PBC and PSC: Back to Basics

Disclosure No financial interest or other relationship with the manufacturer(s) of the product(s) or provider(s) of the service(s) that will be discussed in this presentation. PBC and PSC: Back to Basics grace.kim@ucsf.edu Outline In chronic cholestatic liver disease, liver biopsy plays a supporting role Case-based discussion Clinical information, including laboratory findings and radiographic features, must be integrated for diagnosis Case 1 clinical history 54 year old woman, asymptomatic, incidentally discovered to have elevated alkaline phosphatase (ALP) and positive antimitochondrial antibodies (AMA) Liver biopsy performed 1

What finding would you like to see on biopsy so you can diagnosis it as PBC? A. Portal and lobular inflammation B. Infiltrate with easily identified plasma cells C. Florid duct lesion D. Ductular reaction E. Ductopenia F. Periportal copper deposition G. CK7 positive periportal hepatocytes H. Nodular regenerative hyperplasia I. Biliary pattern of cirrhosis AASLD and EASL recommendations 2 of 3 required criteria for PBC diagnosis Presence of antimitochondrial antibodies (AMA) Alkaline phosphatase (ALP) at least 1.5 times upper limit of normal for >24 weeks Histologic evidence of PBC, specifically nonsuppurative cholangitis and duct injury Bowlus CL, Gershwin ME. The diagnosis of primary biliary cirrhosis. Autoimmun Rev. 2014 Apr-May;13(4-5):441-4. Lindor KD, et al. Primary biliary cirrhosis. Hepatology 2009;50:291 308. EASL. Clinical Practice Guidelines: management of cholestatic liver diseases. J Hepatol 2009;51:237 67. AASLD and EASL recommendations 2 of 3 required criteria for PBC diagnosis Presence of antimitochondrial antibodies (AMA) Alkaline phosphatase (ALP) at least 1.5 times upper limit of normal for >24 weeks Histologic evidence of PBC, specifically nonsuppurative cholangitis and duct injury Antimitochondrial antibodies (AMA) Major autoantigen target by PBC patient sera M2 antigen fraction E2 subunits of Pyruvate dehydrogenase complex (PDC-E2) Branched chain 2-oxo-acid dehydrogenase complex (BCOADC- E2) 2-oxo glutarate dehyrogenase complex (OGDC-E2) E1α and E3 binding protein of PDC Bowlus CL, Gershwin ME. The diagnosis of primary biliary cirrhosis. Autoimmun Rev. 2014 Apr-May;13(4-5):441-4. Lindor KD, et al. Primary biliary cirrhosis. Hepatology 2009;50:291 308. EASL. Clinical Practice Guidelines: management of cholestatic liver diseases. J Hepatol 2009;51:237 67. Muratori L, et al. Antimitochondrial Antibodies and Other Antibodies in Primary Biliary Cirrhosis: Diagnostic and Prognostic Value. Clin Liver Dis 2008 May;12(2):261-76. 2

AMA test methodology Indirect immunofluorescence assay (IFA) Positive titer is 1:40 Sensitivity 70-90% Enzyme-linked immunosorbent assay (EIA) AMA-M2 antibodies is most frequently used First generation utilized PDC-E2 10% of PBC pts only react to BCOADC-E2 and/or OGDC-E2 MIT3 or BPO expresses BCOADC-E2, PDC-E2 and OGDC- E2 epitopes Sensitivity 94% Venn diagram of serum reactivity of PBC patients Dähnrich C, et al. New ELISA for detecting primary biliary cirrhosis-specific antimitochondrial antibodies. Clin Chem. 2009 May;55(5):978-85. Selmi C, Bowlus CL, Gershwin ME, Coppel RL. Primary biliary cirrhosis. Lancet. 2011 May 7;377(9777):1600-9. Dähnrich C, et al. New ELISA for detecting primary biliary cirrhosis-specific antimitochondrial antibodies. Clin Chem. 2009 May;55(5):978-85. AMA positive also in <1% of healthy adults Possibly early preclinical stage Patients with other diseases 10-20% of AIH <10% of HCV <1% of steatohepatitis Rare reports associated with DILI AASLD and EASL recommendations 2 of 3 required criteria for PBC diagnosis Presence of antimitochondrial antibodies (AMA) Alkaline phosphatase (ALP) at least 1.5 times upper limit of normal for >24 weeks Histologic evidence of PBC, specifically nonsuppurative cholangitis and duct injury ~20% of pts have other autoimmune diseases Infection mycobacteria and E.coli (cross reactivity) O'Brien C, et al. Long-term follow-up of antimitochondrial antibody-positive autoimmune hepatitis. Hepatology. 2008 Aug;48(2):550-6. Ravi S, et al. Autoimmune Markers Do Not Impact Clinical Presentation or Natural History of Steatohepatitis-Related Liver Disease. Dig Dis Sci. 2015 Dec;60(12):3788-93. Chantran Y, et al. Autoantibodies in primary biliary cirrhosis: antimitochondrial autoantibodies. Clin Res Hepatol Gastroenterol. 2013 Sep;37(4):431-3. Bowlus CL, Gershwin ME. The diagnosis of primary biliary cirrhosis. Autoimmun Rev. 2014 Apr-May;13(4-5):441-4. Lindor KD, et al. Primary biliary cirrhosis. Hepatology 2009;50:291 308. EASL. Clinical Practice Guidelines: management of cholestatic liver diseases. J Hepatol 2009;51:237 67. 3

7829 new requests of autoantibody screen 29 pts had Incidental finding of +AMA by IFA, titer 1:40 Normal serum bilirubin, ALP, and transaminase Diagnostic liver histology of PBC at presentation in 40% of cases Liver histology was diagnostic of or compatible with PBC in 24 pts and normal in only 2 pts (7%) 10-year follow-up of cohort Conclusion Patients with AMA but no other signs or symptoms of PBC seem to have slow disease progression AASLD and EASL recommendations 2 of 3 required criteria for PBC diagnosis Presence of antimitochondrial antibodies (AMA) Alkaline phosphatase (ALP) at least 1.5 times upper limit of normal for >24 weeks Histologic evidence of PBC, specifically nonsuppurative cholangitis and duct injury Florid duct lesion aka chronic nonsuppurative cholangitis Lymphohistiocytic inflammation centered on an interlobular bile duct (<100µm) and is associated with bile duct epithelial damage and epithelial reactive changes. Bowlus CL, Gershwin ME. The diagnosis of primary biliary cirrhosis. Autoimmun Rev. 2014 Apr-May;13(4-5):441-4. Lindor KD, et al. Primary biliary cirrhosis. Hepatology 2009;50:291 308. EASL. Clinical Practice Guidelines: management of cholestatic liver diseases. J Hepatol 2009;51:237 67. 4

The name PBC First described - 1851 Xanthomatous biliary cirrhosis - 1949 Xanthoma seen in 15-50% of pts and first finding in <1% Primary biliary cirrhosis - 1950 Expected survival no different from the general population in 2 of 3 patients diagnosed and treated with UDCA and only a minority will ever develop cirrhosis Acronym PBC Primary biliary cholangitis 2015 Name change approved by EASL, AASLD, AGA Addison T, Gull W. On a certain affection of the skin vitiligoidea a plana, b tuberosa. Guy s Hospital Reports 1851;7:265 276. Hanot V. Étude sur une forme de cirrhose hypertrophique du foie [cirrhose hypertrophique avec ictere chronique]. Paris: JBBaillère,1876. Macmahon HE, Thannhauser SJ. Xanthomatous biliary cirrhosis; a clinical syndrome. Ann Intern Med. 1949 Jan;30(1):121-79. Corpechot C, et al. The effect of ursodeoxycholic acid therapy on the natural course of primary biliary cirrhosis. Gastroenterology. 2005 Feb;128(2):297-303. Sherlock S. Primary billiary cirrhosis (chronic intrahepatic obstructive jaundice). Gastroenterology. 1959 Nov;37:574-86. Rubin E, Schaffner F, Popper H. Primary biliary cirrhosis. Chronic non-suppurative destructive cholangitis. Am J Pathol. 1965 Mar;46:387-407. Beuers U, et al. Changing nomenclature for PBC: From 'cirrhosis' to 'cholangitis'. Hepatology. 2015 Nov;62(5):1620-2 Case 1 pathologic diagnosis Feature consistent with primary biliary cirrhosis/primary biliary cholangitis Meets all three criteria Case 1 treatment Ursodeoxycholic acid (UDCA) FDA approved drug for PBC since 1998 Well-tolerated Better prognosis when given at early stage 5

Diagnostic criteria Emphasize Patchy distribution and range of histologic features Stains supportive of chronic biliary disease Case 2 not much clinical history 55 year old woman with elevated LFT Liver biopsy performed Case 2 pathologic diagnosis Portal and lobular inflammation or mild nonspecific changes. Do you then... 1. Go on to next case? 2. Send it to UCSF GI/Hepatobiliary Pathology Consult Service? 3. Inquire about laboratory results? 6

Diagnostic approach to cholestasis in adult patients We called for laboratory test results 2 Elevated ALP (264) Mildly elevated AST (62) and ALT (51) Positive AMA (M2 157.7) EASL. Clinical Practice Guidelines: management of cholestatic liver diseases. J Hepatol 2009;51:237 67. Case 2 clinical history and labs Scenario A ALP elevated and AMA positive Case 2 clinical history and labs Scenario B If ALP elevated and AMA negative Diagnosis: Portal and lobular inflammation; see comment. Comment: Describe features, state this can represent an early manifestation of PBC Other characteristic clinical features PBC-specific ANAs (Sp100 and gp210) Elevated serum IgM Hypercholesterolemia/Xanthomas Sicca syndrome Pruritus Fatigue Bowlus CL, Gershwin ME. The diagnosis of primary biliary cirrhosis. Autoimmun Rev. 2014 Apr-May;13(4-5):441-4. 7

Diagnostic approach to cholestasis in adult patients Case 2 clinical history and labs Scenario B If ALP elevated and AMA negative 4 3 Diagnosis: Portal and lobular inflammation; see comment. Comment: Describe features, consider repeat AMA test or use of a more sensitive assay; but could represent an early manifestation of AMAnegative PBC (autoimmune cholangitis), if DILI and primary and secondary sclerosing cholangitis has been excluded EASL. Clinical Practice Guidelines: management of cholestatic liver diseases. J Hepatol 2009;51:237 67. Bowlus CL, Gershwin ME. The diagnosis of primary biliary cirrhosis. Autoimmun Rev. 2014 Apr-May;13(4-5):441-4. Range of histologic features in PBC Non-specific features including portal tracts with no alterations to mild portal and lobular inflammation Duct injury +/- ductular reaction Patchy ductocentric lymphocytic cholangitis to florid duct lesion Duct loss / ductopenia Accompanied by portal-based fibrosis to biliary cirrhosis 8

Portal tract alteration Duct injury Epithelial cells stratified, hyperplastic, attenuated, or ectatic Cytology with swollen, vacuolated, or eosinophilic cytoplasm and pyknotic nuclei Inflammation Lymphoid aggregate, ductocentric, intraepithelial or completely replace duct, and can have interface activity Composed of epithelioid or foamy histiocytes and lymphocytes, plasma cells, and/or eosinophils Florid duct lesion? 9

Florid duct lesion Other autoantibodies in PBC Antinuclear antibodies (ANA) Positive in ~50% of PBC pts irrespective of AMA status Positive in up to 85% of AMA-negative PBC pts Rim-like pattern with g210 and p62 Multiple nuclear dots with Sp100 Smooth muscle antibody (SMA) Positive in 2/3 of PBC pts 10

Supportive of chronic biliary disease Periportal hepatocytes Have cytoplasmic copper deposition on copper stain Immunoreactive for CK7 Case 3 clinical history 46 year old woman with elevated ALP (238) Normal AST (33), ALT (53), Tbili (0.3) 10 months later found to have positive AMA (titer 1:640) Liver biopsy performed Copper (rubeanic acid) stain 11

40x CK7 Case 3 pathologic diagnosis Liver, core needle biopsy: Features consistent with primary biliary cirrhosis/primary biliary cholangitis; see comment. Comment: Portal and lobular inflammation Duct injury and loss (confirmed on CK7) Cholestatic effect (focal periportal copper and CK7 positive hepatocytes) Early stage Staging systems Stage Ludwig Scheuer 1 2 Portal inflammation (duct damage can be present) Periportal inflammation Florid duct lesion Ductular reaction (periportal fibrosis often present) 3 Bridging fibrosis (ductopenia usually present) 4 Biliary cirrhosis Not useful in predicting prognosis due to Heterogeneity in the distribution of features Combined information about inflammation and fibrosis 12

Bridging fibrosis and ductular reaction 13

Case 4 clinical history 50 year old woman Negative HCV, HBsAb, and AMA Positive ANA Elevated IgM (622) and IgG (4051) Mildly elevated ALT (94), AST (93), total bili (13.4) Case 4 pathologic diagnosis Cirrhosis with ductopenia and cholate stasis suggestive of AMA-negative PBC; see comment. If negative imaging studies aka autoimmune cholangiopathy or autoimmune cholangitis Indistinguishable from PBC pts who are AMA-positive O'Brien C, et al. Long-term follow-up of antimitochondrial antibody-positive autoimmune hepatitis. Hepatology. 2008 Aug;48(2):550-6. 14

Describe the features seen A. Portal and lobular inflammation B. Infiltrate with easily identified plasma cells C. Florid duct lesion D. Ductular reaction E. Ductopenia F. Periportal copper deposition G. CK7 positive periportal hepatocytes H. Nodular regenerative hyperplasia I. Biliary pattern of cirrhosis Hepatologist wants to know Can the described features be seen in PBC Or is it another disease process Autoimmune hepatitis Overlap syndrome Primary sclerosing cholangitis Drug reaction (DILI) Large duct obstruction Sarcoidosis Cholangiography is gold standard for diagnosis of PSC Magnetic resonance cholangiopathy (MRCP) Method of choice because it is non-invasive Sensitivity of 86% and specificity of 94% Endoscopic retrograde cholangiopancreatography (ERCP) Optimal for early changes when duct have shallow ulcers without stricture Distribution Frequent involves intra- and extra-hepatic bile ducts, 87% Intrahepatic ducts alone, 11-25% Extrahepatic ducts alone, 2% Case 5 clinical history 45 year old man with ulcerative colitis and primary sclerosing cholangitis who undergoes liver transplant 15

Cirrhotic with duct ectasia or loss Hilar periductal inflammation Hilar duct dialation or ulcerated with bile extravasation and inflammation Range of histologic features in PSC* Non-specific features including portal tracts with no alterations to mild portal inflammation Ductular reaction with duct injury Can have lobular inflammation Accompanied by portal-based fibrosis Periductal fibrosis or fibro-obliterative duct lesion Biliary cirrhosis *Histologic features overlaps PBC 16

Age (years) Comparison between PSC vs PBC Clinical, immunologic and imaging PSC Wide age range, most between 25-40; can occur in children PBC Typically >50, does not occur in children Gender Male preponderance (2-3:1) Female preponderance (9-14-:1) Disease association Serum immunoglobulins Autoantibodies Cholangiography Idiopathic inflammatory bowel disease, especially ulcerative colitis No significant increase No specific antibodies; AMA rare Stricturing and beading of large ducts; normal in smallduct PSC Other autoimmune diseases such as Sjogren syndrome, and autoimmune thyroid disease Elevated IgM AMA, ANA-centrometric type Normal extrahepatic and large intrahepatic ducts Modified Table 26.4 Practical Hepatic Pathology: A Diagnostic Approach, 1 st Edition A Volume in the Pattern Recognition Series, Expert Consult 2011 by Saunders, an imprint of Elsevier Inc. Philadelphia, PA Small duct PSC Frequency of 11-17% Involves smaller caliber bile ducts Liver biopsy required for diagnosis Bile duct injury Comparison between PSC vs PBC Pathology PSC Affects large intra- and extra-hepatic ducts PBC Affects small interlobular bile ducts Florid duct lesion Rare Characteristic Portal inflammation Tends to be less Typically prominent Ductular reaction Typically prominent Typically less prominent Obliterative fibrosis of medium and large ducts Characteristics but often not sampled on biopsy Absent Periportal copper* Present Present *Nonspecific feature of chronic cholestasis Fibro-obliterative duct lesion Modified Table 26.4 Practical Hepatic Pathology: A Diagnostic Approach, 1 st Edition A Volume in the Pattern Recognition Series, Expert Consult 2011 by Saunders, an imprint of Elsevier Inc. Philadelphia, PA CK7 17

Septal/interlobular NOT A SPECIFIC FEATURE ducts OF with periductal fibrosis PRIMARY SCLEROSING CHOLANGITIS Case 6 clinical history 42 year old man with ulcerative colitis and elevated alkaline phosphatase Negative autoimmune panel and hyperglobulinemia (IgG 1827) Normal MRCP Liver biopsy was performed Variability in distribution Portal zones 18

CK 7 immunohistochemical stain Copper (rubeanic acid) stain Case 6 pathologic diagnosis Features consistent with chronic biliary tract disease; see comment. Comment: Describe features (portal information with duct loss/ductopenia and septal and focal bridging fibrosis; chronic biliary process supported by stains). Potential etiology small duct PSC vs AMA-negative PBC. Chronic biliary tract diseases Elevated ALP No visible cholestasis on biopsy Small duct PSC Early stage PSC and PBC 19

Case 7 clinical history 71 year old man with progressive jaundice Infectious complication following enolymphatic sac enhancement surgery for vertigo. Elevated ALP (245) and Tbili (12) Is this PSC? Case 7 pathologic diagnosis Cholestasis, portal inflammation and ductular reaction; see comment. Differential includes large duct obstruction or drug reaction LiverTox database DILI due to Augmentin toxicity 20

Secondary sclerosing cholangitis Secondary sclerosing cholangitis Schistosomiasis Infection (AIDS cholangiopathy) Vascular (ischemic cholangiopathy/ischemic stricturing) Toxic (intra-arterial chemotherapy such as floxuridine) Congenital (Caroli disease) Infiltrative (cholangiocarcinoma) Hepatolithiasis Trauma (surgical biliary trauma) Immunologic (IgG4-related sclerosing cholangitis) IgG4-related sclerosing cholangitis * Case 8 clinical history * Most have associated autoimmune pancreatitis type 1 Isolated cholangitis (10%) Two forms Mass-forming hilar lesion mimics cholangiocarcinoma PSC-like intra- and extra-hepatic biliary strictures mimics PSC Steroid-responsive strictures 55 year old man with obstructive jaundice Imaging: common bile duct stricture, suggestive of cholangiocarcinoma Cytology and biopsy inconclusive Resection specimen 21

Courtesy of Dr. Sanjay Kakar Courtesy of Dr. Sanjay Kakar IgG4 plasma cells >10 HPF Courtesy of Dr. Sanjay Kakar Courtesy of Dr. Sanjay Kakar 22

Requests for IgG4 stain IgG-related sclerosing cholangitis One of the criterion is >10 IgG4+ plasma cells/hpf Also observed in other diseases PSC 23% (23/98 explanted liver large bile duct) 22% of pts had elevated serum IgG4 AIH Rare reports (1/9 and 2/60 liver biopsies) Case 9 clinical history 62 year old man with autoimmune pancreatitis Elevated AST (47) and ALP (267) ANA and AMA negative Elevated IgG4 (226) Zhang L, et al. IgG4+ plasma cell infiltrates in liver explants with primary sclerosing cholangitis. Am J Surg Pathol. 2010 Jan;34(1):88-94. Koyabu M, et al. Analysis of regulatory T cells and IgG4-positive plasma cells among patients of IgG4-related sclerosing cholangitis and autoimmune liver diseases. J Gastroenterol. 2010 Jul;45(7):732-41. Umemura T, et al. Clinical significance of immunoglobulin G4-associated autoimmune hepatitis. J Gastroenterol. 2011 Jan;46 Suppl 1:48-55. 23

Case 9 pathologic diagnosis Features of biliary obstruction; see comment. Comment: No IgG4+ plasma cells, does not exclude IgG4-related disease. ERCP demonstrated pancreatic duct and intrahepatic biliary stricturing felt to be consistent with either PSC or IgG4 cholangiopathy Treated with steroids with normalization of liver enzymes and decreased IgG4 Conclusions Chronic biliary tract diseases: PBC and PSC Similarities Overlapping histologic features Patchy distribution that can be non-specific early in the disease process Distinctive Clinical, laboratory and radiographic findings is essential PBC progresses slowly to cirrhosis and UDCA is available Periductal fibrosis observed in primary or secondary sclerosing cholangitis Nakanuma staging system Score 0 1 2 3 Fibrosis Bile duct loss Deposition of orceinpositive granules No portal fibrosis or No bile duct loss No deposition fibrosis limited to portal tracts Portal fibrosis with Loss in <1/3 of Deposition of granules in periportal fibrosis or portal tracts periportal hepatocytes in incomplete septal <1/3 of portal tracts fibrosis Bridging fibrosis with variable lobular disarray Cirrhosis with regenerative nodules and extensive fibrosis Loss in 1/3-2/3 of portal tracts Loss in >2/3 of portal tracts Deposition of granules in periportal hepatocytes in 1/3-2/3 of portal tracts Deposition of granules in periportal hepatocytes in >2/3 of portal tracts 24

Stage Scheuer Ludwig Nakanuma 1 Florid duct lesion Portal Sum of 0 points (no progression) 2 Ductular reaction Periportal Sum of 1-3 points (mild progression) 3 Bridging fibrosis Bridging fibrosis Sum of 4-6 points (moderate progression) 4 Biliary cirrhosis Biliary cirrhosis Sum of 7-9 points (advance progression) Stage 4 (total score 9/9) Fibrosis 9/3, bile duct loss 3/3, orcein (copper) deposition 3/3 Hepatitis activity 0/3, cholangitis activity 0/3 HA 0 (no activity) adf Nakanuma grading system Grade Hepatitis Cholangitis Grade No interface and no or No cholangitis +/- mild minimal lobular hepatitis duct epithelial damage HA 1 (mild activity) HA 2 (moderate activity) HA 3 (marked activity) Focal interface hepatitis and mild to moderate lobular hepatitis Between HA1 and HA3 Marked interface hepatitis, moderate to marked lobular hepatitis or zonal necrosis Issue with interobserver variability At least one focus of evident chronic cholangitis Two more foci of evident chronic cholangitis At least of focus of chronic non-suppurative destructive cholangitis (granulomatous cholangitis) CA 0 (no activity) CA 1 (mild activity) CA 2 (moderate activity) CA 3 (marked activity) Granuloma Diagnosis? Case Quick look at APeX revealed history of sarcoidosis Granuloma Case 25

Martin JA. Endoscopic Management of Primary Sclerosing Cholangitis: State of Art. Am J Gastroenterol. 2007;102,S32-37. Fibro-obliterative duct lesion Trichrome and copper stains CK7 26

Diagnosis? More information 66 year old man History of common bile duct stones and biliary strictures Liver showed focal portal inflammation, minimal ductular reaction, and rare periductal fibrosis Pathologic diagnosis: Features of biliary tract disease; see comment. Etiology includes early stage PSC, chronic obstruction (hepatolithiasis or recurrent pyogenic cholangitis). Case 8 clinical history 52 year old man with BMI of 30 and diabetes mellitus, and elevated alkaline phosphatase Negative ANA, ASMA, and AMA 27

What is the diagnosis/diagnoses? MRCP beaded Case 8 diagnosis Request for IgG4 stain Features supportive of early stage primary sclerosing cholangitis. Can cholestasis occur? Superimposed steatohepatits, possibly alcoholic steatohepatitis 28

PSC and IgG4 related sclerosing cholangitis IgG4 stain: 23% of PSC have >5 IgG4+ plasma cells per HPF Absent: Portal-based inflammatory nodules: lymphocytes, plasma cells, eosinophils, fibroblasts Obliterative phlebitis not seen Accentuation of inflammation around bile ducts uncommon Pseudotumor-like hilar mass 29