 (5%) pancreatic ductal adenocarcinomas were positive for BRAFV600E by IHC. The sensitivity and specificity of expression of albumin, as detected by bISH, for distinguishing bile duct adenomas from metastatic pancreatic adenocarcinomas were 92% and 100%, respectively; the sensitivity and specificity of BRAFV600E IHC for distinguishing bile duct adenomas from metastatic pancreatic adenocarcinomas were 43.8% and 95.3%, respectively.
CONCLUSIONS: Diagnostically challenging examples of bile duct adenoma may be distinguished from metastatic pancreatic adenocarcinoma by the use of albumin bISH.

Treatment with Optifast reduces hepatic steatosis and increases candidacy rates for living donor liver transplantation.
Doyle A, Adeyi O, Khalili K, et al. Liver Transpl. 2016; 22(9):1295-1300

This study used paired liver biopsies to document improvements in steatosis levels in liver living donors, who subsequently successfully donated portions of their liver. Optifast is shown as a viable intervention for improving donor liver pool.

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

Monday, October 3, 2016

Journal Watch July-August 2016

Clinical Gastroenterology and Hepatology

Development and Validation of the Framingham Steatosis Index to Identify Persons with Hepatic Steatosis.
Long MT, Pedley A et al. Clin Gastroenterol Hepatol. 2016;14:1172-1181.

A large cross-sectional study of 1181 members of the Framingham Third Generation cohort was performed to investigate the accuracy of serum levels of aminotransferases in detection of hepatic steatosis. Participants with hepatic steatosis had higher ALT and AST levels compared with those without steatosis. The ratio of ALT/AST identified people with hepatic steatosis with highest c-static value of 0.728. A Framingham Steatosis Index (FSI) was derived to include patient age, sex, BMI, triglycerides, hypertension, diabetes, and ratio of ALT/AST for prediction of hepatic steatosis. The model was validated in the external multiethnic NHANES III cohort of 4489 participants, which demonstrated good discrimination and calibration.

Journal of Hepatology

Neutrophil Gelatinase-Associated Lipocalin Is a Biomarker of Acute-On-Chronic Liver Failure and Prognosis in Cirrhosis.
Ariza X, Greupera I et al. J Hepatol. 2016; 65:57-65.

No biomarker is available for detection acute-on-chronic liver failure (ACLF), a syndrome occurs in cirrhosis characterized by acute decompensation of the disease, organ failure(s) and high mortality rate.  Ariza et al. evaluated urine and plasma levels of neutrophil gelatinase-associated lipocalin (NGAL) in 716 patients with complications of cirrhosis. 148 patients (20.7%) had ACLF, 568 (79.3%) had acute decompensation without ACLF. Patients with ACLF had significantly higher levels of both urine and plasma NGAL compared with those without ACLF. Multivariate analysis revealed uNGAL and pNGAL were independent predictors for ACLF as well as 28 day transplant-free mortality.  Additional gene expression study in 29 liver biopsies found lipocalin-2 gene (LCN2) was marked upregulated in patients with ACLF compared to all other groups. The data suggests that NGAL is a diagnostic and prognostic biomarker for ACLF.

American Journal of Surgical Pathology

Distinct Clinicopathologic and Genetic Features of 2 Histologic Subtypes of Intrahepatic Cholangiocarcinoma
Hayashi et al. Am J Surg Pathol. 2016 Aug;40(8):1021-30.

Conventional subtyping of intrahepatic cholangiocarcinoma (ICC) into large duct-type and small duct-type ICC subtypes can sometimes be challenging due to ambiguity in anatomic location and overlapping histologic features.  Given these limitations, these authors investigated the utility of grouping ICC into 2 subtypes: Type 1 (mucin production; S100P positive; N-cadherin and NCAM negative) and Type 2 (absent or scant mucin production; S100P negative; N-cadherin and/or NCAM positive;).  102 consecutive ICCs were evaluated by Alcian blue and immunohistochemistry staining; KRAS and IDH1/IDH2 mutation testing by PCR and FGFR2 translocation testing by FISH were performed on the majority of cases.  By conventional subtyping, cases were categorized as follows: 33 large duct-type, 36 small duct-type, 33 indeterminate ICC.  Using the proposed classification system, the same cases were grouped as follows: 42 Type 1, 56 Type 2, 4 indeterminate.  Type 1 usually had higher levels of serum CEA (median 6.2 ng/mL) and CA 19-9 (median 1159 U/mL) and tumors more often showed perineural invasion and lymph node metastasis.  KRAS mutation was significantly more frequent in Type 1 (29%) whereas IDH1/IDH2 mutation (40%) and FGFR2 translocation (11%) were exclusively seen in Type 2.  Type 2 tumors were more frequently present in patients with chronic liver diseases.  Of the 3 IHC markers, S100P was the most consistent and discriminatory; N-cadherin and NCAM should be reserved for cases where S100P is indeterminate.  While the authors demonstrated clinicopathologic differences between Type 1 and Type 2 ICC, the significance of these findings on outcome is unclear given that multivariate Cox regression showed no prognostic differences.

Immunostains Used to Subtype Hepatic Adenomas Do Not Distinguish Hepatic Adenomas From Hepatocellular Carcinomas
Liu et al. Am J Surg Pathol. 2016 Aug;40(8):1062-9.

The immunostain panel of liver fatty acid-binding protein (LFABP), serum amyloid A (SAA) protein, C-reactive protein (CRP), and glutamine synthetase (GS) are used to subtype hepatocellular adenoma (HCA).  In practice, however, some pathologists use these immunostains as an aid in diagnosis when distinguishing between HCC and HCA in a manner that is akin to “off label” use of medications for certain treatments by physicians in specific clinical settings.  This study sought to determine the validity of such practice by examining expression of these markers in 159 HCCs (47 full section tissue blocks, 112 from tissue microarray).  Proportion of HCCs showing positive staining are as follows: SAA 17%, CRP 54%, GS 49%; LFABP showed loss of expression in 23%.  An additional 7 cases of fibrolamellar HCC were positive for CRP in 100% and SAA in 43%; LFABP was lost in 57%.  Although 79% of HCCs that showed loss of expression of LFABP also stained positively for GS, there was no association between marker expression and other clinicopathologic features.  This study reaffirms that the immunostain panel comprised of LFABP, SAA, CRP, and GS is intended for use in subtyping HCA.  This panel should only be used after the diagnosis of HCA has been established and not for distinguishing HCC from HCA.

Cystoisospora belli Infection of the Gallbladder in Immunocompetent Patients
Lai et al. Am J Surg Pathol. 2016 Aug;40(8):1070-4.

This is the largest case series to date investigating clinicopathologic features in 18 immunocompetent patients with Cystoisospora belli infection of the gallbladder.  Histologic features evaluated included the presence, type and/or degree of cholecystitis, epithelial disarray (displacement of nuclei from their normal basal location by parasite-containing vacuoles), architectural distortion, mural thickening/serositis, intraepithelial lymphocytosis, and intramucosal eosinophilia.  Subjects ranged from 17 to 61 years of age (mean 33 years) with a female predominance (4.3:1).  Clinical indications were not unique and included usual reasons for cholecystectomy.  Each case was diagnosed on light microscopy by observation of the characteristic eosinophilic, oval-to-banana-shaped intraepithelial parasitic forms within perinuclear vacuoles, although such findings were focal in 8.  94% of cases displayed epithelial disarray and 83% showed rare intraepithelial lymphocytosis.  Of the 11 cases that had follow-up information, none had evidence of Cystoisospora infection within the biliary or tubular GI tract.  Biliary cystoisosporiasis is likely an underrecognized entity that presents with nonspecific symptoms and appears to be a self-limited infection in immunocompetent patients.


Immunoglobulin G4+ B-cell receptor clones distinguish immunoglobulin G 4-related disease from primary sclerosing cholangitis and biliary/pancreatic malignancies
Doorenspleet ME et al. Hepatology 2016;64:501-507.

IgG4-related disease involving the pancreas/pancreatobiliary tree can pose particularly difficult diagnostic challenges, and can closely mimic primary sclerosing cholangitis (PSC) and/or pancreatobiliary malignancy. Patients often have elevated serum IgG4 levels; however, approximately 30% of patients with IgG4-related pancreatitis (and/or cholangiopathy) have normal levels of serum IgG4, and elevated IgG4 levels can be seen in up to 30% of patient with PSC or pancreatobiliary malignancy. The authors demonstrate the peripheral blood presence of IgG4 B-cell receptor clones in IgG4-related pancreatitis/cholangitis patients as compared to patients with PSC and pancreatobiliary malignancies. They also demonstrate the diagnostic accuracy of IgG4/IgG RNA ratio by PCR in peripheral blood. The IgG4/IgG RNA ratio performed better than serum IgG4 in sensitivity (94% vs 86%) and specificity (99% vs 73%), and correlated with treatment response.

Hepatocellular adenoma with malignant transformation in a patient with neonatal portal vein thrombosis
Arrive L, et al. Hepatology 2016;64:675-677.

The authors report an unusual case of a 41 year-old woman with a past medical history of neonatal portal vein thrombosis with cavernous transformation of the portal vein, and multiple hepatocellular lesions including large regenerative nodules, focal nodular hyperplasias, and HNF1A inactivated adenomas measuring up to 11.9 cm. The largest resected lesion was an HNF1A inactivated adenoma with several foci of well-differentiated HCC. The tumor did not show diffuse glutamine synthetase expression, or nuclear/cytoplasmic staining with B-catenin.

American Journal of Pathology

Divergent Inflammatory, Fibrogenic, and Liver Progenitor Cell Dynamics in Two Common Mouse Models of Chronic Liver Injury
Kohn-Gaone, J et al. American Journal of Pathology 2016;186:1762-1774.

Two common mouse models for chronic liver disease -- choline-deficient, ethionine-supplemented diet (CDE) and thioacetamide supplementation (TAA) -- were compared. CDE mice showed portal-based injury, whereas TAA mice had centrizonal-based disease and a more severe phenotype.

Journal of Gastroenterology and Hepatology

Coffee consumption protects against progression in liver cirrhosis and increases long-term survival after liver transplantation
Friedrich K. et al. J Gastroenterol Hepatol. 2016 Aug;31(8):1470-5.

In this study, the impact of coffee consumption was investigated in regard to progression of end-stage liver disease (ESLD) and long-term survival in patients who had liver transplantation. Coffee consumption habits in 379 patients with ESLD awaiting liver transplantation and 260 patients after liver transplantation were studied. One hundred ninety-five patients with ESLD consumed coffee on a daily basis, and 184 did not. Actuarial survival was lower (P = 0.041) in non-coffee drinkers (40.4 ± 4.3 months, 95% confidence interval [CI]: 32.0–48.9) compared to coffee drinkers (54.9 ± 5.5 months, 95% CI: 44.0–65.7). In subgroup analysis, the survival of patients with alcoholic liver disease (ALD; P = 0.020) and primary sclerosing cholangitis (PSC; P = 0.017) was improved with coffee intake while unaffected in patients with chronic viral hepatitis (P = 0.517) or other liver disease entities (P = 0.652). Multivariate analysis showed that coffee consumption in PSC and ALD patients was an independent risk factor (odds ratio [OR]: 1.94; 95% CI: 1.15–3.28; P = 0.013) along with MELD score (OR: 1.13; 95% CI: 1.09–1.17; P = 0.000). Following liver transplantation, long-term survival was longer in coffee drinkers (61.8 ± 2.0 months, 95% CI: 57.9–65.8) than non-drinkers (52.3 ± 3.5 months, 95% CI: 45.4 –59.3; P = 0.001). Coffee consumption reduced disease progression in ALD and PSC patients with ESLD and improved long-term survival after liver transplantation. Thus, regular coffee intake might be recommended for these patients.

Human Pathology

Hepatic small vessel neoplasm, a rare infiltrative vascular neoplasm of uncertain malignant potential.
Gill RM, et al. Hum Pathol. 2016 Aug;54:143-51.

This study reports a series of 17 cases of a novel vascular tumor of the liver designated as ‘hepatic small vessel neoplasm’ (HSVN). These tumors occur in adults, have infiltrative borders and are comprised of small sized vascular channels lined by endothelial cells that can show hobnail appearance. Immunohistochemistry for endothelial markers (CD31, CD34, FLI-1) is positive. The hobnail appearance along with infiltrative borders raises the possibility of angiosarcoma. The lack of significant cytologic atypia and mitoses along with low Ki-67 (typically <10%) favors HSVN. Strong p53 and diffuse c-Myc staining is more common in angiosarcoma.  HSVNs showed an activating hotspot GNAQ mutation in 2 of 3 (67%) cases tested, while a hotspot mutation in PIK3CA was seen in one case. Complications like rupture, hemorrhage, disseminated intravascular coagulation, Kasabach-Merritt syndrome, recurrence or metastasis have not been reported with HSVN, but the study recommends complete resection and close follow-up as the outcome data is based on limited number of cases.


Any value in a specialist review of liver biopsies? Conclusions of a 4-year review.
Paterson  AL, et al. Histopathology 2016 Aug;69(2):315–321.

The authors reviewed discrepancies between the primary and specialist liver pathologists in 1265 liver biopsy reports over 4 years. They concluded that specialist review was necessary but not in all cases, as non-specialist pathologists did well with cases like viral hepatitis, fatty liver, and malignancies, while most of the 59% cases with discrepancies were biliary, autoimmune hepatitis, and cases with vascular/architectural abnormalities. Aims: Liver pathology is a challenging subspecialty, with histopathologists frequently seeking specialist opinions. This study aims to determine the impact of specialist reviews on the final diagnosis and patient management. Methods and results: Agreement with the initial reporting centre in the histopathological diagnosis of 1265 liver biopsies was determined. The nature of differences was explored in more depth for 103 discrepant cases. Differences in the histopathological interpretation were present in 749 of 1265 (59%) biopsies, of which 505 of 749 (67%) were predicted at the time of reporting to impact upon patient management. Agreement was good in cases with chronic viral hepatitis, fatty liver disease, malignancy and minimal pathological changes, while diagnostic differences occurred in more than 70% with biliary disease, autoimmune hepatitis or vascular/architectural changes. A clinical review of a subset of reports with histopathological differences predicted changes in patient management in 63 of 103 (61%). Conclusions: Clinically significant differences in liver biopsy interpretation between local pathologists and subspecialists are common. Diagnoses with frequent discrepancies, such as biliary disease, may benefit from a specialist review as standard when diagnosed initially, while cases requiring specialist advice from disease subgroups where discrepancies are less common, such as chronic viral hepatitis, could be selected during the clinicopathological conference process.

Loss of ezrin in human intrahepatic cholangiocarcinoma is associated with ectopic expression of E-cadherin.
Guedj N, et. Al. Histopathology. 2016 Aug;69(2):211-21.

The authors investigated the expression of ezrin in cholangiocarcinoma (intra-hepatic), a plasma membrane protein restricted to cholangiocytes in the liver. Using immunohistochemistry on 94 tumor micro-arrays, they found that 48% of their cases had weak/lost ezrin expression, more likely in peripheral than perihilar tumors, and correlated with a more aggressive phenotype. Aims: Ezrin connects proteins from the plasma membrane to the subcortical cytoskeleton, and contributes to epithelial integrity by interacting with the cell–cell adhesion molecule E-cadherin. In the liver, ezrin is restricted to cholangiocytes, where it regulates biliary secretory functions. During carcinogenesis, ezrin expression is impaired and associated with enhancement of cell migratory activity in cancer cells; therefore, we aimed to analyze ezrin in cholangiocarcinogenesis. Methods and results: Ezrin expression was evaluated by immunohistochemistry on tissue microarrays from 94 surgical specimens of intrahepatic cholangiocarcinoma (CCA), and correlated with clinicopathological factors and E-cadherin expression. Ezrin function was also analyzed in human CCA cell lines. In CCA, ezrin was negative/weakly expressed in 49 cases (52%) and moderately/strongly expressed in 45 cases (48%), mostly in cell cytoplasm. The negative/weak expression of ezrin was more frequent in peripheral than in perihilar CCA (P = 0.002), and was associated with high tumour size (P = 0.001), low mucus secretion (P = 0.042), the presence of satellite nodules (P = 0.024), and ectopic cytoplasmic expression of E-cadherin (P = 0.005). In vitro, silencing of ezrin in CCA cells caused internalization of E-cadherin and favored cell migration. Conclusions: Ezrin is down-regulated during cholangiocarcinogenesis, and its loss results in a more aggressive phenotype.

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

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).

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. 


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. 


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.


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.


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