Ch. 13 - Liver

Question 1

What types of liver pathology are amenable to FNA sampling?

Answer 1

Liver masses; not for diffuse disease (cirrhosis, hepatitis) which relies on architecture for Dx.

Question 2

What are the normal cellular elements of liver?

Answer 2

Hepatocytes, bile duct epithelium, Kupffer cells, and sheets of mesothelial cells.

Question 3

Describe the morphology of hepatocytes.

Answer 3

Large polygonal cells with round central nuclei (sometimes multinucleated). Cytoplasm is abundant and granular and may contain lipofuscin, hemosiderin, or bile. Look for trabeculae.

Question 4

Describe the morphology of bile duct epithelium and Kupffer cells.

Answer 4

Bile duct epithelium: Cuboidal/flat cohesive cells arranged in honeycombs.

Kupffer cells: Basically macrophages, sometimes hemosiderin-laden.

Question 5

Describe the cytology of bacterial/fungal and amebic abscesses.

Answer 5

Bacterial/fungal: Acute infiltrate, debris, maybe organisms

Amebic: Anchovy paste gross appearance. Necrosis with little inflammation. Trophozoites (resemble histiocytes with ingested RBCs).

Question 6

Describe the cytology of echinococcal cysts.

Answer 6

Fragments of laminated membrane, sometimes with scolices or hooklets.

Question 7

What types of non-parasitic cysts can be found in the liver?

Answer 7

Cuboidal or columnar (biliary), ciliated, mucinous (bile duct cystadenoma).

Question 8

Describe the cytology of cirrhosis.

Answer 8

Normal appearing hepatocytes, maybe some steatosis and focal atypia. Need to get core biopsy…

Question 9

Describe the cytology of FNH.

Answer 9

Normal looking hepatocytes, maybe some steatosis and bile ductular cells.

Question 10

Distinguish between the clinical significance and cytology of FNH and hepatic adenoma.

Answer 10

Both affect adult women. FNH can be recognized clinically by its radiologic central scar. Bile duct epithelium should not be seen in hepatic adenoma, which also confers a minor risk of HCC transformation.

Question 11

Describe the cytology of hepatic adenoma.

Answer 11

Normal appearing hepatocytes, some steatosis and naked arterioles.

Question 12

Describe the cytology of bile duct hamartoma (“von meyenberg complex”).

Answer 12

Hypocellular specimen containing many benign ductal cells and some hepatocytes.

Question 13

Describe the cytology of liver angioma.

Answer 13

3-D arcades of spindled cells with blood, maybe some hepatocytes.

Question 14

When is hepatic angiomyolipoma sampled?

Answer 14

Only when it is fat-poor and cannot be recognized as AML on imaging, analogous to those of the retroperitoneum.

Question 15

Describe the cytology of angiomyolipoma.

Answer 15

Fat cells, blood vessels, and spindled to epithelioid myoid cells. May have some EMH.

Question 16

What are some normal markers of benign hepatocytes?

Answer 16

HepPar1, TTF-1 (cytoplasmic only), ARG-1, CAM5.2, polyclonal CEA (canalicular pattern).

Question 17

What are the three architectural patterns of usual HCC?

Answer 17

Trabecular, pseudoglandular (acinar), and compact.

Question 18

What are the variants of HCC?

Answer 18

Fibrolamellar (young pts, good px)
Sarcomatoid
Scirrhous 
Lymphoepithelioma-like
Undifferentiated

Question 19

What histologic features are distinct for HCC?

Answer 19

Hyaline (Mallory) bodies, globular hyaline bodies, and bile.

Question 20

Describe the cytology of well-differentiated HCC.

Answer 20

Highly cellular smears of enlarged hepatocytes with high N:C ratios arranged in thick plates. Hyaline intracytoplasmic globules.

Question 21

Describe the cytology of HCC, fibrolamellar variant

Answer 21

Large polygonal cells with abundant eosinophilic cytoplasm and dense bands of fibrosis. Hyaline intracytoplasmic globules.

Question 22

Describe the cytology of cholangiocarcinoma.

Answer 22

Isolated cells or crowded sheets with glandular differentiation and nuclear enlargement.

Question 23

What are the risk factors for cholangiocarcinoma. Where can they occur?

Answer 23

Liver fluke, PSC, nonbiliary cirrhosis, thorotrast, vinyl chlorides. May be intrahepatic or extrahepatic (hilar = “Klatskin”).

Question 24

Describe the cytology of hepatoblastoma.

Answer 24

Similar to that of HCC but within the spectrum of SRBCTs

Question 25

Describe the cytology of angiosarcoma.

Answer 25

May be well-differentiated (spindled, syncytial) or poorly differentiated (epithelioid, even rhabdoid). Vacuolated cytoplasm. Look for anastomosing vascular pattern on cell blocks.

Question 26

Describe the cytology of epithelioid hemangioendothelioma.

Answer 26

Hypocellular specimen; large polymorphous cells with folded nuclear outline and some giant cells.

Question 27

What cancers are very likely to metastasize to liver?

Answer 27

Colorectal, lung, pancreas, stomach, and breast.

Question 28

What stains are helpful for distinguishing HCC from benign liver?

Answer 28

Reticulin stain (for architecture, generally not helpful in cytology) and glypican-3 (GPC3) which is positive in HCC but not benign hepatocyte.

Question 29

What stains are helpful for diagnosing NETs? What about pancreatic NETs?

Answer 29

Synaptophysin, chromogranin, CD56.

Pancreatic: Islet-1 and PAX-8.

Question 30

What stains distinguish seminoma/dysgerminoma from embryonal carcinoma and yolk sac tumor?

Answer 30

Seminoma: PLAP, CD117, OCT-3/4, NANO-G, SALL4.

Embryonal/Yolk: AFP, EMA, CEA, Keratins.