Liver and Gallbladder Surgical Pathology

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Liver and Gallbladder Surgical Pathology

  1. 1. SURGICALSURGICAL LIVERLIVER andand BILIARYBILIARY PATHOLOGYPATHOLOGY of Dr. Florencio C. Dizonof Dr. Florencio C. Dizon By Dr. Noel C. Santos, M.D.
  2. 2. LIVER PATHOLOGYLIVER PATHOLOGY  Focal liver lesionsFocal liver lesions – Tumor-like lesions and tumorsTumor-like lesions and tumors  Liver transplantationLiver transplantation  Diseases of gallbladder and bile ductsDiseases of gallbladder and bile ducts – Diseases of gall bladderDiseases of gall bladder – Diseases of extrahepatic bile ductsDiseases of extrahepatic bile ducts – TumorsTumors
  3. 3. Focal liver lesionsFocal liver lesions  Tumor-like lesions of the liverTumor-like lesions of the liver – FNHFNH, NRH, mesenchymal hamartoma, cysts,, NRH, mesenchymal hamartoma, cysts, inflammatory pseudotumor, abscessus, infarctusinflammatory pseudotumor, abscessus, infarctus  Benign liver tumorsBenign liver tumors – Non epithelialNon epithelial:: haemangiomahaemangioma, fibroma,, fibroma, angiomyolipoma etcangiomyolipoma etc – EpithelialEpithelial:: adenomaadenoma (HCA, CCA)(HCA, CCA)  Malignant liver tumorsMalignant liver tumors – Non epithelialNon epithelial: haemangiosarcoma, -endothelioma: haemangiosarcoma, -endothelioma embryonal sarcoma, lymphomaembryonal sarcoma, lymphoma – EpithelialEpithelial:: hepatocellular cc, cholangiocellular cc.,hepatocellular cc, cholangiocellular cc., mixed, hepatoblasomamixed, hepatoblasoma
  4. 4. Classification of liver cystsClassification of liver cysts I.I. ParasiticParasitic II.II. Non parasiticNon parasitic A. SoliterA. Soliter B. HerediterB. Herediter 1. Non communitating ductal1. Non communitating ductal 2. DPM („ductal plate malformatio”-2. DPM („ductal plate malformatio”- communitating)communitating) •• CHF (cong. hepatic fibrosis)CHF (cong. hepatic fibrosis) •• ARPKDARPKD •• syndromes (Meckel-Gruber, Ivemark)syndromes (Meckel-Gruber, Ivemark) 3. Isolated hepatic3. Isolated hepatic *Witzleben, G. L., Ruchelli, E.*Witzleben, G. L., Ruchelli, E.
  5. 5. Ecchinococcus cyst
  6. 6. 1 cm Hepar polycysticum
  7. 7. II. Non parasiticII. Non parasitic C.C. Systemic biliary dilatativeSystemic biliary dilatative 1. Without choledochus cyst1. Without choledochus cyst („simple” Caroli disease)(„simple” Caroli disease) 2. With choledochus cyst2. With choledochus cyst D. OtherD. Other 1.1. Traumatic, infarctusTraumatic, infarctus 2. Duodenal duplication2. Duodenal duplication 3.3. Tumors with cystTumors with cyst •• cystadenoma/-carcinomacystadenoma/-carcinoma •• mesenchymal hamartomamesenchymal hamartoma •• giant cavernous haemangiomagiant cavernous haemangioma •• teratomateratoma •• otherother 4.4. PeliosisPeliosis *Witzleben, G. L., Ruchelli, E.*Witzleben, G. L., Ruchelli, E. Classification of liver cystsClassification of liver cysts
  8. 8. 1 cm Mesenchymal hamartoma (children, benign)
  9. 9. Peliosis hepatis (dilated sinusoids)
  10. 10. Tumor-like focal liver lesionsTumor-like focal liver lesions – Focal nodular hyperplasia (FNH)Focal nodular hyperplasia (FNH) – InflammatorInflammatoryy pseudotumorpseudotumor – Mesenchymal hamartomaMesenchymal hamartoma – NoduNodulalar regenerar regeneratitiv hyperplasiav hyperplasia – InfarctInfarct – Granulomas (Boeck, tbc etc)Granulomas (Boeck, tbc etc)
  11. 11. Focal nodular hyperplasia (FNH) - Female predominance, - Well circumsized, - No capsule - Central scar (fibrous septa radiate, “focal cirrhosis”) - Color (pale, fatty, haemorrhagic etc.) - Bile ducts: numerous, tortuous - Inflammatory cells
  12. 12. Focal Nodular Hyperplasia (FNH) (central scar!!!)
  13. 13. 1 cm Focal nodular hyperplasia
  14. 14. 1 cm Focal nodular hyperplasia (cental fibrosis)
  15. 15. Infarctus anaemicus hepatis,
  16. 16. Classification of primary liverClassification of primary liver tumorstumors Epithelial Hepatocellular adenoma Cholangiocellular adenoma/cystadenoma Biliary papilloma/papillomatosis Hepatocellular carcinoma -Cholangiocellular carcinoma Mixed carcinoma Hepatoblastoma Nonepithelial Haemangioma Angiolipoma/myolipoma Fibroma Haemangiosarcoma Haemangioendothelioma Carcinoid, lymphoma, etc Benign Malignant
  17. 17. 1 cm Haemangioma hepatis (the most common primary liver tumor)
  18. 18. Haemangioma hepatis (giant form)
  19. 19. Hepatocellular adenoma - Female predominance - Associated with oral contraceptives, anabolic steroids - Sharply demarcated, - Encapsulated - Homogenous structure, but hemorrhage, necrosis common, - Steatosis, no bile ducts in the tumor
  20. 20. Adenoma hepatocellulare (yellow, steatosis, capsule)
  21. 21. 1 cm Adenoma hepatocellulare (extended bleeding, rupture might occur)
  22. 22. Cytological smear, HE stain Fine needle aspiration from the liver
  23. 23. Border of liver and tumor (after formalin fixation).
  24. 24. Hepatocellula adenoma with extended peliosis. The tumor cells are similar to normal hepatocytes. HE stain
  25. 25. Classification of primary liverClassification of primary liver tumorstumors Epithelial Hepatocellular adenoma Cholangiocellular adenoma/cystadenoma Biliary papilloma/papillomatosis Hepatocellular carcinoma -Cholangiocellular carcinoma Mixed carcinoma Hepatoblastoma Nonepithelial Haemangioma Aangiolipoma/myolipoma Fibroma Haemangiosarcoma Haemangioendothelioma Carcinoid, lymphoma, etc Benign Malignant
  26. 26. Hepatocellular carcinoma - Cirrhosis (70%) - Association with HBV/HCV/alkohol etc - Gross: uneven border, usually no capsule, haemorrhage, necrosis - Hist: trabecular, pseudoglandular (acinar), clear cell, scirrhous, fibrolamellar (grades I-IV) - Progression: infiltration of capsule (if exists), venous invasion
  27. 27. HCC extracapsular cirrhosis HCC necrosis
  28. 28. HCC
  29. 29. 1 cm Fibrolamellar HCC
  30. 30. Different histological types of HCC HCC, trabecular HCC, pseudoglandular HCC, anaplastic HCC, venous invasion
  31. 31. Characteristics of HCCCharacteristics of HCC  5% of malignant tumors5% of malignant tumors  564 000564 000 new cases annuallynew cases annually  (in 2000) and similar death(in 2000) and similar death  Incidence is dubbled in the pastIncidence is dubbled in the past 20 yrs (Japan, USA, Sweden,20 yrs (Japan, USA, Sweden, France)France)  7.7. in malesin males  9.9. in femelsin femels  Characteristic geographyCharacteristic geography  Etiological factors:Etiological factors: HBV, HCVHBV, HCV,, AFB1 (80%), alkohol etcAFB1 (80%), alkohol etc Unknown 35% HBV/HDV 5% HBV 15% HCV 45% Koff RS, et al.Koff RS, et al. ViralViral Hepatitis.Hepatitis. 2nd ed. 1994.2nd ed. 1994.
  32. 32. HBV, HCV HCC Mutagen effects Cirrhosis ! Aflatoxin Fusarium toxin Hepatocarcinogenesis Etiological factors Alcohol Androgens Metabolic diseases Schistosoma
  33. 33. proto Onkogenes c-myc, N-ras, c-fos HCC Citokines TGF-α, HGF ! IGF-I, IGF-II., TGF-β, Tumor suppressor genes p53, p16, RB Hepatocarcinogenesis LOH 1p,1q, 2q, 4q, 5q, 6q, 9p, 9q, 10q, 11p, 13q, 16p, 16q, 17p, 22/APC Adhesion molecules Integrins, E-cadherin, β-catenin ! Ampl. Chromos- region 1q, 8q
  34. 34.  p53p53  ((p53, p14p53, p14 ARFARF , MDM2), MDM2)  wntwnt  ((ββ-catenin-catenin))  RB1RB1  ((p16p16 INK4aINK4a ,, p15p15 INK4bINK4b ,, RB1RB1, CDK4,, CDK4,  cyclin D1)cyclin D1) Most common altered pathways in HCCMost common altered pathways in HCC Edamoto et al. Int.J.Cancer 2003.106:334-341Edamoto et al. Int.J.Cancer 2003.106:334-341 Suriawinata A. and Ruliang Xu, Seminars in liver Disease, 2004Suriawinata A. and Ruliang Xu, Seminars in liver Disease, 2004
  35. 35. Classification of tumors of bile duct and gall bladderClassification of tumors of bile duct and gall bladder originorigin)) Intrahepatic cholangiocarcinoma (ICC)Intrahepatic cholangiocarcinoma (ICC) (synonim: cholangiocellular carcinoma)(synonim: cholangiocellular carcinoma) •• peripheralperipheral ((CK7CK7+, CK20-)+, CK20-) •• hilar (Klatskin tumor)hilar (Klatskin tumor) from d. hepaticus (bifurcatio)from d. hepaticus (bifurcatio) (CK7+/CK20+)(CK7+/CK20+) Extrahepatic bile duct carcinomaExtrahepatic bile duct carcinoma (EBDC)(EBDC) CK7CK7++ /CK20/CK20++ Gallbladder carcinomaGallbladder carcinoma CK7CK7++ /CK20/CK20++ ICC osztályozása a májtumor TNM szerint; EBDC osztályozása „saját” TNM szerintICC osztályozása a májtumor TNM szerint; EBDC osztályozása „saját” TNM szerint Cabibi et al. P.R.P., 2001, 22:114-23; Okuda et al. J. Gastroent.Hepatol. 2002, 17:1049-55Cabibi et al. P.R.P., 2001, 22:114-23; Okuda et al. J. Gastroent.Hepatol. 2002, 17:1049-55
  36. 36. Most common metastaticMost common metastatic liver tumorsliver tumors  Gastrointestinal tract, gallbladder,Gastrointestinal tract, gallbladder, bile ducts , pancreasbile ducts , pancreas  LungLung  KidneyKidney  BreastBreast  MelanomaMelanoma  neuroendocrinneuroendocrin
  37. 37. Metastatic liver tumors
  38. 38. Klatskin tumor (Hilar CCC).
  39. 39. Cholangiocellular carcinoma.
  40. 40. Cholangiocellular carcinoma. Ductus choledocus Tumor, protruding from the Liver
  41. 41. Case reportCase report 54 y male54 y male Jaundice, 3 wJaundice, 3 weekeekss CT: enlarged tumor like alteration in the headCT: enlarged tumor like alteration in the head region of the pancreas, multiple foci in theregion of the pancreas, multiple foci in the liverliver Liver biopsy (frozen saLiver biopsy (frozen sammple)ple)
  42. 42. Liver Glandular tumor with fibrotic stroma
  43. 43. DiagnosisDiagnosis Cholangiocellular (Cholangiocellular (““bile duct”) adenomabile duct”) adenoma
  44. 44. Attention!Attention! It might mimic CCC or metastatic tumorIt might mimic CCC or metastatic tumor (especially on frozen section)(especially on frozen section)
  45. 45. Biliary hamartoma (von Meyenburg complex)
  46. 46. Biliary hamartoma (von Meyenburg complex)
  47. 47. Gallbladder 1. Tumorlike lesions - inflammatory origin (polyp, xanthogranulomatous cholecystitis etc) - hyperplasia (papillary, adenomyomatous) - Heterotopic tissue (pancreas, stomach, endocrin) - other
  48. 48. Gallbladder 2. Tumors Benign - adenoma - cystadenoma - papillomatosis - mesenchymal Malignant - epithelial - adenocarcinoma - adenosquamosus cc. - squamosus cc. - differenciálatlan - cystadenocarcinoma - mesenchymal - endocrin - carcinoid
  49. 49. Gallbladder carcinoma Gross - infiltrating - exophytic Histology - adenocarcinoma Immunohistochem - CEA - CA 19-9 Other - TNM - occult carcinoma - in situ carcinoma
  50. 50. Gallbladder cc Adenocarcinoma
  51. 51. Ductus choledochus carcinoma
  52. 52. Cholangiocellular carcinoma.
  53. 53. Thank you for listening……Thank you for listening……
  54. 54. SURGICALSURGICAL LIVERLIVER andand BILIARYBILIARY PATHOLOGYPATHOLOGY of Dr. Florencio C. Dizonof Dr. Florencio C. Dizon By Dr. Noel C. Santos, M.D.

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