Pathology of The Liver - Practice. 2017/ semester

Transcription

1 Pathology of The Liver - Practice 2017/ semester

2 Classification of Liver Diseases Non-neoplastic Metabolic diseases Congenital anomalies Circulatory disorders Hepatitis Infectious Toxic Autoimmune Diseases of bile ducts Neoplastic Focal tumor-like lesions (nodules) * * * * Benign Malignant Epithelial Non-epithelial (mesenchymal) Primary Metastatic Childhood Adulthood

3 Natural History of Chronic Liver Diseases (general features) Chronic injury Hepatocyte damage / degeneration Activation of immune cells Activation of Ito-cells (qhsc ahsc) Activation of myofibroblasts Fibrosis Cirrhosis HCC

4 Abstinence Alcoholic Liver Disease % STEATOSIS Fatty degeneration Perivenular fibrosis Not 'one' disease but a spectrum! NORMAL LIVER FIBROSIS CIRRHOSIS 10-20% ALCOHOLIC HEPATITIS Liver cell necrosis Inflammation Mallory bodies Fatty degeneration High mortality in fulminant cases! 10-35%

5 Soft, yellow, greasy Fragile Enlarged Empty vesicles in hepatocytes, corresponding to dissolved lipids (centrolobular in an early stage)

6 Perivenular fibrosis around central veins pericellular fibrosis - 'chicken wire' Mallory-Denk bodies Tangled aggregates of intermedate filaments Non-specific, present in other liver diseases: PBC, PSC, Wilson, HCC Hepatocyte balooning Swelling of hepatocytes

7 Alcoholic hepatitis neutrophil granulocytes around liver cells showing hyalin necrosis Alcoholic cirrhosis Typically micronodular

8 Nonalcoholic Fatty Liver Disease NAFLD, NASH NAFLD NASH Nonalcoholic fatty liver disease Nonalcoholic steatohepatitis Increasing incidency in developed countries Causes: Obesity (central), insulin-resistance, diabetes mellitus, dyslipidemia Mimics the entire spectrum of hepatic changes (macroscopy, microscopy) of alcoholic liver disease Might lead to cirrhosis in the long run

9 Hepatitis - causes Viral Hepatotropic: HAV, HBV, HCV, HDV, HEV Others: CMV, EBV, HSV, Adenovirus Autoimmune Other infections Idiopathic Other (medical herbs) AH1, AH2, AH3 Toxic, drug-induced Alcohol Paracetamol!, etc. NASH

10 Viral hepatitis ACUTE VS CHRONIC Histological picture is usually not specific Centro-/panlobular inflammation Balloon cells one-cell/massive cell death Councilman bodies Fibrosis - not always Lobular disarray Regenerative nests 1% fulminant Portal inflammation ± lobular inflammation Balloon cells 'One-cell' cell death (so called lytic necr.) Fibrosis! (stage) periportal bridging cirrhosis } Grade Histology activity index

11 Chronic hepatitis Portal inflammation + Interface hepatitis Batts KP, Ludwig J. Chronic hepatitis: an update on terminology and reporting. Am J Surg Pathol. 1995;19:

12 Chronic hepatitis Lobular inflammation

13 Chronic hepatitis Fibrosis 0 2 Ishak 4 6 Trichrome staining Batts KP, Ludwig J. Chronic hepatitis: an update on terminology and reporting. Am J Surg Pathol.1995;19: Clin Infect Dis. 2012;56(6): doi: /cid/cis957

14 Chronic hepatitis HBV specialities ground-glass hepatocyte HBsAg accumulation in the endoplasmic reticulum of liver cells HBsAg: HBV surface antigen HBcAg: HBV core antigen HBeAg: HBV e antigen

15 Chronic hepatitis HBV specialities IHC IHC HBsAg citoplasmic, perinuclear 'lunar' positivity Batts KP, Ludwig J. Chronic hepatitis: an update on terminology and reporting. Am J Surg Pathol.1995;19: HBcAg citoplasmic and nuclear positivity = Sign of active replication of viruses

16 Chronic hepatitis HCV specialities Portal lymphoid aggregates often with follicle Macrovesicular steatosis Batts KP, Ludwig J. Chronic hepatitis: an update on terminology and reporting. Am J Surg Pathol.1995;19:

17 End stage of liver diseases Cirrhosis Diffuse transformation of the liver into regenerative parenchymal nodules surrounded by fibrous bands, accompained by functional disorders Decompensatio vascularis et parenchymatosa hepatis Etiology HBV, HCV Alcohol Autoimmune Postnecrotic PBC Wilson disease, haemochromatosis, Gaucher disease, α1-atdeficiency Toxic Morphology Micronodular < 3 mm Macronodular > 3 mm Combined

18 CIRRHOSIS

19 Cirrhosis symptoms icterus/jaundice ascites hepatorenal syndrome coagulopathy gynecomastia hypogonadism hairless skin spider angioma palmar/plantar erythema portal hypertension porto-caval anastomoses hepatic encephalopathy weeping : ascites leaks through liver capsule, drop by drop into abdominal cavity

20 Classification of primary liver tumors Benign hepatocellular lesions (Ø cirrh.) Hepatic adenoma Focalis nodular hyperplasia (FNH) Others (pl. NRH, FFC, pseudolipoma) Benign/Premalignt hepatocellular lesions (cirrh.) Large / macroregenerative nodule Low-grade dysplastic nodule High-grade dyplastic nodule Malignant hepatocellular lesions HCC Benign mesenchymal lesions Cavernosus haemangioma Infantile hemangioendothelioma Mesenchymalis hamartoma Angiomyolipoma Inflammatoric pseudotumor Malignant mesenchymal lesions Angiosarcoma Epithelioid hemangioendothelioma Undifferentiated embryonal sarcoma Kaposi sarcoma Benign biliary tumors Biliar hamartoma Bile duct adenoma Biliar cystadenoma Other Precursor intraductal biliary lesions Biliar dysplasia Intraductal papillary neoplasia Malignant biliary tumors Cholangiocarcinoma intrahepatic Hematopoietic Primer hepatic lymphoma Lymphomas, leukaemias Fletcher: Diagnostic Histopathology of Tumors (3rd Edition)

21 Cavernous hemangioma Most common primary tumor of the liver Usually an incidental finding Thought to be congenital, doesn't grow, doesn't cause symptoms More frequent in women, might grow when taking hormonal contraceptives circumscribed, reddish-brownish,spongy,size 5 cm If > 5 cm giant hemangioma Usually soliter - (can be multiplex in eg. von Hippel-Lindau syndrome) Complication: Kasabach-Merritt syndrome, rarely: rupture Treatment: surgical resection

22 Cavernous hemangioma

23 Cavernous hemangioma Wikimedia commons

24 Hepatocellular carcinoma (HCC) Epidemiology: 6. most common malignant tumor (female: 8., male: 5.) 2. most common tumorous cause of death (after lung tu.) 80% of cases occur in underdeveloped regions Far-East, Africa 50% in China! Background: cirrhosis (70-90%), chronic liver disease: hepatotropic viruses (HBV, HCV), alcohol, NAFLD, other

25 Hepatocellular carcinoma (HCC) Causes (every disease, that leads to cirrhosis): Chronic HBV infection Chronic HCV infection Alcohol Aflatoxin-B1 NAFLD - NASH _Gasztro_Fak_Maj_epeutak_daganatai_HritzI.pdf

26 Hepatocellular carcinoma (HCC) Diagnosis: radiology core biopsy /FNAB Prognosis: median survival 6-9 months, 5 year survival ~10-20% Therapy: surgical (early stage, 15-35%) ablation (RFA, PEI, TACE, ) sorafenib Histological types: trabecular, pseudoglandular, solid, scirrhosus, --- Fibrolamellar (separate subtype)

27 HCC

28 HCC

29 Metastasis of Adenocarcinoma In The Liver 20x more frequent, than primary liver tumor Most common 'source' GI tract ( portal circulation) but can originate from any site One of the most common 'target organ' for metastasis formation is liver METASTATIC LIVER TUMOR VERSUS PRIMARY LIVER TUMOR Multiplex Well-circumscribed,expansive growth Liver is not cirrhotic (usually) Soliter Infiltrative growth Liver is cirrhotic (usually)