Contributed by Parmjeet Randhawa, M.D.
PATIENT HISTORY: The patient has a history of a liver mass. No other clinical history is available at this time.

Final Diagnosis (Case 93)

PART 1: LIVER, NEEDLE BIOPSY-
  1. MODERATELY DIFFERENTIATED HEPATOCELLULAR CARCINOMA.
  2. CHRONIC HEPATITIS, CAUSE UNCERTAIN, WITH MILD INFLAMMATORY ACTIVITY, MACROVESICULAR STEATOSIS, AND PORTAL TO PORTAL BRIDGING FIBROSIS (See comment).

Previous Biopsies on this Patient:
None

TPIS Related Resources:
Liver Transplant Topics
Neoplasia Transplant Topics


Gross Description - Case 93

Two (2) consult slides and one (1) consult block.


Microscopic Description - Case 93

The tissue submitted consists of a needle biopsy of the liver with multiple portal triads. The architecture is distorted by focal portal to portal bridging fibrosis. The lobule shows mild to moderate macrovesicular steatosis, with occasional neutrophils. Convincing Mallory' s hyaline, sinusoidal fibrosis and perivenular sclerosis are not observed. There is no evidence for granulomatous inflammation, viral inclusions, duct loss or duct lesions. Also included in the sample are multiple foci of moderately differentiated neoplastic cells, which resemble hepatocytes, are arranged in trabeculae/pseudoglandular forms, and show bile production. The tumor is supplied by aberrant vessels, but no vascular invasion is seen.

The modified hepatitic activity index should be assigned as follows:
MODIFIED HEPATITIS ACTIVITY INDEX (HAI) GRADING
GRADING RANGE SCORE
Periportal or periseptal interface hepatitis (piecemeal necrosis) (0-4) 1
Confluent necrosis (0-6) 0
Focal (spotty) lytic necrosis, apoptosis and focal inflammation (0-4) 2
Portal inflammation. (0-4) 2
TOTAL (0-18) 5/18
STAGING
Fibrosis
(0-6) 4-5/6

The numerical scoring system of the modified histologic activity index (Modified HAI) has been developed to grade the liver biopsies of chronic active hepatitis. This is based on four categories of periportal or periseptal interface hepatitis (piecemeal necrosis), confluent necrosis, focal (spotty) lytic necrosis, apoptosis and focal inflammation, with a total score of up to 18. This scoring system is correlated well with the severity of disease.
A copy of the original paper published by the Journal of Hepatology, 1995 [Hepatology 1995; 22:696-699] is available in the Department of Pathology upon request.

The presence of macrovesicular steatosis and scattered lobular neutrophils suggests that alcohol use, diabetes, and obesity be excluded as a cause of liver disease, even though all the criteria of a steatohepatitis are not satisfied. Viral and metabolic studies would also be of interest, if clinically indicated. The degree of fibrosis is difficult to estimate in peritumoral samples, but is felt to represent Stage 4 of 6 in Ishak et al' s scoring sytem. Clinical correlation with synthetic liver function tests and the degree of portal hypertension is suggested.


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