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. 

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.


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.


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.


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
Vashal Chandan,  MBBS, Assistant Professor of Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN

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

Saturday, March 26, 2016

Congratulations to the Winners of 2016 HPHS Trainee Award

Winner of The 2016 HPHS Best Abstract

Dr. Rondell Graham (Mayo Clinic Rochester, mentor: Dr. Michael Torbenson)
PRKACA Fluorescent In Situ Hybridization Reveals Novel Findings in Fibrolamellar Carcinoma

Drs. Fiel, Graham and Adeyi

First Runner-up Abstract

Dr. Ashley Stueck (Mt. Sinai Medical Center NY, mentor: Dr. M. Isabel Fiel)
A Novel Histologic Diagnostic Algorithm for Hepatic Graft Versus Host Disease

Drs. Adeyi, Stueck and Fiel

Second Runner-up Abstract

Dr. Mamta Pant (Medical College of Wisconsin, mentor: Dr. Kiyoko Oshima)
Are Eosinophilic Glassy Globules in Autoimmune Hepatitis a Histologic Clue to Diagnosis?

Drs. Fiel, Pant and Adeyi

Tuesday, January 26, 2016

President's Message January 2016

Dear Friends and Colleagues,

I hope everyone has had a great holiday season and are well into 2016. Please see the HPHS website for the latest edition of The Literature Watch. This free series is posted every two months. The Interesting Case series is also posted four times each year.

The deadline to submit trainees’ USCAP abstracts for the HPHS awards is Feb. 27. Every year the HPHS recognizes trainees deemed to have submitted the winning abstracts to the Annual USCAP conferences. The winning abstract is awarded a cash prize while the first and second runners up are also recognized at the HPHS Annual meeting during the USCAP conference, which this year will be in Seattle, WA.

We look forward to seeing you at our next HPHS business meeting in Seattle in March!

Isabel Fiel, M.D.
President, Hans Popper Hepatopathology Society

Interesting Case January 2016

Clinical History

A 51 years old woman was referred for liver transplantation on account of end-stage primary biliary cirrhosis (PBC). She had presented with variceal bleeding outside. Her liver was found to be enlarged but she had normal INR and albumin although bilirubin was slightly elevated at 1.8 mg/dL (31 μmol/L). She however had other features of portal hypertension including splenomegaly and low platelets (78,000/µL).  Serologically she was AMA positive (high titer), IgM was elevated but IgG and IgA were normal. Liver enzymes were AST 12 U/L, ALT 10 U/L, and ALP 200 U/L (on Urso treatment). Ultrasound confirmed nodular and cirrhotic liver. She was listed for transplantation as end-stage PBC.

She successfully underwent living related liver transplantation. The explanted liver weighed 1233 gm and appeared vaguely nodular but not cirrhotic. Cut sections revealed no mass lesions. Micrographs from the explanted liver are shown.

Rhodanin copper stain

Liver Explant Microscopic Findings

The explant showed a nodular liver with areas of sinusoidal dilatation, and occasional incomplete septae, but no evidence of cirrhosis. Rare florid ducts of PBC are present but there is mild ductopenia that came down to approximately just 20% of the terminal bile ducts; the larger bile ducts appear normal as are most of the small/terminal bile ducts. Several small portal tracts however have increased portal and occasionally periportal fibrosis and no visible portal veins. The larger portal tracts often have small portal veins when compared with the corresponding hepatic artery or bile duct, with thickening of the veins walls (obliterative portal venopathy). Reticulin stain demonstrates nodularity not bordered by fibrous septae, the edge of the nodules having compressed reticulin fibers (NRH). Sections from the hilum demonstrate major but non-occlusive portal vein thrombus.


Non-cirrhotic portal hypertension from a combination of nodular regenerative hyperplasia (NRH), portal vein thrombosis, and obliterative portal venopathy (OPV) in a patient transplanted for Primary Biliary Cirrhosis

Major Learning Points

  1. Portal hypertension in patients with normal liver function (albumin, bilirubin, INR) should raise the possibility of non-cirrhotic cause.
  2. Primary biliary cirrhosis and other chronic biliary diseases could cause portal hypertension from NRH and/or obliterative portal venopathy without being cirrhotic or “end-stage”.
  3. Liver explant examination is important to verify cause of liver disease as this has a significant implication on post-transplant course and management.


Portal hypertension is a common end-stage presentation of many chronic liver diseases the likelihood of which parallels severity of cirrhosis. As such patients with Childs-Pugh C cirrhosis have worse manifestations of liver failure from cirrhosis than Childs-Pugh A and B patients. Symptomatic cirrhosis is typically accompanied by abnormal liver function tests (albumin, INR/coagulation parameters, and bilirubin) although liver enzymes could remain normal or near normal even in advanced cirrhotics. Portal hypertension with normal liver function could occur in compensated cirrhosis but normal function accompanied by symptoms of portal hypertension like variceal bleeding in this patient, should raise the possibility that portal hypertension may not be arising from cirrhosis. This is because decompensated cirrhosis is a reflection of failing ability of liver parenchyma to optimally function. Whereas most (not all) cases of non-cirrhotic portal hypertension with normal hepatic mass are less likely to manifest as functional abnormality. In such cases features of PH are limited to vascular shuntings (varices and sometimes encephalopathy) and splenomegaly (including low platelets).

Also liver vasculature could be secondarily affected by chronic biliary diseases as exemplified by this case. For this reason, and for several years, PBC for example has been recognized as a cause of NRH and associated with OPV. It has been postulated that repeated pre-sinusoidal injury possibly from PBC-associated portal inflammation could secondarily cause inflammation and loss of small portal veins over time, leading to NRH. [Kew MC, et al. Gut. 1971;12(10):830-4]. In this case and possibly in combination with other factors, the direct effect of chronic portal vein injury is also manifested as obliterative portal venopathy, OPV. 

OPV, (also called hepato-portal sclerosis, HPS), is an entity in which portal hypertension resulted from injury to and thickening of the wall of large and intermediate intrahepatic portal veins and obliteration of the smaller veins (Nayak NC & Ramalingaswami V. Arch Pathol 1969; 87: 359-69; Aggarwal S et al. Dig Dis Sci 2013; 58: 2767-76.).  It could complicate a long list of diseases including PBC as well as many systemic and organ-specific immunologic diseases (Lee H, Rehman AU, Fiel MI 2015 J Pathol Transl Med Epub ahead of print), for which reason an immunologic basis has been proposed. Another association with the OPV is thrombophilia (Hillaire S, et al. Gut 2002; 51: 275), with some OPV patients secondarily developing secondary portal vein thrombosis, also seen in the present case. 

It would therefore appear that the findings in the presented case are part the same process that started with vascular (portal vein) injury in the context of PBC leading to OPV, which in turn gave rise to NRH (Wanless IR, et al. Medicine (Baltimore) 1980; 59: 367-79.); and ultimately portal hypertension. The development of large portal vein thrombosis could be from portal hypertension since this patient has so far not been found to have a thrombophilic state. She is now 3 years post-transplant and doing excellently well.  

Case contributed by:
Oyedele Adeyi, M.D.
University of Toronto


  1. Abraham SC, Kamath PS, Eghtesad B, Demetris AJ, Krasinskas AM. Liver transplantation in precirrhotic biliary tract disease: Portal hypertension is frequently associated with nodular regenerative hyperplasia and obliterative portal venopathy. Am J Surg Pathol. 2006;30(11):1454-61
  2. Kew MC, Varma RR, Dos Santos HA, Scheuer PJ, Sherlock S. Portal hypertension in primary biliary cirrhosis. Gut. 1971;12(10):830-4
  3. Nayak NC, Ramalingaswami V. Obliterative portal venopathy of the liver: associated with so-called idiopathic portal hypertension or tropical splenomegaly. Arch Pathol 1969; 87: 359-69.
  4. Aggarwal S, Fiel MI, Schiano TD. Obliterative portal venopathy: a clinical and histopathological review. Dig Dis Sci 2013; 58: 2767-76.
  5. Lee H, Rehman AU, Fiel MI. Idiopathic Noncirrhotic Portal Hypertension: An Appraisal. J Pathol Transl Med. 2015 Nov  [Epub ahead of print]
  6. Hillaire S, Bonte E, Denninger MH, et al. Idiopathic non-cirrhotic intrahepatic portal hypertension in the West: a re-evaluation in 28 patients. Gut 2002; 51: 275-80.
  7. Wanless IR, Godwin TA, Allen F, Feder A. Nodular regenerative hyperplasia of the liver in hematologic disorders: a possible response to obliterative portal venopathy. A morphometric study of nine cases with an hypothesis on the pathogenesis. Medicine (Baltimore) 1980; 59: 367-79.

In Memoriam Professor Sir Roderick N. M. MacSween, BSc, MBChB, MD, 1935-2015

Roderick Norman McIver MacSween, (or Roddy, as most of us called him), was born in 1935 in the Western Isles of Scotland (Kinloch, Isle of Lewis) the son of a manse and a native Gaelic speaker who learned English when he went to school.  He attended Glasgow University, graduating with a BSc with Honours in Physiology in 1956 and MB ChB in 1959.  He chose Pathology as a career and in 1963, and joined the Western Infirmary, Glasgow.   He became a lecturer in 1965 and after gaining his MRCPath in 1967, a post-graduate fellowship allowed him to study at Colorado University Medical Center in Denver from January 1968 to December 1969, where he further developed his interest in iron metabolism.  On his return to the Western Infirmary in 1970, he was awarded a Wellcome Senior Research Fellowship and working with Professor John Anderson, earned an MD with Honours in 1973 with a thesis on “Clinico-Pathological and Immunological Studies in Liver Disease”.  Rising rapidly through the ranks of Senior Lecturer, Reader and Titular Professor, he succeeded John Anderson as the sixth holder of the Chair of Pathology at the Western Infirmary and Head of Department in 1984, positions he held until his retirement in 1999. 

In 1985 he was elected Fellow of the Royal Society of Edinburgh and served on its Council from 1992-1995. His served as Vice-President of the Royal College of Pathologists from 1995-1996 and as President from 1996-1999. He also served as Editor of IAP journal “Histopathology” from 1985-96, President of the British Division of the IAP, and Chairman of the British Association for Study of the Liver.  His leadership skills were also recognized in other medical disciplines where he served as Chairman of the Academy of Medical Royal Colleges from 1998-2000.  He retired in 1999 and became Sir Roddy when he was knighted in 2000 for services to Medicine and Pathology.  A member of the General Medical Council from 1999-2003, his numerous charitable works included serving as Chairman of Tenovus Scotland, Chairman of the Medical Advisory Committee of the Children’s Liver Foundation and as a Committee Member of the British Lung Foundation (Scotland). He was also Chair of the Unrelated Liver Transplant Regulatory Authority and President of the Royal Philosophical Society of Glasgow.  

Professor Sir Roddy MacSween (Roddy) was a skilled interpreter of liver biopsies with a national and international reputation and a world-wide referral practice.  In 1978 he was invited to join a unique distinguished international hepatopathology group known as the Gnomes, the name applied to them by Dame Sheila Sherlock (London) after their first meeting in Zurich.  She claimed that the liver Gnomes, like the financial Gnomes of Zurich, were manipulating interpretation and classification in hepatopathology.  Roddy had many other accomplishments, including prestigious lectureships, numerous publications, and significant editorial duties.  Perhaps he is most widely recognized by our society for his editorship of Pathology of the Liver, the first edition with Peter Anthony and Peter Scheuer as co-editors, with further editions in 1987, 1994 and 2002.  The textbook’s comprehensive nature by this time was reflected in a review which stated “If it’s not in MacSween, it’s not in the liver”.  He retired as an editor for the 2007 fifth edition, but his successors retitled the book MacSween’s Pathology of the Liver in order to carry on the significance of the name of the founder.  The 6th edition was published in 2012, and the 7th edition is in preparation.   This authoritative textbook rapidly became and has remained the definitive textbook for liver pathology around the world.

He married Marjory Brown, a fellow medical student (and later, dermatologist), in 1961.  Together, they enjoyed their family (children Ruth and Gordon, and grandchildren), and loved to travel and visit friends worldwide, as well as play golf.  

Throughout his career he was beloved by his students, residents, and other mentees as an outstanding teacher with endless energy and enthusiasm, and a caring mentor.  As many of you know, he formed friendships easily.  A continual stream of visitors from around the world spent time with him learning the art of liver biopsy interpretation.  No matter how busy he was, he always made time to view his set of case slides with each at a double-headed microscope, and he would bade them farewell with the words “thank you for paying us the complement of coming here to study”.  Many of these visitors have become leaders in liver pathology worldwide.

On his death, many remember him as one of the giants and luminaries of liver pathology, and praise him for the great legacy he left liver pathology for future generations.  Their memories are also filled with appreciation for his enthusiasm and ability in teaching, his encouragement to many to pursue their studies, and most significantly, his great warmth and generous, kind spirit that put all at ease, no matter what their personal status or relationship to him.  

He will be greatly missed as a friend, colleague, and mentor, but we rejoice that his legacy and memory will live on the hearts and minds of pathologists worldwide, and we thank you, Sir Roddy, for inspiring us in so many ways.

In loving memory,

Linda Ferrell, MD
Emerita Professor, University of California San Francisco

Monday, January 25, 2016

Journal Watch November-December 2015

Clinical Gastroenterology and Hepatology, Nov-Dec 2015

The art and Science of Diagnosing and Managing Drug-induced Liver Injury in 2015 and Beyond 
James H. Lewis  Clin Gastroenterol Hepatol. 2015;13:2173-2189.

In this review article, the author summarizes the key advances in the clinical diagnosis and management of idiosyncratic drug induced liver injury (DILI) during the last decade. It is estimated that about half of the cases of acute liver failure (ALF) occurring annually in the United States are due to DILI, especially from acetaminophen (40%), but also other drugs (11%) such as herbal compounds and dietary supplements (HDS). The classic host risk factors for DILI are age (>65 years), gender (female), use of alcohol and obesity. Daily drug doses of 50-100mg are more hepatotoxic than <10mg.  Three main biochemical injury patterns have been recognized: hepatocellular, cholestatic and mixed. The diagnosis of DILI is clinically challenging as DILI can mimic all known causes of acute and chronic liver diseases. Liver biopsy findings may be supportive for DILI but most helpful in excluding other possible causes. Recently, substantial progresses have been made in identifying predictive biomarkers (microRNA 122, high mobility group box-1 and keratin 18) and genetic risk factors (HLA and cytochrome phenotypic alterations) for DILI.  Preventing DILI is limited to liver associated biochemistry (ALT) monitoring and restricting access to certain drugs.  Liver transplantation remains an important treatment procedure for irreversible ALF. The first published guidelines on the diagnosis and management of DILI has been offered by the American college of Gastroenterology. In addition, a LiverTox Web site ( has been launched recently.

Journal of Hepatology, Nov-Dec 2015

Progenitor cell markers predict outcome of patients with hepatocellular carcinoma beyond Milan criteria undergoing liver transplantation
Miltiadous O, Sia D et al. Journal of Hepatology 2015; 63: 1368-1377. 

Liver transplantation (LT) is an effective treatment option for patients with HCC within Milan criteria. The concept of a modest expansion beyond the Milan criteria has been proposed without gaining global acceptance. The current study explored the possibility of using gene signatures to identify patients with HCC beyond Milan criteria who nevertheless may have acceptable outcomes with LT. 132 patients with HCC beyond Milan criteria underwent LT at two medical centers were included in the study. Explant tumors were analyzed for genomic signatures and Immunohistochemical markers, and then correlated with patient outcome. At a median follow up of 88 months, the 5-year survival and recurrent rates were 57% and 35%, respectively. In the multivariate analysis, S2 gene signature (HR = 3.18, p = 0.001), tumor diameter >5 cm (HR=5.06, p<0.001), and outside up-to-7 rule (HR=2.50, p= 0.002) were independently associated with 5 year survival. CK19 (HR = 2.91, p = 0.001), tumor diameter >5 cm (HR=3.37, p=0.023) and satellites (HR = 2.98, p <0.001) were independent predictors of recurrence. Combination of progenitor signatures (CK19 and S2) improves prediction both OS and recurrence.  Patients with one and/or both signatures had a 45% 5-year OS and 53% recurrence vs. 67% 5-year OS and 19% recurrence when neither signature was present. These results suggested that the gene signatures of progenitor cell (CK19/S2) may be potential makers for stratifying patients with HCC in high and low risk for both recurrence and survival.

Histopathology, Nov-Dec 2015

CAMTA1 is a useful immunohistochemical marker for diagnosing epithelioid haemangioendothelioma. 
Shibuya R, Atsuji A, Eisuke S, Hiroshi H, Kei Y, Masanori H. Histopathology 2015;67(6):827-835.
Molecular characterization of epithelioid haemangioendotheliomas identifies novel WWTR1–CAMTA1 fusion variants. 
Patel NR, Salim AA, Sayeed H, Sarabia SF, et al. Histopathology 2015;67(5):699-708.

Epithelioid hemangioendothelioma is an intermediate grade endothelial neoplasm that could be primary in or metastatic to the liver. The WWTR1–CAMTA1 translocation leading to CAMTA-1 overexpression had been found to be very specific for majority of EHE, while the remaining lesions carry the alternative YAP1–TFE3 translocation. Until now the way to demonstrate these translocations had been by PCR for the fusion gene transcript and/or FISH methods. However the first study, Shibuya R et al report successful use of CAMTA1 antibody by immunohistochemistry with a sensitivity of 87.5% and specificity of 99.6%. Only one false positive case in a breast ductal carcinoma was reported.
The second study Patel NR et al reported successful use of RT-PCR and direct gene sequencing in epithelioid hemangioendothelioma, majority of their cases arising from or involving the liver.  In addition to detecting the WWTR1–CAMTA1 transcript in 14 of 18 cases, 4 cases, when directly sequenced also showed novel in-frame fusion transcripts. Only 1 of 18 cases demonstrated YAP1–TFE3 fusion transcript and this case also showed strong nuclear TFE3 immunostain. Other degrees of TFE3 stain were found in 5 other cases, 3 of which had no YAP1–TFE3 fusion transcript; the remaining 2 failed RT-PCR. The use of TFE3 immunostain required a specific (strong nuclear) staining pattern for specificity in cases harboring the YAP1–TFE3 translocation.

Journal of Gastroenterology and Hepatology, Nov-Dec 2015

Intimate association of visceral obesity with non-alcoholic fatty liver disease in healthy Asians: A case-control study.
Ha Y et al. Journal of Gastroenterology and Hepatology. Nov. 2015, 30 (11):1666-72.

The study was to identify factors associated with non-alcoholic fatty liver disease (NAFLD) in Asian subjects. Potential living liver donors without hepatic steatosis (< 5%: n = 1353, group 1) were considered as controls, and subjects with mild (5-33%: n = 724, group 2) and moderate/severe (> 33%: n = 116, group 3) steatosis were defined as study groups. Age and gender were matched, which resulted in 83 matched subjects in each of the three groups. The area of abdominal (visceral and subcutaneous) fat was measured in all subjects by unenhanced computed tomography. Serum AST, ALT, gamma-glutamyltranspeptidase, total cholesterol and triglyceride levels, and visceral fat amount were found directly correlated with the grade of steatosis, while high-density lipoprotein cholesterol levels were inversely correlated. In a multivariate model, visceral fat amount was significantly correlated with both mild and moderate/severe NAFLD groups (P < 0.05). Body mass index (BMI), ALT, and subcutaneous fat were significant predictors of only moderate/severe NAFLD group (P < 0.05).The findings indicate that visceral adiposity makes non-obese subjects more susceptible to NAFLD, compared with subcutaneous fat and BMI.

American Journal of Pathology, Nov-Dec 2015

Mice with Hepatic Loss of the Desmosomal Protein ϒ-catenin are Prone to Cholestatic Injury and Chemical Carcinogenesis
Zhou L et al.  Am J of Pathol 2015;185:3274-3289.

The role of β-catenin as an important component of the adherens junction and canonical Wnt signaling is fairly well understood. In this paper, however, the authors explore the role of ϒ-catenin, an important component of desmosomes, in liver pathobiology. This study used conditional knockout (KO) mice, bile duct ligation (BDL) and a model of chemical carcinogenesis (CC, diethylnitrosamine). KO mice at baseline showed a significant change in the desmosome composition, although the desmosome structure and function were maintained. However, KO mice subjected to BDL showed increased injury and fibrosis, and KO mice subjected to CC showed enhanced tumorigenesis via Wnt signaling. The authors conclude that ϒ-catenin appears to have a tumor suppressor function which could have therapeutic implications.

Hepatology, Nov-Dec 2015

CX3CR1 is a Gatekeeper for Intestinal Barrier Integrity in Mice: Limiting Steatohepatitis by Maintaining Intestinal Homeostasis
Schneider KM et al. Hepatology 2015;62:1405-1416.

CX3CR1 is G protein-coupled chemokine receptor expressed on macrophages that is involved in maintaining intestinal homeostasis in addition to playing a role in several of the manifestations of the metabolic syndrome. Since diet induced intestinal dysbiosis is a driver for NASH, the authors studied wild type and CX3CR1 deficient mice exposed to 2 diet-induced models of NASH (high fat diet or MCD diet). CX3CR1 protected mice from excessive liver steatosis and inflammation, as well as systemic glucose intolerance. Lack of CX3CR1 altered the intestinal microbiota composition, was linked to an impaired mucosal barrier and a greater amount of bacterial translocation. Nonabsorbable antibiotic treatment showed a marked improvement in steatohepatitis. The authors conclude microbiota-mediated activation of the innate immune responses through CX3CR1 is crucial for controlling NASH progression. With regards to the gut-liver axis, CX3CR1 is an essential gatekeeper and maintains the intestinal mucosal barrier.

A Novel Noninvasive Diagnostic Method for Nonalcoholic Steatohepatitis Using Two Glycobiomarkers
Kamada Y et al. Hepatology 2015;1433-1443.

Two glycobiomarkers, fucosylated haptoglobin (Fuc-Hpt) and Mac-2 binding protein (Mac2bp), were used to predict the degree of NASH ballooning and fibrosis, respectively. By combining the 2 serum markers together and using logistic regression analysis, the authors developed a prediction model for the diagnosis of NASH. This model was then validated using 382 biopsy proven NAFLD patients. Furthermore, the utility of this model was tested in a larger population of 803 NAFLD patients undergoing medical health checkups. The authors conclude that this serologic test-based glycobiomarker model is a novel NASH diagnostic modality that could replace liver biopsy.

Association of Nonalcoholic Fatty Liver Disease with Hepatocellular Carcinoma in the United States from 2004 to 2009
Younossi ZM et al. Hepatology 2015;62:1723-1730.

The SEER registries from 2004-2009 along with Medicare-linkage files and ICD codes were used to assess the prevalence and mortality of patients with NALFD-HCC in comparison with other chronic liver diseases such as HCV, HBV and alcoholic liver disease. Almost 5,000 cases of HCC and almost 15,000 controls without HCC were identified for statistical analysis. During the 6 year period NAFLD-HCC showed a 9% annual increase. NAFLD-HCC patients were older, had shorter survival time, more heart disease and were more likely to die from their primary liver cancer (all P < 0.0001). In multivariate analysis, NAFLD increased the risk of 1-year mortality. The authors conclude that NAFLD is becoming a major cause of HCC in the United States and that NAFLD-HCC is associated with a shorter survival time, more advanced stage and lower possibility of receiving a liver transplant.

Prospective Evaluation of the Diagnostic Accuracy of Hepatic Copper Content as Determined Using the Entire Core of a Liver Biopsy Sample
Yang Xu et al. Hepatology 2015;62:1731-1741.

Hepatic copper determination is an important tool for establishing the diagnosis of Wilson disease (WD), however, the methodology has not been standardized, the diagnostic accuracy prospectively validated and the optimum cut off value established. This is a prospective study of 3,350 consecutive patients who underwent core liver biopsy; 691 of those patients underwent liver biopsy with two passes, of which 178 were diagnosed with WD using a clinical and laboratory values based WD score (e.g., neuropsychiatric symptoms, Kayser-Fleischer rings, serum ceruloplasmin, urinary copper excretion, ATP7B mutation analysis etc) in combination with clinical follow up. ROC analysis supported a hepatic copper content cut off of 209 µg/g dry weight for the diagnosis of WD, if PBC and PSC have been excluded, instead of the two commonly cited but widely divergent cut off values of 250 µg/g dry weight and 75 µg/g dry weight. Copper deposition is unevenly distributed in the liver parenchyma and sample size is very important. Stringent study methodology was used to conclude that two passes of liver biopsy should be performed and a dedicated entire core of liver should be used for copper determination. The authors reiterate that histochemical staining is often negative when copper is diffusely distributed in the hepatocyte cytoplasm and histochemistry is more accurate only when copper is sequestered into lysosomes.

Human Pathology, November 2015

Immunohistochemical characterization of the regenerative compartment in biliary atresia: a comparison between Kasai procedure and transplant cases.
Kuo FY, et al. Hum Pathol. 2015;46(11):1633-9. 

This study examines immunohistochemical expression of CD56, CK7 and CK19 in relatively early biliary atresia (BA) patients (those undergoing Kasai procedure, n=24) vs, those with relatively late disease (those undergoing liver transplantation, n=64). The degree of ductular reaction and CK19 staining was similar on both groups. CD56 staining was seen significantly more often in liver transplant group. The authors suggest that the regenerative compartment shows more expansion in BA patients undergoing transplant and that there is more active regeneration in livers with advanced-stage BA.

Diagnostic value of maspin in distinguishing adenocarcinoma from benign biliary epithelium on endoscopic bile duct biopsy.
Chen L, et al. Hum Pathol. 2015;46(11):1647-54. 

The authors have shown in their previous studies that immunohistochemistry for insulin-like growth factor II mRNA-binding protein 3, S100P, and the von Hippel-Lindau gene product
(pVHL) can help to distinguish benign vs. malignant biliary epithelium. This study examines maspin (a serine protease inhibitor) expression by immunohistochemistry in 134 endoscopic bile duct biopsies (adenocarcinoma 45, atypical 31, and benign 58). Positive staining with maspin was seen more often in malignant cases, with diffuse nuclear and cytoplasmic staining of intermediate to strong intensity. Maspin was positive in 67% of atypical cases, which was consistent with an adenocarcinoma diagnosis made on follow-up. Maspin+/S100P+/pVHL- phenotype was present in 75% of malignant cases, while no benign biopsy showed this pattern.

Gastroenterology, Nov-Dec 2015

Liver Histology and Clinical Trials for Nonalcoholic Steatohepatitis-Perspectives From 2 Pathologists
Kleiner DE, Bedossa P. Gastroenterology. 2015 Nov;149(6):1305-8.

This is a very thoughtful commentary on various aspects of steatohepatitis by two experienced and widely respected hepatopathologists. The authors highlight the following points and diagnostic challenges:
(1) NAFL and NASH are considered as a dichotomous concept from the viewpoint of clinical trials. This is an oversimplification and does not allow proper categorization of cases with intermediate features. The NASH CRN has used the term ‘borderline NASH’ for these cases. For binary analysis in clinical trials, the NASH CRN has included these cases with cases showing definite NASH. The author state that further work is needed to clarify the utility of a more detailed histologic classification of NAFLD.
(2) Since binary classification into NAFL and NASH somewhat artificial, the authors advocate the concept that NAFLD is a chronic liver disease with a continuous spectrum, both in terms of disease activity and fibrosis.
(3)Histologic activity in NAFLD is reflected by features that are used to diagnose NASH: ballooning and lobular inflammation). European FLIP (Fatty Liver Inhibition of Progression) consortium has proposed the SAF (steatosis, activity, fibrosis) score. This involves semiquantitative evaluation of steatosis, activity (ballooning, inflammation), and fibrosis. This score does not include steatosis as part of disease activity, which is different from the NAFLD activity score (NAS).
(4) Fibrosis is a histologic marker of disease stage, and is more strongly associated with adverse clinical outcomes than histologic activity. Fibrosis has much higher reproducibility between pathologists compared to disease activity, and is an excellent indicator of adequacy of the biopsy (recommended 2 cm core using at least a 16-G needle). Hence regression of fibrosis may be the best marker to test drug efficacy. However, fibrosis regression is likely to take more time compared to markers of disease activity, and need a more generous biopsy. Despite these challenges, fibrosis regression is a goal that can be achieved for clinical trials as has been demonstrated in the FLINT study over a 72-week period. An expanded semiquantitative fibrosis staging system (from 0 to 6, similar to Ishak scheme for chronic viral hepatitis) or morphometric techniques may help in assessing fibrosis regression in shorter trials.
(5) Defining resolution of NASH is difficult, but is often required for clinical trials. The authors suggest that this should be defined as loss of ballooning (to a score of 0), with at least a 1-point decrement in lobular inflammation, without worsening of fibrosis.

Extrahepatic Morbidity and Mortality of Chronic Hepatitis C
Negro F, et al. Gastroenterology. 2015;149(6):1345-60. 

Extrahepatic manifestations associated with chronic hepatitis C includes mixed cryoglobulinemia which can manifest as cutaneous/visceral vasculitis, glomerulonephritis and B-cell lymphoma. Insulin resistance, diabetes, and atherosclerosis are common in hepatitis C cases and can lead to increased cardiovascular disease. Fatigue and cognitive impairment can also occur as part of neurological manifestations. The multisystem disease may be related to endocrine disturbances, viral replication in extrahepatic tissue, or an aberrant systemic immune reaction. Treatment with interferon alfa and ribavirin can improve the extrahepatic effects and the use of new interferon-free regimens may lead to greater improvements in extrahepatic manifestations. It is possible that extrahepatic manifestations can become an indication for treatment even if significant liver disease is not present.

American Journal Gastroenterology, Nov-Dec 2015

Changing Nomenclature for PBC: From 'Cirrhosis' to 'Cholangitis'
Beuers U, Gershwin ME, Gish RG, et al. Am J Gastroenterol. 2015 Nov;110(11):1536-8.

In this position paper sponsored by the European Association for the Study of Liver Diseases of the authors describe the history of the nomenclature of primary biliary cirrhosis and propose an alternative name given that many patients with this disease do not present with cirrhosis.  A survey was sent out to expert in the fields and “primary biliary cholangitis” had the broadest support.  The authors contend that this change will have critical implications for patients by removing the stigma of cirrhosis.