9. Neoplasms

Question 1

Neoplasms of the liver and biliary tract

Answer 1

1. Hemangioma of Liver
2. Liver cell adenoma
3. Hepatocellular carcinoma
4. Hepatoblastoma
5. Cholangiocarcinoma
6. Carcinoma bile duct
7. Carcinoma of the Gallbladder

Question 2

Epidemiology & Associations of Hemangioma of Liver

Answer 2

1. Most common benign tumour of the liver

2. Can be seen in all ages, both genders

Question 3

Morphology of Hemangioma of Liver

Answer 3

1. Usually found directly beneath liver capsule

2. Cavernous in nature, composed of vascular channels in a bed of fibrous connective tissue

Question 4

Pathological Effects & Complications of Hemangioma of Liver

Answer 4

1. Mostly symptomless
2. May rupture & cause bleeding
3. Thrombosis with hemangioma resulting in:
   - Thrombocytopenia
   - Hypofibrinogenemia

Question 5

Epidemiology & associations of liver cell adenoma

Answer 5

Occurs exclusively in women of childbearing age

- Strongly associated with female hormones (hence associated with oral contraceptive use as well)

Question 6

Morphology of liver cell adenoma

Answer 6

1. [Grossly]
   - Solitary well-defined lesion
   - 2-15cm in diameter
   - Yellowish
2. [Histologically]
   - Well differentiated trabeculae of liver cords separated by sinusoids
   - Prominent vessels distributed through the tumour substance
   - Absence of normal portal tracts

Question 7

Pathological Effects & Complications of liver cell adenoma

Answer 7

1. Abdominal discomfort

2. Intraperitoneal hemorrhage (those in subcapsular regions)

Question 8

Epidemiology of hepatocellular carcinoma

Answer 8

Global distribution of cases coincides with distribution of HBV endemicity

Question 9

Etiologies & Associations of hepatocellular carcinoma

Answer 9

1. Cirrhosis
2. Hepatotropic viruses chronic infection (HBV, HCV)
3. Thorium dioxide (thorotrast) exposure
4. Aflatoxins
   - Produced by fungus Aspergillus flavus
   - Gives characteristic p53 mutation

Question 10

Morphology of hepatocellular carcinoma

Answer 10

1. [Grossly]
   - May appear as unifocal mass (typically large), multifocal widely distributed nodules (typically against a background of cirrhosis), or diffuse infiltrative cancer
   - Variegated in cut section (yellowish background, grey necrosis, red hemorrhage, green bile)
2. [Histologically]
   - Trabeculae of hepatocytes separated by sinusoids
   - Neoplastic hepatocytes have eosinophilic cytoplasm, display pleomorphism
   - Bile production (HCC is the only tumour that elaborates bile)

Question 11

Clinical features of hepatocellular carcinoma

Answer 11

1. Predilection for invasion of vascular structures
   - Portal vein obstruction
   - Hepatic vein obstruction (Budd-Chiari syndrome)
2. Tumour marker: alpha-fetoprotein
3. Prognostic factors:
   - Stage
   - Encapsulation
   - Number of tumours
   - Fibrolamellar variant (solitary tumour not associated with HBV/HCV/cirrhosis, typically occurs in children; better prognosis)
   - Presence of cirrhosis (worse prognosis)

Question 12

Epidemiology & Associations with Hepatoblastoma

Answer 12

1. Occurs almost exclusively in infants

2. Not associated with cirrhosis

Question 13

Morphology of Hepatoblastoma

Answer 13

1. Primitive looking neoplastic hepatocytes

2. Presence of non-hepatic tissue types (e.g. osteoid)

Question 14

Clinical features of hepatoblastoma

Answer 14

1. Tumour marker: alpha-fetoprotein
2. Prognostic factors:
   - Stage
   - Histologic subtypes (fetal type better prognosis, anaplastic & macrotrabecular types worse prognosis)
   - Generally better prognosis than hepatocellular carcinoma

Question 15

Definition of cholangiocarcinoma

Answer 15

Cancer of the intrahepatic bile ducts

Question 16

Etiologies & Associations of cholangiocarcinoma

Answer 16

1. Caroli disease
2. Congential hepatic fibrosis
3. Thorium dioxide (Thorotrast) exposure
4. Intrahepatic lithiasis
5. Clonorchiasis

Question 17

Morphology of cholangiocarcinoma

Answer 17

1. Glandular differentiation

2. Glandular structures embedded in dense sclerotic stroma

Question 18

Definition of carcinoma bile duct

Answer 18

Cancer of the extrahepatic bile ducts

Question 19

Etiologies & Associations of carcinoma bile duct

Answer 19

1. Caroli disease
2. Congential hepatic fibrosis
3. Thorium dioxide (Thorotrast) exposure
4. Intrahepatic lithiasis
5. Clonorchiasis

Question 20

Morphology of Carcinoma Bile Duct

Answer 20

1. Found anywhere along extrahepatic biliary tree (from
   hepatic bile ducts to ampulla of Vater)
   - Tumours found at junction of right & left hepatic ducts (perihilar) are known as Klatskin tumours
2. Small thickening of wall with papillary growth into lumen
3. Glandular differentiation

Question 21

Clinical features of carcinoma bile duct

Answer 21

1. Causes obstructive jaundice

2. Generally, prognosis is poor

Question 22

Etiologies and associations of carcinoma of the gallbladder

Answer 22

1. Gallstones

2. Parasitic diseases of biliary tract

Question 23

Morphology of carcinoma of the gallbladder

Answer 23

1. [Grossly]
   - Diffuse infiltrative growth (70%) or polypoid exophytic growth (30%)
2. [Histologically]
   - Glandular differentiation
   - Glandular structures found within densely fibrotic background

Question 24

Clinical features of carcinoma of the gallbladder

Answer 24

1. Propensity to invade liver, stomach & duodenum
2. Metastases to liver, pericholedochal & duodenal lymph nodes
3. General prognosis is poor