Approach & Interpretation of Liver Biopsy.

1. Approach & Interpretation of
Liver Biopsy
Dr. Indranil Bhattacharya
Consultant Pathologist
Dept. of Pathology & Laboratory Medicine
Jagjivan Ram Hospital
Mumbai

2. Contents
• Indications of liver biopsy
• Lab. investigations
• Techniques of liver biopsy
• Needles of liver biopsy
• Processing and staining
• Normal histology
• Approach to liver biopsy interpretation
• Interpretation of different pathological
conditions

3. Indications of liver biopsy
• Make or confirm the diagnosis
• Assess the severity of liver damage
• Assess the prognosis of a given case
• Monitor the response to the treatment

4. Clinical and Lab. Investigations
• History and general physical examination
• Lab investigation
– Liver Function Tests (LFT)
– CBC
– Prothrombin time, INR & aPTT
– Bleeding time
– Clotting time
– USG, CT, MRI

5. Liver Function Tests
• Hepatic integrity
– Serum aspartate aminotransferase (AST)
– Serum alanine aminotransferase (ALT)
– Serum lactate dehydrogenase
• Biliary excretory functions
– Serum bilirubin
– Serum alkaline transferase
– gamma glutamyl transferase
• Hepatocyte synthetic function
– Serum proteins
– Coagulation proteins
– Serum ammonia

6. Techniques of liver biopsy
1. Percutaneous
- Transthoracic
– Subcostal
• Blind procedure
• Image guided – USG,
CT, MRI
• Plugged liver biopsy
– Gelatin, gel foam
plugged

7. 2. Transvenous (Transjugular)
• Done in
coagulation
disorders or ascites
• Performed in a vascular
catheterisation laboratory
with videofluoroscopy
equipment and proper
cardiac monitoring

8. 3. Laparoscopic liver biopsy
• When transvenous
liver biopsy is not
available.
• In patients who have
a combination of a
focal liver lesion and
a coagulopathy.

9. ● The first liver aspirate was performed by the
German physician Paul Ehrlich in 1883.
● Percutaneous liver biopsy was first reported in
the 1920s.
● The transjugular approach was pioneered by
Radiologist Charles Dotter in the 1970s

10. Needles for Liver Biopsy
Broadly classified into:
• Suction needles
– Menghini,
– Klatskin,
• Cutting needles
– Vim-Silverman,
– Tru-cut (commonly used)
• Spring-loaded cutting needles that have a
triggering mechanism.

12. Vim Silverman Needle

13. Tru cut needle

14. Processing the sample
• Place on the filter paper
• Fix immediately
– Buffered Formalin (Routine)
– Alcohol (Glycogen Storage Disorder)
– 2.5% Buffered Glutaraldehyde (for EM)
– Frozen Sections (for Fat)
• Fix overnight
• Take sections
• Stain

15. Special stains
Masson trichrome, stains blue color to
collagen and red color to hepatocytes
H & E stain of hepatic lobule

16. Special stains
Perls Prussian Blue for iron,
hepatocytes have taken the blue stain
PAS positive in glycogen storage right
side and after treating it with diastase, left
side

17. Special stains
PAS+diastase for alpha1 antitrypsin
deficiency Hepatocytes have taken
magenta color
Oil Red O stain highlighting fat
globules in a frozen section of the liver.

18. Special stains
Rhodanin stain for copper, hepatocytes
have taken orange red color in the upper
nodule.
Congo red stain orange - staining of
vascular amyloid deposition,
characteristic apple-green
birefringence under polarized
microscopy (inset)

19. Special stains
Orcein stain for elastic fibres is positive in
two portal tracts (P) but not in the
intervening area of collapse. A necrotic
bridge (arrow) is also negative.
Inset: This contrasts with an elastic fibre-
rich septum in chronic liver disease.
P
P
Reticulin stain of micronodular cirrhosis.
Stains collagen

20. Adequacy of liver biopsy
• Biopsy length > 1 cm
• At least 10 portal tracts should be seen
• Any amount of tissue that yields diagnosis
• Transjugular biopsy : smaller, thinner,
fragmented tissue cores (4 fragmented
cores) or at least 4-6 portal tracts
• Best is laparoscopic biopsy

21. Histology
Lobular Model
• 2-3 mm diameter lobule
• Hexagonal shape
• The central hepatic
vein (terminal hepatic
vein)
• Portal tracts at
the periphery
• Portal tract- portal vein,
hepatic artery, bile duct

22. Histology Cont...
• Hepatocytes around
– Central vein – centrilobular
(zone3),
– Portal tract - periportal (zone 1),
– in between mid zonal (zone 2)
• Hepatocytes – polygonal,
central single nucleus, cells
arranged in plates.
• Sinusoids on either side of
cell plate
• Sinusoids – lined by
fenestrated endothelial cells
P
B
D

23. Histology Cont...
• Space of disse – lies below the endothelial lining
of sinusoids has stellate cells.
• Kupffer cells - mononuclear phagocytic cells, on
luminal side of sinusoids.

24. Bile canaliculi – seen in between hepatocytes, 1-2 𝛍
diameter, drain into canal of hering, in turn drain into bile duct.

25. Acute Injury
Response of liver parenchyma to acute injury
• Necrosis
– Hepatocytes swells
– Blebs are formed and carry out organelles out of
the cell
– Cell rupture
– Macrophage infiltration at the site of necrosis
• Apoptosis
– Nuclear pyknosis, karyorrhexis
– Acidophilic bodies – councilman bodies

26. Disease process continues
• Spotty necrosis/ focal necrosis -
Death of individual hepatocytes or small
groups of these cells
• Confluent necrosis – widespread
parenchymal loss, a zonal loss of
hepatocytes

27. • Bridging necrosis:
Necrosis link central veins to portal tracts
or bridge the adjacent portal tract.
• Panlobular and multilobular necrosis:
Confluent necrosis involving entire
single lobules or several adjacent
lobules respectively.

28. Bridging necrosis
p
c

29. Panlobular and multilobular necrosis

30. Scar formation and regression
• Stellate cells – most important, myofibroblastic
properties

31. Approach to liver biopsy interpretation
• Architecture
– Maintained
– Collapse
– Fibrosis
• Hepatocellular
changes
– Necrosis
– apoptosis
• Cholestasis
– Canalicular
– Ductular
• Portal tract
– Inflammation
– Edema
– Bile ductular reaction
– Ductopenia
– Fibrosis
• Inflammatory infiltrate
– Neutrophils
– Eosinophils
– Mononuclear cell

32. Acute Viral Hepatitis

33. Acute viral hepatitis
• Usually Pan lobular
– Centrilobular – hepatitis B, C
– Periportal – hepatitis A
• Hepatocytes – ballooning,
pale granular cytoplasm or
shrinkage, nuclear pyknosis
– acidophilic bodies
(Councilman bodies),
• Bilirubinostasis
• Mononuclear and
lymphocytic infiltration
• Spotty necrosis

34. Acute viral hepatitis
Bridging necrosis - curved lines of necrotic debris and collapse extend from a portal
tract to central venule.
C
P

35. Acute viral hepatitis
Multilobular necrosis Portal tract (arrow) can be identified but the parenchyma has
been replaced by inflammatory cells, necrotic debris

36. Fate and morphological sequel of
acute viral hepatitis
• Resolution
• Scarring
• Chronic hepatitis
• Cirrhosis
• Acute liver failure
• Hepatocellular carcinoma

37. Chronic Hepatitis
Classic causes of chronic hepatitis:
• Hepatitis B, with or without HDV infection.
• Hepatitis C.
• Autoimmune Hepatitis.
• Drug-induced hepatitis – Methotrexate, OCP,
Vitamin A, Acetaminophen.
• Chronic Hepatitis of unknown cause.

38. Chronic Hepatitis
The portal tract is heavily infiltrated
with lymphocytes (H&E)
Interface hepatitis - process of inflammation
and erosion of hepatic parenchyma at its
junction with portal tracts or fibrous septa
(H&E)

39. Chronic hepatitis
Chronic hepatitis with lobular activity. Clumps of inflammatory cells, some of them
associated with hepatocyte loss, extend through the parenchyma. The portal tract
above is inflamed (H&E.)

40. Chronic Hepatitis B
The central part of the cytoplasm has a
homogeneous ground glass appearance.
Sanded nuclei - fine granular,
eosinophilic
Cytoplasmic inclusions of HBsAg are
present.

41. Chronic hepatitis C
• The portal tract is
heavily infiltrated by
lymphocytes.
• A lymphoid
follicle with
germinal center
has formed.
• 15-25% may have
steatosis.

42. Autoimmune hepatitis
• Female predilection.
• Chronic progressive hepatitis with features of
autoimmune diseases.
– Genetic predisposition.
– Associated with other autoimmune disorders.
– Therapeutic response to immunosuppression.

43. Autoimmune Hepatitis
Type 1
– Any age (Middle aged to old age)
– Presence of antinuclear antibodies (ANA), anti
Smooth Muscle Actin antibodies (SMA), anti
Soluble Liver Antigen/ Liver-Pancreas antigen
(anti-SLA/LP), Anti Mitochondrial (AMA)
Antibodies.
Type 2
– Children and teenagers
– Anti Liver Kidney Microsome -1 antibodies.

44. Autoimmune Hepatitis
Interface hepatitis: Plasma cell predominates in the mononuclear inflammatory
infiltrate

45. Autoimmune Hepatitis
Hepatocytes rosettes in areas of activity
Confluent necrosis, parenchymal collapse
Plasma cell infiltration seen
(characteristic)

46. Drug Induced Hepatitis

47. Drug induced hepatitis

48. Necroinflammatory Score for Chronic
Hepatitis (HAI / Knodell Score)

49. Necroinflammatory score for Chronic Hepatitis
(HAI / Knodell score)

50. Grading for Chronic Hepatitis
Minimal activity (grade 1). Inflammation
is confined to the portal tracts and there is
no interface hepatitis. The lobular
parenchyma is quiescent.
Mild activity (grade 2). Focal interface
hepatitis present (right periportal region) in
addition to portal tract inflammation. A few
lobular necroinflammatory foci are also
seen at right

51. Grading for Chronic Hepatitis
Moderate activity (grade 3). More
extensive interface hepatitis is present
than in grade 2, but involving <50% of the
circumference of most portal tracts.
Marked activity (grade 4). The portal tract
is diffusely inflamed and shows extensive
circumferential interface hepatitis. Similar
changes affect virtually all portal tracts
with this grade of activity, often with
considerable lobular activity.

52. Cirrhosis
• Results from interplay between parenchymal
damage, fibrinogenesis, fibrinolysis and
hepatocellular regeneration.
• Main Causes
– Hepatitis B, C
– Alcohol abuse
– Biliary diseases
– Metabolic disorders
– Drugs, toxins
– Autoimmune hepatitis
– Venous outflow obstruction

53. Criteria for cirrhosis
1. Fundamental
– Nodularity
– Fibrosis
2. Relative
• Fragmentation
• Abnormal structure
• Hepatocellular changes
– Regenerative hyperplasia
– Pleomorphism
– Large-cell dysplasia (large-cell change)
– Small-cell dysplasia (small-cell change)

54. Classification
Based on size of the nodule
• Micronodule - < 3 mm
causes - Alcohol, Metabolic, Hemochromatosis, Wilson's Disease
• Macronodule - > 3 mm
causes – Viruses (B,C), Toxins, Poisoning
• Mixed – equal number of both nodules

55. Cirrhosis
Cirrhosis: micronodular pattern.
Nodules are of lobular size or smaller.
Reticulin stain
Cirrhosis: macronodular pattern. Nodules
are larger than 3 mm. Reticulin stain

56. Fragmented sample
Cirrhosis: fragmented sample. A specimen obtained by the biopsy method has
broken into rounded fragments peripherally circumscribed by fibrosis, reticulin stain

57. Abnormal structures
Cirrhosis: selective sampling. A nodule
has been cored out of the connective tissue
by the biopsy procedure, but a thin layer of
connective tissue (arrow) has adhered to the
nodule margin. (Needle biopsy, reticulin.)
Cirrhosis: distorted reticulin pattern.
The distortion has resulted from
abnormal and irregular hepatocyte
growth patterns. (Needle biopsy,
reticulin.)

58. Hepatocellular changes
Cirrhosis: hepatocellular regeneration.
Liver - cell plates are two or more cells thick,
indicating active growth. (Needle biopsy,
H&E.)
Cirrhosis: large-cell dysplasia, nuclei of
the enlarged hepatocytes irregular in shape
and vary greatly in size and staining

59. Hepatocellular changes
Cirrhosis: small-cell dysplasia (small-cell change). The hepatocytes below and
to the right have normal-sized nuclei, but their overall size is reduced. Nuclear–
cytoplasmic ratios are therefore increased. (Needle biopsy, H&E.)

60. Assessment of cause for cirrhosis
– regular
– irregular
• Bile ducts
– Ductular reaction
– Ductopenia
– fibrosis
• Blood vessels
– Narrowing
– Ischemic changes
• Pattern of nodules
and fibrosis
• Steatohepatitis
• Evidence of viral
infection
• Abnormal deposits
– Iron
– Copper, copper-
associated protein
– α1-Antitrypsin globules

61. Ishak score for Staging of fibrosis

62. Alcoholic Liver Disease
3 forms of alcoholic liver injury:
• Hepatocellular Steatosis
• Alcoholic Hepatitis (Steatohepatitis)
• Steatofibrosis

63. Hepatic Steatosis
There are large fat vacuoles in perivenular hepatocytes, displacing the nuclei to the
edges of the cells. (Needle biopsy, H&E.)

64. Steatohepatitis
Alcoholic steatohepatitis. Ballooning,
necrosis, Inflammatory cells, mainly
neutrophils. Densely stained Mallory bodies
(arrows). Many hepatocytes contain large fat
vacuoles. (Needle biopsy, H&E.)
ASH cannot be differentiated from NASH.
Mallory bodies. The Mallory bodies in this
example of steatohepatitis stain strongly for
ubiquitin (arrows)

65. Steatofibrosis
Micro nodules entrapped in blue-staining fibrous tissue.
Fat accumulation no longer seen, burned out stage. (Masson Trichrome stain)

66. Metabolic Liver Diseases
• Non Alcoholic Fatty Liver Disease (NAFLD)
• Hemochromatosis
• Wilson disease
• 𝛂1 antitrypsin deficiency
• Glycogen Storage diseases
• Gaucher’s disease
• Niemann–Pick disease

67. Non Alcoholic Fatty Liver Disease
• NAFLD is a group of conditions that have in
common the presence of hepatic steatosis (Fatty
liver), in individuals who do not consume alcohol,
or do so in very small quantities (less than 20gm
of ethanol/ week)
• NAFLD
– Fatty liver
– NASH
– Fibrosis
– Cirrhosis
• Associated with metabolic syndrome

68. NASH
NASH predominantly mononuclear
inflammatory cell infiltrate with both small
and large fat droplets (H&E)
Steatofibrosis prominent at portal region,
extending along the sinusoids in a chicken
wire pattern around the hepatocytes (Masson
Trichrome )

69. NAFLD Score

70. Hemochromatosis
• Excessive iron absorption, most of which is
deposited in parenchymal organs like liver,
pancreas, heart, joints, endocrine organs.
• Normal iron pool 2-6 gm in adults.
• 0.5 gm stored in liver (98% in hepatocytes).
• Disease manifestation appear when the iron
load > 20gm.

71. Hemochromatosis
• Mutations of TFR1, TFR2, HJV, HFE gene
mutation lead to decrease production of
hepcidin and increased absorption of iron and
increased release into circulation.
• Serum ferritin >1000 µg/L.
• Transferrin saturation > 45%.
• Serum iron > 150 µg/dl.

72. Classification of Hemochromatosis

73. Hemochromatosis
Hepatocytes showing iron overload, stained blue color in perl’s prussian blue stain.
Note the inflammation characteristically absent.

74. Wilson disease
• Autosomal recessive disorder
• Mutation of the ATP7B gene,
• Impaired copper excretion into bile and a failure
to incorporate copper into ceruloplasmin
• Copper accumulate in liver and later brain
• Serum ceruloplasmin < 20 mg/dl
• 24 hr Urine copper > 100 𝛍g/dl
• Total serum Cu < 60 𝛍g/dl

75. Wilson’s disease
Fatty change, mild to moderate hepatocytic
necrosis, with inflammatory infiltrate,
intranuclear glycogen inclusions also seen.
The upper nodule is strongly positive for
copper, stained orange-red. The lower
nodule is completely negative. (Wedge
biopsy, Rhodanine Stain)

76. Glycogen Storage Diseases
• A hereditary deficiency of one of the enzymes
involved in the synthesis or sequential
degradation of glycogen.
• The liver is important in glycogen metabolism.
• Type 1 (von Gierke) is most common for liver –
absence of Glucose 6 phosphatase.

77. Von Gierke disease
Type I glycogen storage disease, PAS positive and after treating with diastase
hepatocytes are swollen and resemble plant cells, the abundant glycogen displaces
the organelles of affected cells to the periphery. Sinusoids are compressed. Slender
periportal fibrous scars often develop.

78. Gaucher’s disease
• Autosomal recessive disorders resulting from
mutations in the gene encoding
glucocerebrosidase.
• Glucocerebrosidase - cleaves the glucose
residue from ceramide.
• The enzyme defect, glucocerebroside
accumulates in phagocytes, kupffer cells.

79. Gaucher’s disease
Pale-staining, striated Kupffer cells containing stored lipid are present within
sinusoids. The affected cells compress hepatocytes and sinusoids and may give
rise to portal hypertension. Pericellular fibrosis is a common finding.

80. Niemann–Pick disease
Lysosomal accumulation of sphingomyelin due
to an inherited deficiency of sphingomyelinase.

81. Niemann–Pick disease
Accumulation of sphingomyelin in both hepatocytes and macrophages. The latter
are greatly swollen, foamy and diastase–PAS positive to a variable extend,
Niemann–Pick disease may progress to cirrhosis.

82. 𝛂1- Antitrypsin deficiency
• Autosomal recessive disorder
• Low levels of α1-antitrypsin
• Normal Functions – inhibitors of protease,
elastase, protease 3, cathepsin G which are
released by neutrophils at the site of
inflammation
• Mutated α1-antitrypsin protein abnormally
folded inside the ER and lead to apoptosis of
cell.

83. 𝛂1- Antitrypsin deficiency
Hepatocytes near periportal region contain mutated proteins, and stained magenta
color for PAS+diastase. May also show steatosis, necrosis and fibrosis.

84. Cholestasis diseases
• Refers to impairment
of bile flow.
• In light microscope-
bile pigment within
bile canaliculi,
hepatocytes and
other sites.
• Bile is seen in the form
of bile thrombi (bile
plugs) in dilated
canaliculi

85. Large bile-duct obstruction
• Causes in children
– Biliary atresia
– Cystic fibrosis
– Choledochal cyst
• Causes in adults
– Gallstones
– Malignancies of biliary tree, head of pancreas
– Stricture from previous surgery

86. Large bile-duct obstruction
• Dilatation inter
canaliculi
• Portal tract edema
• Bile duct proliferation
at the margin of
portal tract
• Mild inflammatory
infiltrate

87. Chronic bile-duct obstruction and biliary
cirrhosis (Secondary Biliary Cirrhosis)
Bile duct obstruction persists, bile duct infarct and increasing fibrosis.
Jigsaw puzzle shape

88. Primary Biliary Cirrhosis (PBC)
• Autoimmune disease characterized by
nonsuppurative, inflammatory destruction of
small and medium sized intrahepatic bile
ducts.
• Antimitochondrial antibodies recognize E2
component of pyruvate dehydrogenase
complex of mitochondrial membrane,
• Altered MHC II of bile ductal epithelial cells
seen, causes autoactivation of T cells.

89. Stages of Primary Biliary Cirrhosis

90. Primary Biliary Cirrhosis
Granulomatous lesion surrounding bile duct with mononuclear cell infiltration. Florid
duct lesion

91. Primary Biliary Cirrhosis
Ductular reaction with periportal hepatitis A lymphoid aggregate and a follicle
with a germinal Centre (arrow)

92. PBC
Scarring; bridging necrosis, septal fibrosis
There is extensive scarring with irregular
nodule formation. Aggregates of
lymphocytes mark the former sites of bile
ducts

93. Primary Sclerosing Cholangitis (PSC)
• Inflammation and obliterative
fibrosis of intrahepatic and
extrahepatic bile ducts, with
dilation of preserved segments.
• Immunological mediated injury to
bile duct.
• T cells in periductal region.
• Autoantibodies to HLA-B8, MHC
antigens.
• pANCA can be noted in circulation.
• On cholangiographic
demonstration of the
characteristic beading
of bile ducts.
• May be associated with
Inflammatory Bowel Disease (IBD)

94. Primary Sclerosing Cholangitis
A bile duct undergoing degeneration is entrapped in a dense, “onion-skin”
concentric scar

95. Cholestasis of sepsis
By 3 main mechanism:
1. Direct effect of intrahepatic bacterial
infection (abscess, bacterial cholangitis)
2. Ischemia relating to hypotension due to
sepsis (when liver is cirrhotic)
3. Response to circulatory microbial products
(most common)

96. Cholestasis of
sepsis
Canalicular cholestasis – bile plug at
centrilobular canaliculi, sometime associate
with kupffer cell activity and mild portal tract
inflammation.
Ductular cholestasis – dilated canal of
hering and bile ductules at the interface of
portal tracts and parenchyma become dilate
and contains bile plug

97. Biliary atresia
• Partial or complete obstruction of the lumen
of the extrahepatic biliary tree within the first 3
months of life.
• Most common cause of neonatal cholestasis.
• 2 types
– Fetal type (20%)
– Perinatal type (80%)

98. Cont..
• Fetal form
– Malrotation of abdominal viscera
– Interrupted inferior vena cava
– Polysplenia
– Congenital heart disease
• Perinatal form
– Viral (reovirus, rotavirus, CMV)
– Autoimmune reaction

99. Biliary Atresia
An expanded, inflamed portal tract at left contains many proliferated bile ducts,
some of which are filled with inspissated bile.

100. Congenital Hepatic Fibrosis
• Autosomal recessive inherited condition.
• Due to Ductal plate malformation.
• Presents with hepatomegaly or portal.
hypertension, usually in childhood but
occasionally in adults.
• Associated with polycystic disease of kidney.
• Misdiagnosed as cirrhosis.

101. CHF
Several portal tracts are interconnected by bridging fibrous septa containing ductal plate
malformations. The fibrosis surrounds normal parenchyma with a terminal venule (short
arrow) preserved in a central position. Inset: Higher magnification of the abnormal duct
structures seen at lower left (long arrow).

102. Indian Childhood Cirrhosis
● High mortality affecting young Indian children
(and Indian subcontinent).
● Brass and Copper - containing vessels used
for milk feeding - identified as sources of
copper contamination.
● Large amounts of copper and copper
associated protein accumulate in affected
hepatocytes.

103. Indian Childhood Cirrhosis (ICC)
Many liver cells are swollen (centre), and surrounded by fibrosis and mononuclear
cells. Regenerating hepatocytes are organised into small clusters. Disease progress
to micronodular cirrhosis (H&E.)

104. Liver biopsy shows (a) Parenchymal nodules highlighted by the Masson's Trichrome stain
(Masson's Trichrome ×200). (b) Dense pericellular and interstitial fibrosis characteristic
of Indian childhood cirrhosis (Reticulin stain ×200). (c) Diffuse panlobular deposits on
Orcein stain ( arrow) (Orcein ×200) and on (d) rhodanine stain (arrow) (Rhodanine
×400) confirming the presence of copper.

105. ICC - DD

106. Granulomatous lesion

107. TB Granuloma
Sarcoid Granuloma
PBC Granuloma Fibrin Granuloma

108. Nodules and tumors

109. Hepatocellular Adenoma
Liver cells appear normal or contain fat vacuoles. Blood vessels but no portal
tracts are seen within the lesion. (H&E.)

110. Focal Nodular Hyperplasia (FNH)
Central scar with arteriole, periphery shows fibrous septa with bile duct proliferation
(arrow), surrounding the scar is the nodule consists of normal hepatocytes .

111. Nodular Regenerative Hyperplasia (NRH)
This abnormal, nodular growth pattern is not accompanied by fibrosis and therefore
differs from cirrhosis. The parenchymal nodules (N) are often adjacent to nodule (at left)
or surrounding portal tracts. The intervening liver shows flattened and compressed
liver-cell plates and/or sinusoidal dilatation.
N
N

112. Bile-duct adenoma
This subcapsular tumour consists of closely packed well formed bile ducts set in a
dense fibrous stroma. A dense collection of lymphocytes is seen at the edge of
the lesion (bottom).

113. Hemangioma
Locate beneath the capsule. Blood-filled spaces are separated by fibrous septa.
A thick capsule is seen at right. (H&E.)

114. Hepatocellular Carcinoma
• Precursors of hepatocellular carcinoma
1. Chronic cirrhosis
2. Large cell dysplasia
3. Small cell dysplasia
4. Macroregenerative nodule
5. Dysplastic nodule

115. Macroregenerative nodule
This low-magnification view demonstrates the increased size of the nodule
at left compared with the cirrhotic nodules at right.

116. Dysplastic Nodule
The dysplastic nodule at right shows hepatocytes arranged in pseudo acini, with a
less cohesive growth pattern centrally. A cirrhotic nodule is present at lower left.
Cells show nuclear atypia, (H&E)

117. Hepatocellular Carcinoma
Trabeculae-sinusoidal pattern, trabeculae
are thicker and reticulin is often scanty or
even absent, (H&E)
Reticulin is scanty in this example.
Reticulin stain

118. Hepatocellular carcinoma
Adenoid pattern.

119. Grading of HCC
Grade 1 (well differentiated) tumours
have small, round nuclei prominent
nucleoli almost similar to those of normal
and cirrhotic liver.
Grades 2 (Moderately Differentiated)
show progressive alterations in nuclear
contour, chromatin coarseness and hyper
chromaticity

120. Cont..
Grade 3 more nuclear atypia compared
to grade 2 and nuclear crowding is seen
Grade 4 shows marked anaplasia with
giant, multinucleated tumour cells and
atypical mitotic figures

121. HCC - Fibrolamellar type
Occur under the age of 30 yrs, occur as single large, hard, scirrhous tumor. Tumor
cells are well differentiated, shows oncocytic change, separated by parallel
lamellae of dense collagen bundles.

122. Hepatocellular carcinoma
Immunostaining:
1. Hep Par 1 (Hepatocyte)
2. Polyclonal CEA
3. Cytokeratin 7/20 pair (−/− staining)
4. GPC-3/GS/HSP70 trio (Recent and
confirmative, any 2 +ve indicates HCC)
– Glypican-3 (GPC-3)
– Glutamine Synthetase (GS)
– Heat Shock Protein 70 (HSP70)

123. Hepatoblastoma
• Most common liver tumor of early childhood.
• Occur at the age of 3yr
• 2 variants
– Epithelial – polygonal fetal or embryonal cells
arranged in acini, tubules, papillary
– Mixed epithelial and mesenchymal – admixed
with osteoid, chondroid, striated muscle.

124. Hepatoblastoma
Epithelial type - The tumour grows in cords of small hepatocytes with a ‘light-
and-dark’ cells due to the admixed clear (glycogenated) and eosinophilic liver
cells.

125. Cholangiocarcinoma
• Malignancy of the biliary tree, arising from
the bile duct within and outside of the liver
• Risk factors
– Chronic inflammatory conditions
– Primary Sclerosing Cholangitis
– Hepatolithiasis
– Fibropolycystic disease

126. Cont....
• 2 types
– Intrahepatic
– Extrahepatic (perihilar, Klatskin tumor)
• Premalignant lesions – Biliary Intraepithelial
Neoplasias (BilN)
– Low grade BilN 1 and 2
– High grade BilN 3

127. Cholangiocarcinoma
There are islands of adenocarcinoma in the connective tissue, well formed glands
lined by malignant tumor epithelial cells. Lymphovascular and perivascular invasions
are common.

128. Liver allograft rejection
• Acute cellular rejection
– Most common within one month, but can occur
later
– Traid –
– portal inflammation,
– bile-duct damage &
– endothelitis
• Chronic rejection
– Occur after 6 months of transplantation

129. Host vs graft reaction
Acute rejection. Heterogeneous portal
inflammation consisting of lymphocytes,
plasma cells and scattered neutrophils
infiltrates the bile duct (between arrows)
and the portal vein branch at top. (Needle
biopsy, H&E.)
Endotheliitis in acute rejection.
An efferent vein shows lymphocytic
infiltration of its wall. The endothelium is
focally lifted off the underlying vein wall
and partially destroyed. (Needle biopsy,
H&E.)

130. Graft vs Host Reaction
Chronic (ductopenic) rejection.
An hepatic artery branch (arrow) is present in the portal tract but the corresponding
interlobular bile duct has disappeared as a result of rejection. A sparse lymphocytic
infiltrate remains.(Explanted donor liver, H&E.)

131. Vanishing duct syndrome
• Neonatal age
– Biliary atresia
• Adult age
– PBC
– PSC
– Overlap syndrome
– Drug induced
– Chronic graft vs host rejection
– Idiopathic

132. Summary
• Acute severe liver injury and in advanced
stages of fibrosis/cirrhosis – etiological
diagnosis usually not possible.
• Drug induced liver injury can present with any
form of liver injury. Hence we cannot exclude
if clinically suspected.
• Fibrosis with normal liver architecture –
suspect congenital hepatic fibrosis

133. Summary
• Excess iron in liver is not always
hemochromatosis. In fact most common
cause is alcoholic cirrhosis.
• Clinically suspected cirrhosis but no fibrosis on
biopsy than look for NRH, and hepatic venous
outflow obstruction.
• Poorly differentiated HCC and
cholangiocarcinoma difficult to differentiate –
use IHC.

134. Conclusions
● Liver biopsy (LB) is the gold standard method for
assessment of liver histology.
● It provides valuable, otherwise unobtainable information,
regarding the degree of fibrosis, parenchymal integrity,
degree and pattern of inflammation, bile duct status and
deposition of materials and minerals in the liver.
● This information provides immense help in the diagnosis
and prognostication of a variety of liver diseases.

135. Conclusions
● With careful selection of patients, and performance of the
procedure appropriately, the complications become
exceptionally rare in current clinical practice.
● Furthermore, the limitations of sampling error and inter/
intra-observer variability may be avoided by obtaining
adequate tissue specimen and having it reviewed by an
experienced Liver Pathologist.

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