liver 3 kiss 2018 [kompatibilis üzemmód] · 2018. 3. 12. · 2018. 03. 12. 3 liver alterations...
TRANSCRIPT
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LIVER PATHOLOGY(3)
Prof. Andras Kiss. M.D., Ph.D., D.Sc.
Semmelweis University
2nd Department of Pathology
Budapest
February 26. 2018
Vascular disorders
� Inflow – A.hepatica thromb., embolia – infarctus
– V.portae obstruction, thrombosis (pylethrombosis) –portal hypertension, causes
� Trough– congestion, hepar moschatum, peliosis hepatis
� Outflow– Budd-Chiari syndrome
– VOD
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Budd-Chiari syndrome(Extended hemorrhages in the liver parenchyma caused by thrombosis of hepatic veins)
Nemesánszky-Schaff-Szalay Hepatologia Oktató CD2004 Falk
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Liver alterations associated with pregnancy
� Acute steatosis in pregnancy– rare, from mild to severe (could be fatal), 3.trimester,
perinatal, microvesicular steatosis, pancreatitis (common)
� Intrahepatic cholestasis in pregnancy– 3. trimester, icterus, iching, cholestasis, ??
� Praeeclampsy, eclampsy– HELLP-syndrom (hemolysis, elevated liver enzymes,
low platelets), pale liver with red foci, fibrin deposits in sinusoids, hemorrhages
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LIVER PATHOLOGY (3)
• Focal liver lesions
– Benign tumors and tumor-like lesions
– Malignant tumors
• Liver transplantation
• Diseases of gallbladder and bile ducts
– Diseases of gall bladder
– Diseases of extrahepatic bile ducts
– Tumors
• (**)= important , (×), not for exam (extra)!!!
Focal liver lesions (**)
• Tumor-like lesions of the liver
– FNH, NRH, mesenchymal hamartoma, cysts,
inflammatory pseudotumor, abscessus, infarctus
• Benign liver tumors
– Non epithelial: haemangioma, fibroma,
angiomyolipoma etc
– Epithelial: adenoma (HCA, CCA)
• Malignant liver tumors
– Non epithelial: haemangiosarcoma, -endothelioma
embryonal sarcoma, lymphoma
– Epithelial: hepatocellular cc, cholangiocellular cc.,
mixed, hepatoblasoma
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Classification of liver cysts (1) (×)
I. Parasitic
II. Non parasitic
A. Soliter
B. Hereditary
1. Non-communitating ductal
2. DPM („ductal plate malformation”- communitating)
• CHF (cong. hepatic fibrosis)
• ARPKD
• syndromes (Meckel-Gruber, Ivemark)
3. Isolated hepatic
*Witzleben, G. L., Ruchelli, E.
II. Non parasitic
C. Systemic biliary dilatative
1. Without choledochus cyst
(„simple” Caroli disease)
2. With choledochus cyst
D. Other
1. Traumatic, infarction
2. Duodenal duplication
3. Tumors with cyst
• cystadenoma/-carcinoma
• mesenchymal hamartoma
• giant cavernous haemangioma
• teratoma
• other
4. Peliosis
*Witzleben, G. L., Ruchelli, E.
Classification of liver cysts (2) (×)
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Ecchinococcus cyst
1 cm
Hepar polycysticum
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1 cm
Mesenchymal hamartoma (children, benign)
Tumor-like focal liver lesions (**)
– Focal nodular hyperplasia (FNH)
– Inflammatoric pseudotumor
– Mesenchymal hamartoma
– Nodular regenerativ hyperplasia
– Infarct
– Granulomas (Boeck, tbc etc)
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Focal nodular hyperplasia (FNH)(**)- Female predominance,
- Well circumsized, - No capsule
- Central scar (fibrous septa radiate,
„focal cirrhosis”)
- Color (pale, fatty, haemorrhagic etc.)
- Bile ducts: numerous, tortuous
- Inflammatory cells
-important!!!
Focal NodularHyperplasia (FNH)(central scar!!!)
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1 cm
FNH
1 cm
4319-88
FNH
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Haemangiomahepatis(giant form)
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1 cm
1 cm
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Focal Nodular Hyperplasia(FNH)
FibroLamellar hepatocellularCarcinoma (FLC)
Focal Liver Lesions
FNH HCA (prev. FNH – teleang.)
Hemang.
FLC
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Hepatocellular adenoma (HCA) (**)
- Female predominance
- Associated with oral contraceptives,
anabolic steroids
- Sharply demarcated, - Encapsulated
- Homogenous structure, but hemorrhage,
necrosis common,
- Steatosis, no bile ducts in the tumor
adenoma hepatocellulare (HCA)(yellow, steatosis, capsule)
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HCA: Variant 3
„teleangiectatic”
• Monoclonal
• Dilated vessels
• Haemorrhagies
• Less or no steatosis
• Biliary vessels (less in number)
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10 cm
HCA Variant 3
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CK7
Zucman-Rossi et al., Hepatology 2006;43;515
Classification of hepatocellular adenomas:
association with HCC or borderline lesion
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1 cm
Adenoma hepatocellulare (extended bleeding,rupture might occur)
Hepatocellular carcinoma (**)
- Cirrhosis (70%)
- Association with HBV/HCV/alkohol etc
- Gross: uneven border, usually no capsule,
haemorrhage, necrosis
- Hist: trabecular, pseudoglandular (acinar),
clear cell, scirrhous, fibrolamellar (grades
I-IV)
- Progression: infiltration of capsule (if exists),
venous invasion
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HCC
extracapsular
cirrhosis
HCC
necrosis
HCC
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1 cm
Fibrolamellar HCC
SCIENCE 2014 343:1010
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HCC
cirrhosis
cirrhosis
HCC HCC, trabecular form
Different histological types of HCC
HCC, trabecular HCC, pseudoglandular
HCC, anaplastic
HCC, venousinvasion
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Staging of HCC
TNM-Classification
T1 solitary tumor without vascular invasion
T2 solitary tumor with vascular invasion or
multiple tumors < 5 cm diameter
T3 multiple tumors > 5 cm diameter or
tumor invasion of major veins
T4 tumor(s) with invasion of adjacent organs
or perforation of visceral peritoneum
Stage Grouping
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage IIIA T3 N0 M0
Stage IIIB T4 N0 M0
Stage IIIC any T N1 M0
Stage IV any T any N M1
Therapeutic (surgery) relevance
Llovet J.M., Bruix J. Hepatology 2008.48:1312-27
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Llovet J.M., Bruix J. Hepatology 2008.48:1312-27
Llovet J.M., Bruix J.
Hepatology 2008.48:1312-27
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• Proangiogenic factors overexpressed in HCC:
–Vascular endothelial growth factor (VEGF)
–Platelet-derived growth factor (PDGF)
–Placental growth factor
–Transforming growth factor α and β
–Basic fibroblast growth factor
–Epidermal growth factor (EGF)
–Hepatocyte growth factor
–Angiopoietinek
–Interleukin (IL)-4, IL-8
Angiogenesis and HCC
Semela D, Dufour J-F. J Hepatol 2004;41:864–80
Characteristics of HCC
• 5% of malignant tumors
• 564 000 new cases annually
• (in 2000) and similar death
• Incidence is dubbled in the past
20 yrs (Japan, USA, Sweden,
France)
• 7. in males
• 9. in femels
• Characteristic geography
• Etiological factors: HBV, HCV,
AFB1 (80%), alkohol etc
• 5% of malignant tumors
• 564 000 new cases annually
• (in 2000) and similar death
• Incidence is dubbled in the past
20 yrs (Japan, USA, Sweden,
France)
• 7. in males
• 9. in femels
• Characteristic geography
• Etiological factors: HBV, HCV,
AFB1 (80%), alkohol etc
Unknown
35%
HBV/HDV
5%HBV
15%
HCV
45%
Koff RS, et al. Viral Hepatitis. 2nd ed. 1994.
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HBV, HCV
HCC
Mutagen effects
Cirrhosis !
Aflatoxin
Fusarium toxin
Hepatocarcinogenesis
Etiological
factorsAlcohol
Androgens
Metabolic diseases
Schistosoma
Classification of tumors of bile ducts
Cholangiocarcinoma (CC)intrahepatic CCperihilar CC (previously Klatskin tumor)
distal (CC)
•
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Cholangiocarcinoma.
Perihilar CC
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Cholangiocarcinoma.
Ductus choledocus
Tumor, protruding from theLiver
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2014:1-12
Biliary hamartoma (von Meyenburg complex)
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Biliary hamartoma (von Meyenburg complex)
Gallbladder (**)
1. Tumorlike lesions- Inflammatory origin
(polyp, xanthogranulomatous
cholecystitis etc)
- Hyperplasia
(papillary, adenomyomatous)
- Heterotopic tissue (pancreas,
stomach, endocrin)
- Other
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Gallbladder (**)
2. Tumors
Benign
- adenoma
- cystadenoma
- papillomatosis
- mesenchymal
Malignant
- epithelial
- adenocarcinoma
- adenosquamosus cc.
- squamosus cc.
- differenciálatlan
- cystadenocarcinoma
- mesenchymal
- endocrin - carcinoid
Gallbladder carcinoma (**)
Gross
- infiltrating
- exophytic
Histology
- adenocarcinoma
Immunohistochem
- CEA
- CA 19-9
Other
- TNM
- occult carcinoma
- in situ carcinoma
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Gallbladder cc
Adenocarcinoma
Ductus choledochus carcinoma(CC, distal type)
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Most common metastatic liver tumors (**)
• Gastrointestinal tract, gallbladder,
bile ducts , pancreas
• Lung
• Kidney
• Breast
• Melanoma
• Neuroendocrin
Metastatic liver tumors