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Liver and Gallbladder Surgical Pathology

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Liver and Gallbladder Surgical Pathology Liver and Gallbladder Surgical Pathology Presentation Transcript

  • SURGICAL LIVER and BILIARY PATHOLOGY of Dr. Florencio C. Dizon By Dr. Noel C. Santos, M.D.
  • LIVER PATHOLOGY
    • Focal liver lesions
      • Tumor-like lesions and tumors
    • Liver transplantation
    • Diseases of gallbladder and bile ducts
      • Diseases of gall bladder
      • Diseases of extrahepatic bile ducts
      • Tumors
  • Focal liver lesions
    • Tumor-like lesions of the liver
      • FNH , NRH, mesenchymal hamartoma, cysts, inflammatory pseudotumor, abscessus, infarctus
    • Benign liver tumors
      • Non epithelial : haemangioma , fibroma, angiomyolipoma etc
      • Epithelial : adenoma (HCA, CCA)
    • Malignant liver tumors
      • Non epithelial : haemangiosarcoma, -endothelioma embryonal sarcoma, lymphoma
      • Epithelial : hepatocellular cc, cholangiocellular cc., mixed, hepatoblasoma
  • Classification of liver cysts I. Parasitic II. Non parasitic A. Soliter B. Herediter 1. Non communitating ductal 2. DPM („ductal plate malformatio”- communitating) • CHF (cong. hepatic fibrosis) • ARPKD • syndromes (Meckel-Gruber, Ivemark) 3. Isolated hepatic *Witzleben, G. L., Ruchelli, E.
  • Ecchinococcus cyst
  • 1 cm Hepar polycysticum
  • II. Non parasitic C. Systemic biliary dilatative 1. Without choledochus cyst („simple” Caroli disease) 2. With choledochus cyst D. Other 1. Traumatic, infarctus 2. Duodenal duplication 3. Tumors with cyst • cystadenoma/-carcinoma • mesenchymal hamartoma • giant cavernous haemangioma • teratoma • other 4. Peliosis *Witzleben, G. L., Ruchelli, E. Classification of liver cysts
  • 1 cm Mesenchymal hamartoma (children, benign)
  • Peliosis hepatis (dilated sinusoids)
  • Tumor-like focal liver lesions
      • Focal nodular hyperplasia (FNH)
      • Inflammator y pseudotumor
      • Mesenchymal hamartoma
      • Nodu la r regenera ti v hyperplasia
      • Infarct
      • Granulomas (Boeck, tbc etc)
  • 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
  • Focal Nodular Hyperplasia (FNH) (central scar!!!)
  • 1 cm Focal nodular hyperplasia
  • 1 cm Focal nodular hyperplasia (cental fibrosis)
  • Infarctus anaemicus hepatis,
  • Classification of primary liver tumors Epithelial Hepatocellular adenoma Cholangiocellular adenoma/ cy stadenoma Biliary papilloma/papillomatosis Hepatocellular carcinoma -Cholangiocellular carcinoma Mixed carcinoma Hepatoblastoma Nonepithelial H aemangioma A ngiolipoma /myolipoma F ibroma H aemangiosarcoma H aemangioendothelioma Carcinoid, lymphoma, etc Benign Malign ant
  • 1 cm Haemangioma hepatis (the most common primary liver tumor)
  • Haemangioma hepatis (giant form)
  • 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
  • Adenoma hepatocellulare (yellow, steatosis, capsule)
  • 1 cm Adenoma hepatocellulare (extended bleeding, rupture might occur)
  • Cytological smear, HE stain Dr.Járay Balázs Fine needle aspiration from the liver
  • Border of liver and tumor (after formalin fixation).
  •  
  • Hepatocellula adenoma with extended peliosis. The tumor cells are similar to normal hepatocytes. HE stain
  • Classification of primary liver tumors Epithelial Hepatocellular adenoma Cholangiocellular adenoma/ cy stadenoma Biliary papilloma/papillomatosis Hepatocellular carcinoma -Cholangiocellular carcinoma Mixed carcinoma Hepatoblastoma Nonepithelial H aemangioma A angiolipoma /myolipoma F ibroma H aemangiosarcoma H aemangioendothelioma Carcinoid, lymphoma, etc Benign Malign ant
  • 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
  • HCC extracapsular cirrhosis HCC necrosis
  • HCC
  • 1 cm Fibrolamellar HCC
  • Different histological types of HCC HCC, trabecular HCC, pseudoglandular HCC, anaplastic HCC, venous invasion
  • Characteristics of HCC
    • 5% of malignant tumors
    • 564 000 new cases annually
    • (in 2000) and similar death
    • Incidence is dubbled in the past 20 yrs (Japan, USA, Sweden, France)
    • 7. in males
    • 9. in femels
    • Characteristic geography
    • Etiological factors: HBV, HCV , AFB1 (80%), alkohol etc
    Koff RS, et al. Viral Hepatitis. 2nd ed. 1994.
  • HBV, HCV HCC Mutag en effects Cirrhosis ! Aflatoxin Fusarium toxin Hepatocarcinogenesis Etiological factors Al c ohol Androg ens Metaboli c diseases S chistosoma
  • proto Onkog enes c-myc , N-ras, c-fos HCC Citokin es TGF-  , HGF ! IGF-I, IGF-II., TGF-  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 Integrin s , E-cadherin,  -catenin ! Ampl. Chromos- region 1q, 8q
    • p53
        • ( p53, p14 ARF , MDM2)
    • wnt
        • (  -catenin )
    • RB1
        • ( p16 INK4a , p15 INK4b , RB1 , CDK4,
        • cyclin D1)
    Most common altered pathways in HCC Edamoto et al. Int.J.Cancer 2003.106:334-341 Suriawinata A. and Ruliang Xu, Seminars in liver Disease, 2004
  • Classification of tumors of bile duct and gall bladder origin )
    • Intrahepatic cholangiocarcinoma (ICC)
    • (synonim: cholangiocellular carcinoma)
    • • peripheral ( CK7 +, CK20-)
    • • hilar (Klatskin tumor)
    • from d. hepaticus (bifurcatio)
    • (CK7+/CK20+)
    • Extrahepatic bile duct carcinoma (EBDC)
    • CK7 + /CK20 +
    • Gallbladder carcinoma
    • CK7 + /CK20 +
    • ICC 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, 17:1049-55
  • Most common metastatic liver tumors
    • Gastrointestinal tract, gallbladder, bile ducts , pancreas
    • Lung
    • Kidney
    • Breast
    • Melanoma
    • neuroendocrin
  • Metastatic liver tumors
  • Klatskin tumor (Hilar CCC).
  • Cholangiocellular carcinoma.
  • Cholangiocellular carcinoma. Ductus choledocus Tumor, protruding from the Liver
  • Case report
    • 54 y male
    • Jaundice, 3 w eek s
    • CT: enlarged tumor like alteration in the head region of the pancreas, multiple foci in the liver
    • Liver biopsy (frozen sa m ple)
  • Liver Glandular tumor with fibrotic stroma
    • Diagnosis
    • Cholangiocellular ( “ bile duct”) adenoma
    • Attention!
    • It might mimic CCC or metastatic tumor
    • (especially on frozen section)
  • Biliary hamartoma (von Meyenburg complex)
  • Biliary hamartoma (von Meyenburg complex)
  • Gallbladder 1. Tumorlike lesions - inflammatory origin (polyp, xanthogranulomatous cholecystitis etc) - hyperplasia (papillary, adenomyomatous) - Heterotopic tissue (pancreas, stomach, endocrin) - other
  • Gallbladder 2. Tumors Benign - adenoma - cystadenoma - papillomatosis - mesenchymal Malignant - epithelial - adenocarcinoma - adenosquamosus cc. - squamosus cc. - differenciálatlan - cystadenocarcinoma - mesenchymal - endocrin - carcinoid
  • Gallbladder carcinoma Gross - infiltrating - exophytic Histology - adenocarcinoma Immunohistochem - CEA - CA 19-9 Other - TNM - occult carcinoma - in situ carcinoma
  • Gallbladder cc Adenocarcinoma
  • Ductus choledochus carcinoma
  • Cholangiocellular carcinoma .
  • Thank you for listening……
  • SURGICAL LIVER and BILIARY PATHOLOGY of Dr. Florencio C. Dizon By Dr. Noel C. Santos, M.D.