8 years later! Next Generation Sequencing. Pathogenic Findings: HNF1A c.864delinscc, p.g292rfs*25 (NM_ ) (VAF: 59%) HNF1A Loss

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5 8 years later! Next Generation Sequencing Pathogenic Findings: HNF1A c.864delinscc, p.g292rfs*25 (NM_ ) (VAF: 59%) HNF1A Loss Interpretation HNF1A c.864delinscc, p.g292rfs*25 (NM_ ) This insertion/substitution in exon 4 of the HNF1A transcript results in a frameshift of the protein coding sequence (beginning at amino acid 292) and creates a premature stop codon after 25 new amino acids, which would be expected to reduce or abrogate the functional activity of this protein product. This mutational event is actually a combination of a simple somatic single base frameshift insertion directly adjacent to a common benign inherited polymorphism possessed by the patient (c.864g>c). Though only one component of the mutation is pathogenic, they have been merged for reporting purposes in order to provide the most accurate overall coding and protein alteration.

6 Hepatocellular Carcinoma in Normal Liver Abd pain, mass, constitutional symptoms Serum AFP elevated in only 1/3 of patients Search for occult chronic liver disease No special histologic features Precursor lesion unclear

7 Hepatocellular Carcinoma (HCC) Immunohistologic Profile pcea canalicular staining CD10 canalicular staining HepPar1 granular cytoplasmic staining MOC31 no staining Cam 5.2 cytoplasmic staining CD34 increased in endothelial cells TTF-1 cytoplasmic staining (Dako antibody) CK7, CK20, CK19 negative??? In situ hybridization for albumin mrna (Mayo) [AFP cytoplasmic staining]

8 Bile production by tumor cells is diagnostic of hepatocellular origin

9 HepPar1 aka hepatocyte ; hepatocyte antigen Developed at the University of Pittsburgh Staining characteristics: Reactive in > 80% of HCC Non-reactive in some poorly differentiated HCC Can be patchy (20%) Coarse cytoplasmic reactivity Can also be reactive in some gastric, pancreatic, gallbladder, and lung adenocarcinomas Also reactive in benign hepatocytes, FNH, adenoma, MRN, dysplastic nodule

10 70 y.o. male with a 10 cm mass in non-cirrhotic liver

11 HepPar-1

12 35 year old male with an 18 cm liver mass No history of chronic liver disease Non-cirrhotic liver Normal serum AFP level

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14 HepPar-1

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16 Synaptophysin metastatic well differentiated neuroendocrine tumor

17 C y.o. M with a 4 cm liver mass No history of liver disease Serum AFP level is normal Normal liver Tumor

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20 HepPar-1

21 PAX-8 metastatic renal cell carcinoma

22 HepPar-1 False Positive Staining Lung adenocarcinoma (~10%) Esophageal adenocarcinoma (~20%) Pancreatic adenocarcinoma (~10%) Duodenal (small bowel) adenocarcinoma (~25%) Liver (hepatocellular) carcinoma (~80%) Stomach (gastric) adenocarcinoma (> 40%) Gallbladder adenocarcinoma (~30%)

23 HepPar-1 False Positive Staining Stomach (gastric) adenocarcinoma (> 40%) Lung adenocarcinoma (~10%) Pancreatic adenocarcinoma (~10%) Gallbladder adenocarcinoma (~30%) Esophageal adenocarcinoma (~20%) Duodenal (small bowel) adenocarcinoma (~25%) Liver (hepatocellular) carcinoma (~80%)

24 HepPar-1 False Negative Staining Negative in poorly differentiated HCC Quite patchy reactivity in many cases

25 HCC Microarray Analysis Xiao SY et al. Am J Path 2001; 159: Non-HCC HCC Atlas Human 1.2II Atlas Human 1.2II Cytochrome P450 1A1 Cytochrome P450 1b1 Cytochrome P450 2E1 Cytochrome P450 3A3 CD10 43x Cytochrome P450 7A1 Cytochrome P450 51

26 Canalicular CD10 in Normal Liver

27 Well differentiated HCC pcea CD10

28 72 y.o. male with an 8 cm mass in non-cirrhotic liver

29 CD 10

30 Glypican-3 Cell surface heparin sulfate proteoglycan Oncofetal antigen expressed in embryonic kidney and liver Staining characteristics: Cytoplasmic reactivity; can be patchy Up-regulated in about 80% of HCC High rate of reactivity in poorly differentiated HCCs Also reactive in a small number of high grade DNs No reactivity in adenoma and FNH (& well diff HCC) Also reactive in Wilms tumor, melanoma and some ovarian carcinomas Wang HL et al. Arch Pathol Lab Med 2008;132:

31 Poorly diff. HCC TTF-1 (Dako) HepPar-1 Glypican-3

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33 HepPar-1 Arg-1 UREA CYCLE

34 HepPar-1 Arg-1

35 HepPar-1 Arginase-1

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38 Immunohistologic Stains for HCC Cam 5.2 pcea or CD10 HepPar-1 or Arginase-1 Glypican-3 MOC-31 or mcea (negative)

39 Immunohistologic Stains for Masses in Non-Cirrhotic Liver Immunostains are not necessary in every case Polygonal cell tumors in the HCC differential diagnosis: Well differentiated neuroendocrine (carcinoid) tumor Melanoma Angiomyolipoma Hepatoid adenocarcinoma Adrenocortical carcinoma Renal cell carcinoma CAM 5.2, S-100, HMB-45, PAX-8, synaptophysin, CDX2 inhibin, calretinin in selected cases Much less useful stains: CD34, AFP, CK7, CK20

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