Hepatocellular Adenoma

Liver Specialty Evening Conference

Matthew M. Yeh, MD, PhD Professor of Pathology Adjunct Professor of Medicine University of Washington, Seattle Case History • A 65 year-old man presents with abdominal pain and abnormal liver tests.

• Images of the abdomen reveals a liver mass.

• History of non-invasive low-grade urothelial carcinoma 2 months ago, s/p TURP.

• No underlying liver diseases or cirrhosis.

• AFP: Normal.

MR Images in Arterial Phase

Non-cirrhotic liver with segment 8/4 lesion. Arterial phase hyperenhancment.

Courtesy of Dr. Neeraj Lalwani, UWMC, Seattle

MR Images in Venous Phase

Non-cirrhotic liver with segment 8/4 lesion. Subtle washout on venous phase.

Courtesy of Dr. Neeraj Lalwani, UWMC, Seattle

MR Images in Delayed Phase

Non-cirrhotic liver with segment 8/4 lesion. Delayed phase also shows subtle washout on venous phase.

Courtesy of Dr. Neeraj Lalwani, UWMC, Seattle

MR Coronal Image in the Delayed Phase

Non-cirrhotic liver, lesion within segment 8/4 associated with PV thrombosis. Suspicion of liver primary vs. metastasis

Courtesy of Dr. Neeraj Lalwani, UWMC, Seattle

Case

• A CT-guided liver biopsy was performed.

Differential Diagnosis • Benign liver lesions – Hepatocellular – Biliary – Miscellaneous

• Malignant liver lesions – Primary • Hepatocellular • Biliary • Other – Metastatic

Differential Diagnosis • Benign liver lesions – Hepatocellular – Biliary – Miscellaneous

• Malignant liver lesions – Primary • Hepatocellular • Biliary • Other – Metastatic 6th most common cancer

Hepatocellular Carcinoma Risk Factors

Traditional Recently Recognized • HBV • HCV • Metabolic • Cirrhosis syndrome and • Alcohol obesity • Aflatoxin

• Hemochromatosis • Alpha-1-antitrypsin deficiency • Hepatocellular adenoma

Malignant Liver Neoplasms in Non-Cirrhotic Liver

Modified from Dr. Zachary Goodman, with permission Malignant Liver Neoplasms in Cirrhosis

Modified from Dr. Zachary Goodman, with permission

Differential Diagnosis of HCC in Liver Biopsy in Background of Cirrhosis

• Cirrhotic nodules • Macroregenerative nodules • HGDN • Cholangiocarcinoma • Combined hepatocellular cholangiocarcinoma • Metastatic neoplasm

Differential Diagnosis of HCC in Liver Biopsy in Background of Non-Cirrhotic Liver

• Metastatic neoplasm • Focal nodular hyperplasia • Hepatocellular adenoma • Fibrolamellar carcinoma • Cholangiocarcinoma • Combined hepatocellular cholangiocarcinoma • Neuroendocrine neoplasm

Histopathology of HCC

• Evidence of hepatocytic differentiation – Neoplastic cells resemble hepatocytes – Canaliculi +/- bile – Pseudoglandular/pseudoacinar and/or trabecular pattern • Evidence of malignancy – Lack of normal structures – Thickened trabecula or plates – Increased unpaired arteries – Focal absence of reticulin fibers – Increased N/C ratio

Pseudoglands in HCC In the Era of Affordable Care Diagnosis of HCC in Liver Biopsy Helpful Features for Hepatocytic Differentiation

• Bile • Mallory-Denk bodies • Alpha-1-antitrypsin globules • Fat • Iron free foci • But, they are not always there

Diagnostic Feature for Hepatocytic Differentiation: Bile

Mallory-Denk bodies

Diagnostic Feature for Hepatocytic Differentiation: A1AT globules Iron Free Foci in HCC

Cirrhosis HCC

HCC Diagnosis of HCC Immunohistochemistry • CK7 (+/-), CK19(+/-) and CK20 (-) • Hepatocytic differentiation – Alpha fetoprotein (AFP) – Hepatocyte specific antigen (Hep Par 1) – Glypican-3 – Arginase 1 (ARG1) • Canalicular staining pattern – Polyclonal CEA – CD10 – Villin • Activation of sinusoidal endothelial cells in hepatocytic neoplasm – CD34 – CD31

Polyclonal CEA: Canalicular Staining Pattern CD10 Canalicular Staining Pattern Hep Par 1 Staining Can Be Focal in HCC CD34

cirrhosis FNH

HCC CC CD34 Staining in HCC May be Focal CD34 in Cirrhosis Periseptal Staining Hepatocellular Adenoma HCC

Reticulin Stain Well-Differentiated HCC

Reticulin Stain

Reticulin Stain

Fatty liver may be misdiagnosed as HCC due to reticulin loss

From Singhi et al. Am J Surg Pathol 2012 Glypican-3 to Distinguish HCC from Benign Hepatocellular Lesions

• Glypican-3 (GPC3) – A cell surface proteoglycan has been shown to be overexpressed in HCC. – To distinguish HCC from benign hepatocellular mass/lesion, and to some extent, from other malignancies Glypican-3

HCC Cirrhosis Glypican-3 Diagnostic Pitfalls of GPC3

• Focal immunoreactivity can be detected in a small subset of cirrhotic nodules. • Also positive in Specificity issue – Melanoma – SCC of lung – non-seminomatous GCT

• Well Differentiated HCC can be negative. • Expression in HCC can be Sensitivity issue focal. GPC-3 expression rate in various types of hepatocellular nodules in the pooled series of 10 studies. Glypican-3

Moderately-Differentiated HCC

Well-Differentiated HCC Sensitivities of IHC Markers in HCC, CC, and Metastatic Carcinoma HCC CC Metastatic Adenocarcinoma Hep Par 1 86-96% ~12% ~14% GPC3 75-88% ~19% ~6% pCEA 50-96% NA NA MOC31 ~14% 67-100% 66-100% CK7 7-20% 78-100% ~36% CK8/18 ~70% ~20% NA CK19 10% or more 44-80% ~64% CK20 ~5% ~11% ~74% CD34 ~95% NA NA From Chan E and Yeh MM, Clin Liv Dis 2010 Diagnosis of HCC Arginase-1 • Arginase (ARG1): A manganese metalloenzyme active in the urea cycle

• Marker for hepatocytes and hepatocellular neoplasms.

Yan et al, Am J Surg Pathol 2010;34:1147–1154 Arginase-1

HCC

Liver Arginase-1 in HCC

HepPar1

Arg-1 GPC3 It’s not a Perfect World

• Hepatoid adenocarcinomas from non- hepatic sites: 4 of 13 (31%) were positive for arginase-1.

Reis H et al, Pathology 2015 Sensitivity, specificity, positive and negative predictive value of Arginase-1, HepPar-1 for the diagnosis of HCC

Sensitivity Specificity PPV NPV Arginase-1 84% 96% 95% 85% HepPar-1 70% 84% 81% 73% Arginase-1 or 84% 80% 88% 83% HepPar-1

Arginase-1 70% 100% 100% 77% and HepPar-1

Radwan and Ahmed Diagnostic Pathology 2012 Arg1, HepPar-1 and GPC3 in FNA specimen

Diagnosis Arg1 (%) HepPar-1 (%) GPC3 (%) HCC (n=29) 23 (79) 24 (83) 24 (83) Metastasis 0 0 3 (10.7) (n=28) Benign (n=5) 5 (100) 5 (100) 0

Timek DT et al, AJCP 2012 Arg1, HepPar-1 and GPC3 in FNA specimen Antibody Well to moderately Moderately to poorly differentiated HCC differentiated HCC (n=7) (n=22) Arg-1 20(91) 3(43) HepPar1 20(91) 4(57) GPC3 20 (91) 5 (71) 3 markers positive 17 (77) 2 (29) 2 markers positive 4 (18) 2 (29) 1 marker positive 1(5) 2 (29) Negative for all 3 markers 0 1 (14)

Timek DT et al, AJCP 2012

Use of GPC3 and Arg-1 in Scirrhous Hepatocellular Carcinoma

Krings G et al., Modern Pathology 2013 Hep Par 1, GPC3, and Arg-1 stainings of scirrhous HCC, classical HCC and ICC

HepPar1 (%) GPC3 (%) Arg-1 (%) Scirrhous HCC 26 79 85 (n=20) Classical HCC 74 69 95 (n=169) Cholangiocarcinoma 7 6 0 (n=16) P-value (scirrhous vs <0.001 0.440 0.189 classical HCC) P-value (scirrhous 0.029 <0.001 <0.001 HCC vs CC)

Krings G et al., Modern Pathology 2013

Chromogranin

Synaptophysin Hep Par 1

TTF-1 Thyroglobulin In Situ Hybridization for Albumin messenger RNA (Albumin ISH) for Hepatocytic Differentiation

• Clear cell HCC: 93% Sensitivity Other for HCC tumors (N=30). commonly positive AFP 30-50% GCT • HCC: 93% (N=42), Lung, colon, Hep Par 1 >90% esophageal, gastric combined use with Hep Par 1 reaches CD10 60-90% Cytoplasmic 100%. pCEA staining in adenoCa GPC3 60-80% NSGCT, melanoma Arg-1 96% Rare Albumin >95% None ISH Oliveira et al, AJSP 2000 Kakar el al, AJCP 2003 From Shahid et al, AJSP 2015

Current Case

Hep Par 1 Arginase-1

Arginase-1 Arginase-1

CD34 CK7 CK19 CK19 Sensitivities of IHC Markers in HCC, CC, and Metastatic Carcinoma HCC CC Metastatic Adenocarcino ma Hep Par 1 86-96% ~12% ~14% GPC3 75-88% ~19% ~6% pCEA 50-96% NA NA MOC31 ~14% 67-100% 66-100% CK7 7-20% 78-100% ~36% CK8/18 ~70% ~20% NA CK19 10% or more 44-80% ~64% CK20 ~5% ~11% ~74% CD34 ~95% NA NA Chan and Yeh, 2010 CK7 in Classic HCC CK7 in Fibrolamellar Carcinoma

More stains?

• Mucin stain:

• Moc-31 stain: More stains?

• Mucin stain: Negative

• Moc-31 stain: Negative

Additional stains were performed at original institute to exclude other sites • Urothelial • Lung • Adrenal • Colonic • Prostate • Neuroendocrine Additional stains were performed at original institute to exclude other sites • Urothelial: Negative • Lung: Negative • Adrenal: Negative • Colonic: Negative • Prostate: Negative • Neuroendocrine: Negative

Melan A Melan A in Melanoma S100 Cam 5.2 Not a Melanoma

• Negative S100 • Positive CAM5.2 and CK7 • Not typical melan-A staining pattern for melanoma Brief Summary IHC Performed by Contributing Pathologists • Hep Par 1: Negative • Arginase-1: Rare • AFP: Negative • CD10: Negative • Polyclonal CEA: Negative

• Extensive metastatic markers: Negative

More IHC?

Glypican-3 Albumin ISH

Courtesy of Dr. Michael Torbenson Summary

• Hep Par 1: Negative • Arginase-1: Rare • AFP: Negative • CD10: Negative • Polyclonal CEA: Negative • GPC3: Positive • Albumin ISH: Positive • Extensive metastatic markers: Negative

Diagnosis

• Hepatocellular Carcinoma Take Home Points

Take Home Points Diagnosis of HCC • H&E • History, history, history….. • Imaging correlation • IHC/special stains – Hepatocytic markers (combination of multiple markers may be necessary) – Markers to exclude CC and metastasis Acknowledgement

• Dr. Xianyong (Sean) Gui, Univ of Calgary

• Dr. Sarag Boukhar, UWMC, Seattle