Friday, June 19, 2015

President's Message June 2015

Dear Friends and Colleagues,

I hope everyone is doing well as the 2014-2015 academic year is about to end. Our Companion Meeting that was held during the USCAP Annual Meeting in Boston this past March was well-attended and a great success. We garnered high marks and positive feedback from the attendees. Congratulations are in order to all the speakers for this achievement.

The society membership voted upon the proposed modifications to the HPHS By-Laws during the Business Meeting that immediately followed the Companion Meeting. One of the changes that was approved included formalizing the creation of a Website Committee. Its inaugural chair, Arief Suriawinata, reported that the Interesting Case Series published in both the Newsletter and the HPHS website resulted in a record number of web visits (page views). As an aside, as of today, June 15, 2015, per Arief, there have been 16,742 visits to the website. This huge increase is mainly due to the Case Series that is being made available to the general public.

This Case Series section would not have been possible without the Education Committee’s dedication and resolve to generate interesting cases under the leadership of Oyedele Adeyi and the section editor, Cynthia Guy. In addition to the Cases, a new section, Journal Watch, was proposed by Dele Adeyi, which the Exec Com approved today. This will commence in the next issue of the Newsletter. This tremendous accomplishment is giving greater visibility to liver pathology and our Society. This Newsletter would not be possible without the Newsletter Committee chaired by Bita Naini and its very active members, Steve Ward, Erin Rubin and Cynthia Behling, who have worked very hard to keep this Newsletter coming out on a regular basis.

The Membership Committee members chaired by Maha Guindi were kept busy as the USCAP meeting was approaching because applications for membership were at an all-time high this year. A total of 22 were approved for membership (11 regular, 10 associate and 1 international). The By-Laws were also modified to include deliberations for membership to occur quarterly or even on a rolling basis as the need arises. This will hopefully result in keeping a potential member to be interested in the society and not wait for several months before a decision is made.

The HPHS was involved in putting together the liver pathology program at the Asia Pacific International Academy of Pathology that was held in Brisbane two weeks ago. The speakers included Yoh Zen, Yasuni Nakanuma, Young-Nyun Park, Andrew Clouston and Anthony Chan. This was also a successful meeting.

I am lucky to have the help and counsel from the other members of the Executive Committee: Michael Torbenson (incoming President), Matthew Yeh (Past President) and Grace Kim (Secretary-Treasurer) who work diligently behind the scenes but equally share in the responsibilities and challenges of keeping our Society flourishing.

The next newsletter will be published in three months and there will be more to come. I wish everyone a great summer.

Sincerely,

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

Interesting Case June 2015 #1

Case History: 

A 47 year old man with a past medical history of diabetes, hypertension, and obesity presented with abdominal pain, abdominal distension, and lower extremity swelling. A multiphase MRI of the liver revealed multiple calcified and non-calcified hypoenhancing masses, more confluent in, and involving most of, the right hepatic lobe. Smaller discrete lesions were seen in the left lobe, measuring up to 4.1 cm. The right portal vein showed findings suspicious for tumor thrombus. Needle-core biopsies were performed.

Figure 1: 4x, 1st biopsy core.

Figure 2: 10x, 1st biopsy core.

Figure 3: 20x, 1st biopsy core.

Figure 4: 40x, 1st biopsy core.

Figure 5: 40x, 1st biopsy core.

Figure 6: CD34, 1st biopsy core.

Figure 7: 10x, 2nd biopsy core.

Figure 8: 40x, 2nd biopsy core.

Figure 9: CD34, 2nd biopsy core.

Figure 10: CD34, 2nd biopsy core.
In addition to the CD34 immunohistochemistry (IHC) stain shown, the lesional cells were positive for CD31 and Factor VIII.

Diagnosis: 

Epithelioid Hemangioendothelioma

Discussion: 

Epithelioid Hemangioendothelioma (EHE) is a rare, low grade vascular malignancy that was first recognized as a distinct clinicopathologic entity in the early 1980s in the soft tissues and lung. In the latter organ it was originally referred to as intravascular bronchioloalveolar tumor (IVBAT). It is now known to occur in many sites, including the liver.

Its histologic features are quite distinctive in the liver. In hepatic EHE the tumor is often multifocal, with calcifications seen radiographically. They are firm, white to yellow, with ill-defined borders. Tumor cells are both dendritic and epithelioid in various proportions. The spindle cells are irregularly shaped and elongated. Epithelioid cells are rounder with more abundant eosinophilic cytoplasm. Small papillations or tufts of tumor cells may be seen within thin-walled vascular spaces. Abortive vascular differentiation is typically seen, with tumor cell cytoplasm containing a single vacuole representing a capillary luminal space — so-called “blister cells.” Tumor cells lie within a variably myxoid to fibrous stroma. The tumor often infiltrates hepatic vein and portal vein branches, leading to Budd-Chiari syndrome as a possible presentation. The tumor tends to grow around and leave pre-existing hepatic structures intact, particularly at the periphery of tumor nodules. In these areas, only subtle infiltration of tumor cells may be seen within sinusoids, in an otherwise architecturally normal liver, something which can be particularly treacherous in small liver biopsies.

On core biopsy material, the differential diagnosis can be separated into two distinct categories:

  1. the lesion is clearly neoplastic but the histogenesis of the tumor is not obvious
  2. fibrosis vs. EHE.

In the first setting, the lesion is sufficiently cellular and atypical to be clearly neoplastic, and the differential diagnosis often includes carcinomas such as hepatocellular carcinoma, cholangiocarcinoma, or metastatic carcinoma. IHC stains for vascular markers (CD34, CD31, Factor VIII, FLI1), are typically positive in EHEs and negative in carcinomas. Patchy keratin staining can be seen in some tumor cells of EHE, or in entrapped hepatocytes or bile ducts, and care should be taken not to misdiagnose a carcinoma.

In the second setting, the tumor is hypocellular and has a fibrotic stroma, and can closely mimic fibrosis or confluent necrosis with drop-out. In this setting, the tumor can be very difficult to diagnose on limited core biopsy material. One can look for focal areas of greater cytologic atypia, or areas of sinusoidal infiltration of tumor cells. A vascular IHC stain can be helpful to highlight such infiltration, keeping in mind not to misinterpret capillarization of sinusoids, which can be seen in various settings.

The largest series on hepatic EHE is from the AFIP, in which 137 cases were described. It typically occurs in middle-aged adults (though rare cases in children have been reported), with a slight female predominance. It presents with non-specific symptoms such as abdominal pain, nausea and vomiting, hepatosplenomegaly, or as Budd-Chiari syndrome, or as an incidental finding. It is slowly progressive and treated with excision, or transplantation in advanced cases. In this presented case, the patient was immediately referred for liver transplantation. Because the tumor grows so slowly, transplantation can still be performed in the presence of extra-hepatic disease. Overall 5-year survival rate is 43-55%.

More recently, a characteristic translocation has been reported: t(1;3)(p36.3;q25), resulting in a WWTR1-CAMTA1 fusion. This translocation has been shown to occur in the majority of EHEs of various sites, and not in their histologic mimics. A smaller subset of EHEs show a YAP1-TFE3 fusion. A recent study showed a high sensitivity and specificity for a CAMTA1 IHC stain, suggesting its possible utility as a diagnostic marker.

References

Antonescu CR, et al. Novel YAP1-TFE3 fusion defines a distinct subset of epithelioid hemangioendothelioma. Genes Chromosomes Cancer 2013; 52: 775-784.
Errani C, et al. A Novel WWTR1-CAMTA1 Gene Fusion is a Consistent Abnormality in Epithelioid Hemangioendothelioma of Different Anatomic Sites. Genes Chromosomes Cancer 2011; 50: 644-653.
Makhlouf HR, Ishak KG, Goodman ZD. Epithelioid hemangioendothelioma of the liver: a clinicopathologic study of 137 cases. Cancer 1999; 85: 562-582.
Mehrabi A, et al. Primary malignant hepatic epithelioid hemangioendothelioma: a comprehensive review of the literature with emphasis on surgical therapy. Cancer 2006; 107: 2108-2121.
Shibuya R, et al. CAMTA1 is a useful immunohistochemical marker for diagnosing epithelioid hemangioendothelioma. Histopathology 2015 Apr; doi 10.1111/his.12713.

Contributed by:
Nafis Shafizadeh, MD
Southern California Permanente Medical Group

Woodland Hills Medical Center


Interesting Case June 2015 #2

Case History: 

A 62 year old woman with a history of renal cell carcinoma removed years ago presented with a 2.4 cm liver mass found in CT during follow-up. A partial hepatectomy was performed.

Laboratory values: 

ALT, AST, alkaline phosphatase and bilirubin were normal. There is no prior history of liver disease.

Gross examination of the liver resection: 

Cut section reveals a 2.4 cm circumscribed mass with a gray-brown focally spongy appearance.


Figure 1

Figure 2

Figure 3, CD31 immunohistochemistry

Final diagnosis: 

Hemangioma, anastomosing type.

Discussion:

Hepatic hemangioma is a common benign vascular neoplasm in both infants and adults that shares the same growth pattern and prognosis as its cutaneous counterpart. Based on its distribution, hemangioma can be classified as focal, multifocal, or diffuse.  Most hepatic hemangiomas are of the cavernous type followed by the capillary type. Capillary hemangioma, including lobular capillary hemangioma (also known as pyogenic granuloma) commonly presents on the skin and mucosa, although rare liver or gastrointestinal tract examples have been reported. Capillary hemangioma is composed of a lobular proliferation of vascular channels with plump endothelial cells lining the vascular channels. Anastomosing hemangiomas in the liver, as seen in this case, are rare hepatic vascular neoplasms characterized by an interconnecting sinusoidal-like pattern of tightly packed capillary channels. The tumor appears well circumscribed grossly with a gray-brown focally spongy appearance in the liver. Low-power magnification shows a well-demarcated lesion with lobular architecture in the liver. At higher magnification the tumors consists of anastomosing sinusoidal capillary-sized vessels with scattered hobnail endothelial cells within a framework of non-endothelial supporting cells. No mitotic figures or necrosis are observed. Mild cytologic atypia is appreciated. Immunohistochemical stain for CD31 is diffusely positive.

The primary differential diagnosis of anastomosing hemangioma is angiosarcoma. Angiosarcoma of the liver and gastrointestinal tract is rare and behaves aggressively. The overall survival is poor and patients rapidly develop metastases and usually die within 6–12 months. Accurate diagnosis can be challenging, particularly if the patients have no history of exposure to specific toxins including thorium dioxide, arsenicals, and vinyl chloride monomer. Distinguishing anastomosing hemangioma from a well-differentiated angiosarcoma is challenging especially on small biopsies. Histologically, branching, jagged, slit-like vascular channels with prominent cytological alterations and a diffuse infiltrating border is characteristic of angiosarcoma, in contrast to the sharp demarcation, mild cytological atypia, and lack of mitotic figures in anastomosing hemangioma. The absence of multilayering of endothelial cells, high grade cytologic atypia, and mitotic activity coupled with circumscribed borders favor a benign process. Awareness of this entity and attention to cytological features and the overall lobular architecture are essential to avoid diagnostic errors.

In summary, anastomosing hemangiomas in the liver is a rare entity and leads to concern for angiosarcoma. Awareness of this entity can minimize a misdiagnosis of angiosarcoma and avoid unnecessary aggressive treatment.

References 

1. Kulungowski AM, Alomari AI, Chawla A, Christison-Lagay ER, Fishman SJ. Lessons from a liver hemangioma registry: subtype classification. J Pediatr Surg. Jan 2012;47(1):165-170. 
2. Dickie B, Dasgupta R, Nair R, et al. Spectrum of hepatic hemangiomas: management and outcome. J Pediatr Surg. Jan 2009;44(1):125-133. 
3. Abaalkhail F, Castonguay M, Driman DK, Parfitt J, Marotta P. Lobular capillary hemangioma of the liver. Hepatobiliary Pancreat Dis Int. Jun 2009;8(3):323-325. 
4. Nishiyama N, Mori H, Kobara H, et al. Bleeding duodenal hemangioma: morphological changes and endoscopic mucosal resection. World journal of gastroenterology : WJG. Jun 14 2012;18(22):2872-2876. 
5. Giaccaglia V, Stefanuto A, Cavallotti C, Quintiliani A, Stipa F. Transanal excision of rectal pyogenic granuloma: case report and literature review. Surg Laparosc Endosc Percutan Tech. Apr 2011;21(2):e91-92. 
6. Santos J, Ruiz-Tovar J, Lopez A, Arroyo A, Calpena R. Simultaneous massive low gastrointestinal bleeding and hemoperitoneum caused by a capillary hemangioma in ileocecal valve. International journal of colorectal disease. Oct 2011;26(10):1363-1364. 
7. Nagoya H, Tanaka S, Tatsuguchi A, et al. Rare cause of obscure gastrointestinal bleeding due to pyogenic granuloma in the ileum detected by capsule endoscopy and treated with double balloon endoscopy. Dig Endosc. Jan 2010;22(1):71-73. 
8. Park SY, Park CH, Lee WS, Kim HS, Choi SK, Rew JS. Pyogenic granuloma of the duodenum treated successfully by endoscopic mucosal resection. Gut Liver. Mar 2009;3(1):48-51. 
9. Shibuya T, Osada T, Mitomi H, et al. Jejunal capillary hemangioma treated by using double-balloon endoscopy (with video). Gastrointest Endosc. Sep 2010;72(3):660-661. 
10. Benevento A, Boni L, Dionigi G, Besana Ciani I, Danese E, Dionigi R. Multiple hemangiomas of the appendix and liver. J Am Coll Surg. Nov 2003;197(5):860-861. 
11. Lin J, Bigge J, Ulbright TM, Montgomery E. Anastomosing hemangioma of the liver and gastrointestinal tract: an unusual variant histologically mimicking angiosarcoma. The American journal of surgical pathology. Nov 2013;37(11):1761-1765. 
12. Brown CJ, Falck VG, MacLean A. Angiosarcoma of the colon and rectum: report of a case and review of the literature. Diseases of the colon and rectum. Dec 2004;47(12):2202-2207. 
13. Maluf D, Cotterell A, Clark B, Stravitz T, Kauffman HM, Fisher RA. Hepatic angiosarcoma and liver transplantation: case report and literature review. Transplantation proceedings. Jun 2005;37(5):2195-2199. 
14. Alrenga DP. Primary angiosarcoma of the liver. Review article. Int Surg. Apr 1975;60(4):198-203. 
15. Elliott P, Kleinschmidt I. Angiosarcoma of the liver in Great Britain in proximity to vinyl chloride sites. Occupational and environmental medicine. Jan 1997;54(1):14-18. 
16. Bhati CS, Bhatt AN, Starkey G, Hubscher SG, Bramhall SR. Acute liver failure due to primary angiosarcoma: A Case Report and Review of the Literature. World J of Surg Oncol. 2008;6:104.


Contributed by:
Jingmei Lin, MD, PhD
Department of Pathology and Laboratory Medicine
Indiana University School of

Friday, March 27, 2015

Congratulations to Winners of 2015 HPHS Trainee Award!

Winner of The 2015 HPHS Best Abstract
Dr. Emily Waterhouse & Dr. David Solomon (UCSF,  faculty sponsor. Linda Ferrell):
Validation of an RT-PCR assay for detection of recurrent DNAJB1-PRKACA fusion transcripts in fibrolamellar hepatocellular carcinoma

Drs. Fiel, Waterhouse, Solomon and Adeyi


First Runner-up Abstract
Dr.  Christos Tsokos,  UCSF (faculty sponsor Gregor Krings):
Telomerase Reverse Transcriptase Promoter Mutations (mTERTp) in Combined Hepatocellular(HCC)-Cholangiocarcinoma(CC; cHCC-CC) Support Clonal and HCC-like Origin for Both Components

Drs. Fiel, Tsokos and Adeyi


Second Runner-up Abstract
Dr. Dana Balitzer,  UCSF (Faculty sponsor -  Sanjay Kakar):
Autoimmune Hepatitis: Review of Validity of Histologic Features Included in the Simplified Criteria Proposed by the International Autoimmune Hepatitis Group (IAIHG)

Drs. Fiel, Balitzer and Adeyi

Monday, March 23, 2015

Hans Popper Hepatopathology Society Companion Meeting 2015 Handouts

Hans Popper Hepatopathology Society
Sunday, March 22, 2015 - 8:30am to 12:00pm
Hynes Convention Center Ballroom B
8:30 AMCompanion Meeting Moderator- M. Isabel Fiel, MD, Mount Sinai Medical Center, New York, NY Maria Isabel Fiel, MD
8:30 AMLiver Pathology and the Clinician in 2015: At the Crossroads Thomas D. Schiano, MD
8:30 AMPractical Issues and Diagnostic Challenges in Liver Pathology Maria Isabel Fiel, MD
8:50 AMDifferential Diagnosis of Fatty Liver Disease: Not the Usual Culprits Elizabeth M. Brunt, MD
9:20 AMNoncirrhotic Portal Hypertension and Pathology of the Sinusoids Ian R. Wanless, MD
9:50 AMQuestion and Answer Session Maria Isabel Fiel, MD
10:00 AMCoffee Break Maria Isabel Fiel, MD
10:30 AMUpdate on Cholangiocarcinoma and Mixed Hepatocellular-Cholangiocarcinoma Emma E. Furth, MD
11:00 AMBiomedical Informatics 101 Arief Suriawinata, MD
11:20 AMSpecial stains, Immunohistochemistry and Genomic Testing of the Liver: A Guide for the Practicing Pathologist Michael S. Torbenson, MD
11:50 AMQuestions and Answers Maria Isabel Fiel, MD

Tuesday, March 10, 2015

President's Message March 2015

Dear Friends and Colleagues,

I would like to remind you that the HPHS Companion Society Meeting at Boston is scheduled for March 22, 2015 from 8:30am-12 noon. The title is “Diagnostic Challenges and Update in Hepatopathology”. We have created a program that will not only be very educational to our members but will hopefully be interesting to non-members as well. The topics that will be discussed include new therapeutic interventions for hepatitis and liver cancer and what this means to the pathologist, differential diagnosis of fatty liver diseases, vascular diseases and portal hypertension, the basics of biomedical informatics and its applicability in general practice, diagnosis of mixed hepatocellular-cholangiocarcinoma, and the current methods available to assist in reaching a diagnosis in challenging liver pathology cases. 

The Business meeting will immediately follow the companion meeting. Members are encouraged to attend, as we will need to vote on some modifications to the bylaws as a result of the tax-exempt status of the HPHS, as well as some changes to the duties and responsibilities of the members of the Executive Committee.

Please encourage both your junior and senior colleagues to officially become members of the HPHS. Residents and fellows can become Trainee members without having to pay any dues. They can easily transition to Regular membership once they finish their training. Application to membership is available on the website. Please email completed application to Maha Guindi (Maha.Guindi@cshs.org), chair of the membership committee.

I look forward to seeing you all in Boston.

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

Monday, March 9, 2015

Interesting Case March 2015

Clinical History
A 30 year old man was referred for liver transplantation workup for presumed liver cirrhosis from NASH. The clinical diagnosis of NASH cirrhosis was based on hepatosplenomegaly, low platelets and steatosis on liver imaging and the local biopsy. The only risk factor for NASH was hypercholesterolemia. 

Labs
AST 53 U/L, ALT 87 U/L, ALP 75 U/L, platelets 101,000/µL.

The patient was referred to a liver transplantation center and the biopsy was re-evaluated. Images from the liver biopsy are shown below.



Liver Biopsy Findings
The biopsy shows clusters of “sea-blue” cells that contain pale, foamy cytoplasmic material. These cells stain with the macrophage marker CD68, but not the hepatocyte marker Hep-Par1. The hepatocytes have mild microvesicular steatosis, but no features of steatohepatitis are apparent. Also there is only very little fibrosis. By electron micrograph, the macrophages contain laminated myelin figures.

Diagnosis
Sea blue histocytosis syndrome

Major Learning Points
  1. Clinical, non-invasive features of cirrhosis and portal hypertension, such as thrombocytopenia, can have other causes.
  2. Sea-blue histiocytosis (SBH) syndrome can be subtle and not always as prominent as in this case. But SBH syndrome should be kept in mind in certain clinical contexts, including unexplained hepatosplenomegaly.
  3. The published cases of SBH involving the liver are for the most part due to inherited lysosomal storage disorders. Typically the bone marrow is the most commonly affected organ, baring a few exceptions such as patients receiving fat emulsion in total parenteral nutrition.
  4. Electron microscopy, though rarely utilized in today’s clinical hepatopathology practice, could play a helpful role in defining the nature of cytoplasmic accumulations.
Discussion
Steatohepatitis is a common disease and it has become a frequent cause of referral to liver transplantation centers. In addition, the proportion of liver transplantations for NASH is projected to increase due the availability of new highly efficacious direct antiviral agents for hepatitis C. It is worth highlighting the need to carefully evaluate the clinical, non-invasive parameters of cirrhosis knowing that these assessments are surrogates and can sometimes produce false positive results. In this patient with an enlarged spleen, low platelets, hyperlipidemia and radiologic diagnosis of “fatty liver”, the clinical assessment had pointed in the direction of NASH-related end-stage liver disease. Ultimately, however, this proved to be a case of Nieman-Pick disease which manifests characteristically as hepatosplenomegaly, low platelets and hypercholesterolemia.

The accumulation of lipid material in macrophages of several organs, including the liver, spleen, bone marrow, and lymph nodes, is sometimes referred to as “sea-blue histocytosis” (SBH). The name initially originated form the appearance of these macrophages when stained with Giemsa/PAS, although in the case described above this stain was not necessary to demonstrate these cells. There are many causes of SBH, but in general, it is a feature of lipid or ceroid storage disorders, and can be primary or secondary. The term was first applied in 1941 in the Swiss literature by Dr.  Möschlin and later reported as a syndrome in 1970 by Silverstein et al (N Engl J Med 1970; 282:1-4). The syndrome was attributed to adults with Nieman-Pick disease (NPD) in 1977 by Long et al (Am J Med. 1977;62(4):627-35). NPD was ultimately diagnosed in the patient presented above. Following additional studies, he is believed to have Nieman-Pick disease type B. The SBH syndrome is however not unique to NPD and histopathology lacks the specificity to make an etiologic diagnosis in most cases. 

Determining an etiology for SBH syndrome requires the combination of clinical, histopathological, biochemical and genetic information. Some of the other primary/inherited diseases associated with the SBH are cholesterol ester storage disease, Gaucher disease, hypertriglyceridemia (with mutation in the receptor-binding region of the apoE molecule), lecithin-cholesterol acyltransferase deficiency (i.e., Norum disease), ceroid lipofuscinosis and Tangier disease. Several acquired conditions have also been associated SBH, including administration of fat emulsion in total parenteral nutrition, as well as some hematologic conditions. The bone marrow, and less likely the liver, is the usual site of SBH accumulation in these hematologic conditions, such as in myelodysplastic syndrome (J Clin Pathol. 1993 Nov;46(11):1030-2).

Contributed by:
Oyedele Adeyi, MD
Department of Pathology, Toronto General Hospital, Toronto, Ontario.

Monday, February 2, 2015

In Memoriam Boris Henry Ruebner, MD, 1923-2014

Boris H. Ruebner, MD, 1923-2014
Boris, a long time member of the Hans Popper Hepatopathology Society, passed away June 11, 2014 at the age of 90. Boris was born in Düsseldorf. He recalled to me that, at the age of 13, he attended the 1936 Berlin Olympics with his father. He moved to England in the late 1939 where he attended Winchester College, followed by the University of Edinburgh Medical School. After graduation in 1946, he studied and practiced pathology at Hammersmith Hospital in London and the University of Heidelberg. He emigrated to Canada where he was a member of the pathology staff of Dalhousie University in Halifax from 1957 to 1959. He was married on campus in King’s College Chapel. Together, we visited the same chapel during the 2007 Laennec meeting, shortly before his 50th wedding anniversary.

Boris was on the staff of Johns Hopkins University for a decade before being recruited, in 1968, to the inaugural staff of the University of California (Davis). During his long career, he published more than 180 peer-reviewed articles. He was well known for his textbook “Pathology of the Liver and Biliary Tract”, co-authored with Carolyn Montgomery (1982 and 1991). Although Boris officially retired in 1994, he maintained a consultation practice and continued to teach into his late 80s. He was a popular and award-winning teacher. In recognition of his contribution, the Division of Gastroenterology created the Ruebner-Rosenquist Outstanding Teaching Award in 2010.

I was first acquainted with Boris through his writings. While pursuing a project at Johns Hopkins in the 1980s, I reviewed all the autopsy liver slides on file from a period of 80 years and assembled some data. Afterwards, I discovered that Boris had reviewed the same liver slides and had already published similar data.  Boris was always a step ahead of me! We finally met in person at the inaugural planning for the Hans Popper Hepatopathology Society during a USCAP meeting. A few years later, he became one of the founding members of the Laennec Liver Pathology Society. He was present at the first summer meeting in 2000 and every subsequent annual meeting until he was 88. He was a committed traveller and made the Laennec meetings a reason to get about, scrambling over rocks and roots with the fittest. He suffered a ruptured tendon in his mid-80s but continued to press on with the help of great personal tenacity and a stout cane. One memorable summer, at the age of 84, he visited the Hermitage in St Petersburg and returned, travelling alone, with a stop in Nova Scotia to attend the Laennec meeting. From there he took a bus to New York where he boarded his return flight to Davis. He still had the strength to attend 4 annual meetings after that. Travel was a tonic for him, just as his determination was a tonic for us. He was always with us, and now we miss him.

Ian R. Wanless, M. D.
Department of Pathology,
Dalhousie University, Halifax, Canada

Monday, December 15, 2014

President's Message December 2014

Dear Friends and Colleagues,

I would like to remind you that the HPHS  Companion Society Meeting at Boston is scheduled for March 22, 2015 from 8:30am-12 noon. The title is “Diagnostic Challenges and Update in Hepatopathology”. We have created a program that will not only be very educational to our members but will hopefully be interesting to non-members as well. The topics that will be discussed include new therapeutic interventions for hepatitis and liver cancer and what this means to the pathologist, differential diagnosis of fatty liver diseases, vascular diseases and portal hypertension, the basics of biomedical informatics and its applicability in general practice, diagnosis of mixed hepatocellular-cholangiocarcinoma, and the current methods available to assist in reaching a diagnosis in challenging liver pathology cases. Please see the last page of this Newsletter for the list of speakers and the title of their talks. 

The Business meeting will immediately follow the companion meeting. Members are encouraged to attend, as we will need to vote on some modifications to the bylaws as a result of the tax-exempt status of the HPHS, as well as some changes to the duties and responsibilities of the members of the Executive Committee. Please encourage both your junior and senior colleagues to officially become members of the HPHS. Residents and fellows can become Trainee members without having to pay any dues. They can easily transition to Regular membership once they finish their training. Application to membership is available on the website. Please email completed application to Maha Guindi (Maha.Guindi@cshs.org), chair of the membership committee. 

We have officially created a new Website Committee, and I am grateful that Dr. Arief Suriawinata has graciously agreed to be the Chair of this committee. Please see the website for new updates including the discussion and main learning points for the two interesting cases presented in this Newsletter. I would also like to thank Dr. Bita Naini, past member and the new Chair of the Newsletter Committee as the person behind the scenes in making this Newsletter go out. 

I look forward to seeing you all in Boston.

Sincerely,

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

Friday, December 12, 2014

Interesting Case December 2014 #1

Clinical History:

A 29 year old woman with a 5 year history of insulin dependent diabetes mellitus presented with right flank pain and constipation for the past 2 weeks. During the clinical work up, she was diagnosed with diabetic ketoacidosis and acalculous cholecystitis. Due to elevated liver enzymes and hepatomegaly, liver biopsy was performed during the laparoscopic cholecystectomy.

Labs:

At the time of presentation, the patient’s laboratory values were: blood glucose, 434 mg/dL (normal range [NR] 70-100 mg/dL); alkaline phosphatase, 131 U/L (NR 14-127 U/L); AST, 457 U/L (NR 5-46 U/L); ALT, 230 U/L (NR 4-51 U/L) and total bilirubin, 1.1 mg/dL (NR 0.1-1.5 U/L). 

Microscopic Images:


Figure 1. Low power view showing pale liver parenchyma without steatosis or inflammation.

Figure 2. Swollen and rarified hepatocytes with compressed sinusoids.

Figure 3. Hepatocytes with multiple giant mitochondria and glycogenated nuclei.

Diagnosis

Glycogenic Hepatopathy

Discussion

Glycogenic hepatopathy (GH) is not currently commonly seen in practice due to improved diabetic therapies. The typical clinical presentation is elevated blood glucose, elevated liver enzymes, hepatomegaly and abdominal pain. Other signs and symptoms can include abdominal distension, anorexia, nausea, right upper quadrant pain and shortness of breath. The liver biopsy in GH characteristically shows marked accumulation of glycogen in hepatocytes, but the diagnosis requires close clinicopathological correlation. 

The pathophysiology of GH is incompletely understood, but it is thought to be caused by prolonged periods of hyperglycemia in poorly controlled diabetic patients treated with insulin. The elevated blood glucose passes into hepatocytes independent of insulin. This is then followed by periods of insulin therapy in which the hepatic glucose is converted to glycogen and the glycogen becomes trapped in hepatocytes. It is thought that the excess hepatic glycogen accumulation leads to hepatocyte injury and causes “leakage” of aminotransferases. Significant hepatocellular death is not typical.

GH also been reported in patients with type II diabetes mellitus, urea cycle defects, and medication effects (e.g., short-term high dose steroids). The differential diagnosis includes hereditary glycogen storage diseases, smooth endoplasmic reticulum proliferation due to medication effects, and glycogen pseudoground glass changes associated with the intake of multiple medications (poly- pharmacotherapy). Rarely GH can coexist with NAFLD or steatohepatitis. Minimal fibrosis has rarely been described in GH; significant fibrosis is not characteristic.

Case contributed by

Jie Ouyang, M.D. 
Florida Hospital Center for Diagnostic Pathology 
Orlando, Florida 

References