Liver

Question 1

benign mimics of malignancy

Answer 1

HCA

bile duct hamartoma

peribiliary gland hamartoma

adenomatoid tumour

Question 2

malignant mimics of benign

Answer 2

lymphoma/leukaemia

subtle metastatic disease (lobular and signet ring ca)

low grade angiosarcoma (along sinusoids)

Question 3

if nothing, look for…

Answer 3

amyloid

infection (CMV, schistosoma)

vasculitis

thrombi/emboli

hairy cell leukaemia

Question 4

cystic fibrosis (morphology)

Answer 4

stellate scars

irregular bile ducts

inspissated eosinophilic material

Question 5

viral hepatitis

Answer 5

Hep B: ground glass hepatocytes with ‘sanded’ nuclei

Hep C: lymphoid aggregates with germinal centres, granulomas

CMV: microabscesses, granulomas

Question 6

granulomas

Answer 6

PBC

infection (viral, bacterial, fungal, parasitic)

drugs

sarcoid

foreign body (eg IV drug user)

Crohn’s

malignancy esp Hodgkins

Question 7

cirrhosis

Answer 7

viral hepatitis

alcohol

NASH

biliary cirrhosis

autoimmune

metabolic (haemochromatosis, A1T, Wilson’s)

congestion (eg heart failure, Budd-Chiari)

Question 8

causes of biliary cirrhosis

Answer 8

intrahepatic: PBC, PSC
extrahepatic: gallstones, IgG4, biliary atresia, choledochal cyst, tumours

Question 9

non-neoplastic cysts

Answer 9

infection (pyogenic, amoeba, hydatids)

simple biliary cyst

polycystic liver disease

mesenchymal hamartoma

pseudocyst

enteric cysts

Question 10

neoplastic cysts

Answer 10

mucinous cystic neoplasm

intraductal papillary neoplasm

serous cystadenoma

teratoma

cystic malignancy (incl metastases)

Question 11

polycystic liver disease

Answer 11

PLD assoc with ADPKD (more common)

fibrocystic liver disease: autosomal recessive, often assoc with ARPKD

Question 12

hepatocellular lesions

Answer 12

non cirrhotic: HCA, FNH, NRH, fibrolamellar HCC

cirrhotic:

macroregenerative nodule (>8mm)

dysplastic nodule (>1mm)

HCC

Question 13

hepatocellular adenoma (types)

Answer 13

1. HNF1a mutation: steatosis
2. b-catenin mutation: atypia, pseudoglandular, glutamine synthetase+
3. inflammatory: telangiectasia
4. unspecified

Question 14

clues for HCC

Answer 14

loss of portal tracts

unpaired arteries

plates >2 cells thick

small cell change

clone-like subpopulations (haemosiderin free)

mitoses >5/10HPF

reticulin (loss), CD34, glypican 3

Question 15

biliary lesions

Answer 15

bile duct hamartoma (von Meyenberg complex): irregular glands in dense fibrous stroma, bile

peribiliary gland hamartoma (bile duct adenoma): uniform round ducts, less stroma, no bile

cholangiocarcinoma (atypia and mitoses cf above)

Question 16

vascular lesions

Answer 16

cavernous haemangioma

infantile haemangioma

epithelioid haemangioendothelioma

Kaposi sarcoma

angiosarcoma

Question 17

HCC vs cholangioca vs metastatic adenoca

Answer 17

HCC: cirrhosis, HepPar1+, pCEA/CD10 (canalicular), glypican3+

cholangioca: HMWCK, MOC31, CK19+

met ca: CK depends on site, no good markers vs cholangioca

Question 18

HCC vs met large cell neuroendocrine ca

Answer 18

LCNEC: NE markers, CK, TTF1 in 50%

Question 19

Answer 19

fibrolamellar HCC (pleomorphic cells)

Question 20

scirrhous HCC - DDX

Answer 20

radiation (need Hx)

cholangiocarcinoma

epithelioid haemangioendothelioma: young, myxoid stroma, CD31+

Question 21

HCC vs HCA

Answer 21

HCA: OCP use, no cirrhosis, uniform cells, plates <3 cells thick, intact reticulin

Question 22

FNH vs HCA

Answer 22

FNH:

central scar

bile ductules

glutamine synthetase (GS)+ (- in all but beta-catenin HCA)

serum amyloid A (SAA)- (HCA is +)

Question 23

nodular regenerative hyperplasia - features

Answer 23

multiple small nodules throughout liver

no fibrous septa

assoc with portal vein obstruction or vascular flow problem (eg PCV, Budd-Chiari)

GS+ (distinguishes cirrhosis)