1. Icahn School of Medicine at
MMoouunntt SSiinnaaii
Algorithmic Approach to Liver Masses and Cysts
Neil Theise, MD
Departments of Pathology and Medicine (Digestive Diseases)
Mount Sinai Beth Israel Medical Center
New York City
2. Icahn School of Medicine at
MMoouunntt SSiinnaaii
Algorithmic Approach to Liver Masses and Cysts
Download at: NeilTheise on SlideShare.net
Neil Theise, MD
Departments of Pathology and Medicine (Digestive Diseases)
Mount Sinai Beth Israel Medical Center
New York City
3. Icahn School of Medicine at
MMoouunntt SSiinnaaii
Algorithmic Approach led by Romil Saxena Liver Masses Neil Theise, MD
Departments of Pathology and Medicine (Digestive Diseases)
Mount Sinai Beth Israel Medical Center
New York City
4. SOLID MASS
Fibrotic
Background No Fibrotic
Background
+ + + Benign
Hepatoblastoma,
except Fetal Type
Large
Renerative
Nodule
Dysplastic
Nodule
HCC
FNH
HCA
HCC
Fibrolamellar HCC
Hepatoblastoma,
Fetal Type
von Meyenburg
complex
Bile duct
adenoma
Biliary
Adenofibroma
HSA, AFP,
Arg1
Any of: Bile, HSA, Arg1,
CD10, pCEA
Any of: Bile, HSA, Arg1,
CD10, pCEA
Hepatocytes with any of:
Bile, Arg1, HSA, CD10,
pCEA
AND
Ducts/glands/mucin/K19
CholangioCa
Metastasis
Combined
HCC-CholangioCa
Malignant
Immature
appearing cells
Hepatocytes or other large
eosinophilic cells
Ducts/glands/mucin Hepatocytes and
ducts/glands/mucin
Metastasis Metastasis
Metastasis
5. SOLID MASS
Fibrotic
Background No Fibrotic
Background
+ + + Benign
Hepatoblastoma,
except Fetal Type
Large
Renerative
Nodule
Dysplastic
Nodule
HCC
FNH
HCA
HCC
Fibrolamellar HCC
Hepatoblastoma,
Fetal Type
Bile Duct
Adenoma
Peribiliary Gland
Hamartoma
Biliary
Adenofibroma
HSA, AFP
Arg1
Any of: Bile, HSA, Arg1,
CD10, pCEA
Any of: Bile, HSA, Arg1
CD10, pCEA
Hepatocytes with any of:
Bile, HSA, CD10, pCEA
AND
Ducts/glands/mucin/K19
CholangioCa
Metastasis
Combined
HCC-CholangioCa
Malignant
Immature
appearing cells
Hepatocytes or other large
eosinophilic cells
Ducts/glands/mucin Hepatocytes and
ducts/glands/mucin
Metastasis Metastasis
Metastasis
von Meyenburg
complex
Bile duct
adenoma
AFP,
Arg1
Arg1,
Arg1, HSA, CD10,
pCEA
AND
Ducts/glands/mucin/K19
6. WHO Tumours of the DDiiggeessttiivvee TTrraacctt,, 44tthh EEdd..
7. SOLID MASS
Fibrotic
Background No Fibrotic
Background
+ + + Benign
Hepatoblastoma,
except Fetal Type
Large
Renerative
Nodule
Dysplastic
Nodule
HCC
FNH
HCA
HCC
Fibrolamellar HCC
Hepatoblastoma,
Fetal Type
Bile Duct
Adenoma
Peribiliary Gland
Hamartoma
Biliary
Adenofibroma
AFP
Hepatocytes with any of:
Bile, HSA, CD10, pCEA
AND
Ducts/glands/mucin/K19
CholangioCa
Metastasis
Combined
HCC-CholangioCa
Malignant
Immature
appearing cells
Hepatocytes or other large
eosinophilic cells
Ducts/glands/mucin Hepatocytes and
ducts/glands/mucin
Metastasis Metastasis
Metastasis
von Meyenburg
complex
Bile duct
adenoma
HSA, AFP,
Arg1
Any of: Bile, HSA, Arg1,
CD10, pCEA
Any of: Bile, HSA, Arg1,
CD10, pCEA
Arg1, HSA, CD10,
pCEA
AND
Ducts/glands/mucin/K19
8. Dysplastic Nodules
Distinctive nodules which differ from
the surrounding parenchyma in terms of:
size,
color,
texture,
or
degree of bulging from the cut surface…
9.
10.
11.
12.
13. Dysplastic Nodules
Distinctive nodules which differ from
the surrounding parenchyma in terms of:
size,
color,
texture,
or
degree of bulging from the cut surface…
…AND contain portal tracts.
20. Features of High Grade DNs:
Cytologic atypia
e.g. small cell change
Architectural atypia
e.g. pseudogland formation
Clone-like domains
e.g. Mallory body clustering, fatty or
clear cell change, iron resistance, etc.
21.
22.
23.
24.
25. Incidence of DNs in Cirrhotic Livers
Location Source # Cirrhotic
Livers
# w/ DNs (%)
Tokushima Autopsy 315 46 (14%)
New York Explant 44 11 (25%)
San Francisco Explant 110 17 (15%)
Kanazawa Autopsy 209 45 (21%)
New York Explant 155 32 (22%)
Bordeaux Explant 41 10 (24%)
26. Chronic Hepatitis
Hepatitis B and C
Autoimmune hepatitis
Chronic Biliary Tract Disease
PBC, PSC
Metabolic Disease
Genetic hemochromatosis
A-1-AT Deficiency
Toxic Injury
Chronic alcoholic liver injury
32. Features found in dysplastic nodules
LGDN HGDN eHCC
Diffuse hemosiderosis X
Diffuse (or zonal) fatty change X
Angiogenesis (“unpaired arteries”) X
Scirrhous change X
Large cell change X
33. Features found in dysplastic nodules
LGDN HGDN eHCC
Diffuse hemosiderosis X rare rare
Diffuse (or zonal) fatty change X X X
Angiogenesis (“unpaired arteries”)
X XX XXX
Scirrhous change X X X
Large cell change X X X
34. LGDN HGDN eHCC
Diffuse hemosiderosis X rare rare
Diffuse (or zonal) fatty change X
Angiogenesis (“unpaired arteries”) X XX XXX
Scirrhous change X X X
Large cell change X X X
Small cell change X X
Pseudoacinar growth X XX
Iron resistence in otherwise siderotic nodule X X
Mallory body clustering X X
Nodule-in-nodule expansile growth
X X
(with steatosis or other changes above)
Features found in dysplastic nodules
35. Features found in dysplastic nodules
LGDN HGDN eHCC
Diffuse hemosiderosis X rare rare
Diffuse (or zonal) fatty change X
Angiogenesis (“unpaired arteries”) X XX XXX
Scirrhous change X X X
Large cell change X X X
Small cell change X X
Pseudoacinar growth X XX
Iron resistence in otherwise siderotic nodule X X
Mallory body clustering X X
Nodule-in-nodule expansile growth
X X
(with steatosis or other changes above)
Stromal invasion X
75. Chapter 10-4,
N. D. Theise, O. Nakashima, Y. N. Park, Y. Nakanuma
1. Combined HCC-ChC
2. Combined HCC-ChC with stem cell features
A. typical subtype
B. intermediate cell subtype
C. cholangiolocellular subtype
76. Solitary bile
duct cyst
Fibropolycys
tic disease
+/-
associated
renal disease
Obstructive
dilatation of
bile duct
Ciliated
foregut
cyst
Epithelial-lined Without
Epithelial Lining
Cuboidal to
low columnar
Ciliated Biliary / mucinous / oncocytic
+/- papillary architecture
Neoplastic
Benign
Malignant
Mesench.
hamartoma
Undif’d
embryonal
sarcoma
Cavernous
heman-gioma
Cystic
degener-ation
in any
tumor
Cystic
degener-ation
in any
tumor
Hydatid
cyst
Non-neoplastic
Hydatid
cyst
Pyogenic
abscess
Amoebic
abscess
Hemo-rrhagic
cyst
Necrotizing
eosinophilic
granuloma
Laminated
wall
Inflammation,
necrosis
CYST
Ovarian-like stroma w/o Ovarian-like stroma
Cystadenomas and cystadenocarcinomas
77. Cystadenomas Solitary bile and cystadenocarcinomas
duct cyst
Fibropolycys
tic disease
+/-
associated
renal disease
Obstructive
dilatation of
bile duct
Ciliated
foregut
cyst
Epithelial-lined Without
Epithelial Lining
Cuboidal to
low columnar
Ciliated Biliary / mucinous / oncocytic
+/- papillary architecture
Neoplastic
Benign
Malignant
Mesench.
hamartoma
Undif’d
embryonal
sarcoma
Cavernous
heman-gioma
Cystic
degener-ation
in any
tumor
Cystic
degener-ation
in any
tumor
Hydatid
cyst
Non-neoplastic
Hydatid
cyst
Pyogenic
abscess
Amoebic
abscess
Hemo-rrhagic
cyst
Necrotizing
eosinophilic
granuloma
Laminated
wall
Inflammation,
necrosis
CYST
Ovarian-like stroma w/o Ovarian-like stroma
78. Solitary bile
duct cyst
Fibropolycys
tic disease
+/-
associated
renal disease
Obstructive
dilatation of
bile duct
Ciliated
foregut
cyst
Epithelial-lined Without
Mucinous
cystic
neoplasm
Mucinous
cystic
neoplasm
with
associated
invasive
carcinoma
Biliary
intraductal
papillary
neoplasm
Malignant
biliary
intraductal
papillary
neoplasm
Intrahepatic
cholangio-carcinoma
with cystic
change
Epithelial Lining
Cuboidal to
low columnar
Ciliated Biliary / mucinous / oncocytic
+/- papillary architecture
No
epithelial
invasion
into wall
Neoplastic
Benign
Malignant
Mesench.
hamartoma
Undif’d
embryonal
sarcoma
Cavernous
heman-gioma
Cystic
degener-ation
in any
tumor
Cystic
degener-ation
in any
tumor
Hydatid
cyst
Non-neoplastic
Hydatid
cyst
Pyogenic
abscess
Amoebic
abscess
Hemo-rrhagic
cyst
Necrotizing
eosinophilic
granuloma
Laminated
wall
Inflammation,
necrosis
CYST
Ovarian-like stroma w/o Ovarian-like stroma
Epithelial
invasion
into wall
No
epithelial
invasion
into wall
Epithelial
invasion
into wall
