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

Wednesday, August 3, 2016

Journal Watch May-June 2016

Hepatology, May-June 2016

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

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

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

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

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

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

American Journal of Surgical Pathology, May-June 2016

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

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

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

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

Journal of Hepatology, May-June 2016

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

American Journal of Clinical Pathology, May-Jun 2016

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

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

Modern Pathology, May-Jun 2016

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

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

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

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

Journal of Gastroenterology and Hepatology, May-Jun 2016

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

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

Gastroenterology, May –June 2016

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

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

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

Human Pathology, May-June 2016

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

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

Gut, May-June 2016

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

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

American Journal of Gastroenterology, May-Jun 2016

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

Histopathology May-June 2016

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

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

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

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

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

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

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

Liver transplantation, May-Jun 2016

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

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

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

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

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

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

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

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

Wednesday, June 1, 2016

President's Message May 2016

Dear Friends and Colleagues:
Michael Torbenson, MD

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

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

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

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.