Liver Specialty Evening Conference Matthew M. Yeh, MD, PhD Professor of Pathology Adjunct Professor of Medicine University of Washington, Seattle
Case History A 65 year-old man presents with abdominal pain and abnormal liver tests. Images of the abdomen reveals a liver mass. History of non-invasive low-grade urothelial carcinoma 2 months ago, s/p TURP. No underlying liver diseases or cirrhosis. AFP: Normal.
MR Images in Arterial Phase Non-cirrhotic liver with segment 8/4 lesion. Arterial phase hyperenhancment. Courtesy of Dr. Neeraj Lalwani, UWMC, Seattle
MR Images in Venous Phase Non-cirrhotic liver with segment 8/4 lesion. Subtle washout on venous phase. Courtesy of Dr. Neeraj Lalwani, UWMC, Seattle
MR Images in Delayed Phase Non-cirrhotic liver with segment 8/4 lesion. Delayed phase also shows subtle washout on venous phase. Courtesy of Dr. Neeraj Lalwani, UWMC, Seattle
MR Coronal Image in the Delayed Phase Non-cirrhotic liver, lesion within segment 8/4 associated with PV thrombosis. Suspicion of liver primary vs. metastasis Courtesy of Dr. Neeraj Lalwani, UWMC, Seattle
Case A CT-guided liver biopsy was performed.
Differential Diagnosis Benign liver lesions Hepatocellular Biliary Miscellaneous Malignant liver lesions Primary Hepatocellular Biliary Other Metastatic
Differential Diagnosis Benign liver lesions Hepatocellular Biliary Miscellaneous Malignant liver lesions Primary Hepatocellular Biliary Other Metastatic
6 th most common cancer
Hepatocellular Carcinoma Risk Factors Traditional HBV Cirrhosis Alcohol Aflatoxin Recently Recognized HCV Metabolic syndrome and obesity Hemochromatosis Alpha-1-antitrypsin deficiency Hepatocellular adenoma
Malignant Liver Neoplasms in Non-Cirrhotic Liver Modified from Dr. Zachary Goodman, with permission
Malignant Liver Neoplasms in Cirrhosis Modified from Dr. Zachary Goodman, with permission
Differential Diagnosis of HCC in Liver Biopsy in Background of Cirrhosis Cirrhotic nodules Macroregenerative nodules HGDN Cholangiocarcinoma Combined hepatocellular cholangiocarcinoma Metastatic neoplasm
Differential Diagnosis of HCC in Liver Biopsy in Background of Non-Cirrhotic Liver Metastatic neoplasm Focal nodular hyperplasia Hepatocellular adenoma Fibrolamellar carcinoma Cholangiocarcinoma Combined hepatocellular cholangiocarcinoma Neuroendocrine neoplasm
Histopathology of HCC Evidence of hepatocytic differentiation Neoplastic cells resemble hepatocytes Canaliculi +/- bile Pseudoglandular/pseudoacinar and/or trabecular pattern Evidence of malignancy Lack of normal structures Thickened trabecula or plates Increased unpaired arteries Focal absence of reticulin fibers Increased N/C ratio
Pseudoglands in HCC
In the Era of Affordable Care Diagnosis of HCC in Liver Biopsy Helpful Features for Hepatocytic Differentiation Bile Mallory-Denk bodies Alpha-1-antitrypsin globules Fat Iron free foci But, they are not always there
Diagnostic Feature for Hepatocytic Differentiation: Bile Mallory-Denk bodies
Diagnostic Feature for Hepatocytic Differentiation: A1AT globules
Iron Free Foci in HCC Cirrhosis HCC HCC
Diagnosis of HCC Immunohistochemistry CK7 (+/-), CK19(+/-) and CK20 (-) Hepatocytic differentiation Alpha fetoprotein (AFP) Hepatocyte specific antigen (Hep Par 1) Glypican-3 Arginase 1 (ARG1) Canalicular staining pattern Polyclonal CEA CD10 Villin Activation of sinusoidal endothelial cells in hepatocytic neoplasm CD34 CD31
Polyclonal CEA: Canalicular Staining Pattern
CD10 Canalicular Staining Pattern
Hep Par 1 Staining Can Be Focal in HCC
CD34 cirrhosis FNH HCC CC
CD34 Staining in HCC May be Focal
CD34 in Cirrhosis Periseptal Staining
Hepatocellular Adenoma HCC Reticulin Stain
Well-Differentiated HCC Reticulin Stain
Reticulin Stain
Fatty liver may be misdiagnosed as HCC due to reticulin loss From Singhi et al. Am J Surg Pathol 2012
Glypican-3 to Distinguish HCC from Benign Hepatocellular Lesions Glypican-3 (GPC3) A cell surface proteoglycan has been shown to be overexpressed in HCC. To distinguish HCC from benign hepatocellular mass/lesion, and to some extent, from other malignancies
Glypican-3 HCC Cirrhosis
Glypican-3
Diagnostic Pitfalls of GPC3 Focal immunoreactivity can be detected in a small subset of cirrhotic nodules. Also positive in Melanoma SCC of lung non-seminomatous GCT Well Differentiated HCC can be negative. Expression in HCC can be focal. Specificity issue Sensitivity issue GPC-3 expression rate in various types of hepatocellular nodules in the pooled series of 10 studies.
Glypican-3 Moderately-Differentiated HCC Well-Differentiated HCC
Sensitivities of IHC Markers in HCC, CC, and Metastatic Carcinoma HCC CC Metastatic Adenocarcinoma Hep Par 1 86-96% ~12% ~14% GPC3 75-88% ~19% ~6% pcea 50-96% NA NA MOC31 ~14% 67-100% 66-100% CK7 7-20% 78-100% ~36% CK8/18 ~70% ~20% NA CK19 10% or more 44-80% ~64% CK20 ~5% ~11% ~74% CD34 ~95% NA NA From Chan E and Yeh MM, Clin Liv Dis 2010
Arginase (ARG1): A manganese metalloenzyme active in the urea cycle Diagnosis of HCC Arginase-1 Marker for hepatocytes and hepatocellular neoplasms. Yan et al, Am J Surg Pathol 2010;34:1147 1154
Arginase-1 HCC Liver
Arginase-1 in HCC
HepPar1 Arg-1 GPC3
It s not a Perfect World Hepatoid adenocarcinomas from nonhepatic sites: 4 of 13 (31%) were positive for arginase-1. Reis H et al, Pathology 2015
Sensitivity, specificity, positive and negative predictive value of Arginase-1, HepPar-1 for the diagnosis of HCC Sensitivity Specificity PPV NPV Arginase-1 84% 96% 95% 85% HepPar-1 70% 84% 81% 73% Arginase-1 or HepPar-1 84% 80% 88% 83% Arginase-1 and HepPar-1 70% 100% 100% 77% Radwan and Ahmed Diagnostic Pathology 2012
Arg1, HepPar-1 and GPC3 in FNA specimen Diagnosis Arg1 (%) HepPar-1 (%) GPC3 (%) HCC (n=29) 23 (79) 24 (83) 24 (83) Metastasis 0 0 3 (10.7) (n=28) Benign (n=5) 5 (100) 5 (100) 0 Timek DT et al, AJCP 2012
Antibody Arg1, HepPar-1 and GPC3 in FNA specimen Well to moderately differentiated HCC (n=22) Arg-1 20(91) 3(43) HepPar1 20(91) 4(57) GPC3 20 (91) 5 (71) 3 markers positive 17 (77) 2 (29) 2 markers positive 4 (18) 2 (29) 1 marker positive 1(5) 2 (29) Negative for all 3 markers 0 1 (14) Moderately to poorly differentiated HCC (n=7) Timek DT et al, AJCP 2012
Use of GPC3 and Arg-1 in Scirrhous Hepatocellular Carcinoma Krings G et al., Modern Pathology 2013
Hep Par 1, GPC3, and Arg-1 stainings of scirrhous HCC, classical HCC and ICC Scirrhous HCC (n=20) Classical HCC (n=169) Cholangiocarcinoma (n=16) P-value (scirrhous vs classical HCC) P-value (scirrhous HCC vs CC) HepPar1 (%) GPC3 (%) Arg-1 (%) 26 79 85 74 69 95 7 6 0 <0.001 0.440 0.189 0.029 <0.001 <0.001 Krings G et al., Modern Pathology 2013
Chromogranin Synaptophysin
Hep Par 1 TTF-1 Thyroglobulin
In Situ Hybridization for Albumin messenger RNA (Albumin ISH) for Hepatocytic Differentiation Clear cell HCC: 93% (N=30). HCC: 93% (N=42), combined use with Hep Par 1 reaches 100%. Sensitivity for HCC AFP 30-50% GCT Other tumors commonly positive Hep Par 1 >90% Lung, colon, esophageal, gastric CD10 pcea Cytoplasmic 60-90% staining in adenoca GPC3 60-80% NSGCT, melanoma Arg-1 96% Rare Albumin ISH >95% None Oliveira et al, AJSP 2000 Kakar el al, AJCP 2003 From Shahid et al, AJSP 2015
Current Case
Hep Par 1
Arginase-1
Arginase-1
Arginase-1
CD34
CK7
CK19
CK19
Sensitivities of IHC Markers in HCC, CC, and Metastatic Carcinoma HCC CC Metastatic Adenocarcino ma Hep Par 1 86-96% ~12% ~14% GPC3 75-88% ~19% ~6% pcea 50-96% NA NA MOC31 ~14% 67-100% 66-100% CK7 7-20% 78-100% ~36% CK8/18 ~70% ~20% NA CK19 10% or more 44-80% ~64% CK20 ~5% ~11% ~74% CD34 ~95% NA NA Chan and Yeh, 2010
CK7 in Classic HCC
CK7 in Fibrolamellar Carcinoma
More stains? Mucin stain: Moc-31 stain:
More stains? Mucin stain: Negative Moc-31 stain: Negative
Additional stains were performed at original institute to exclude other sites Urothelial Lung Adrenal Colonic Prostate Neuroendocrine
Additional stains were performed at original institute to exclude other sites Urothelial: Negative Lung: Negative Adrenal: Negative Colonic: Negative Prostate: Negative Neuroendocrine: Negative
Melan A
Melan A in Melanoma
S100
Cam 5.2
Not a Melanoma Negative S100 Positive CAM5.2 and CK7 Not typical melan-a staining pattern for melanoma
Brief Summary IHC Performed by Contributing Pathologists Hep Par 1: Negative Arginase-1: Rare AFP: Negative CD10: Negative Polyclonal CEA: Negative Extensive metastatic markers: Negative
More IHC?
Glypican-3
Albumin ISH Courtesy of Dr. Michael Torbenson
Summary Hep Par 1: Negative Arginase-1: Rare AFP: Negative CD10: Negative Polyclonal CEA: Negative GPC3: Positive Albumin ISH: Positive Extensive metastatic markers: Negative
Diagnosis Hepatocellular Carcinoma
Take Home Points
H&E Take Home Points Diagnosis of HCC History, history, history.. Imaging correlation IHC/special stains Hepatocytic markers (combination of multiple markers may be necessary) Markers to exclude CC and metastasis
Acknowledgement Dr. Xianyong (Sean) Gui, Univ of Calgary Dr. Sarag Boukhar, UWMC, Seattle