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Background
This is the most common primary malignant tumor arising within the liver, accounting for >90% of all primary liver cancers. Metastatic tumors to the liver are actually more common, usually from the colon or prostate or breast. It is sometimes erroneously referred to as a hepatoma which should be avoided since this name implies a benign neoplasm. About 350,000 cases per year are diagnosed around the world. It is a global problem with 2-4 annual cases/100,000 in North and South America but 20 annual cases/100,000 around the Mediterranean and 150 annual cases/100,000 in China, Korea, and Taiwan. Males are favored ranging from 2:1 to 8:1.
There is a well-established link with hepatitis B viral infection (HBV) which accounts for the high prevalence throughout the world. In the West, hepatitis C viral infection (HCV) and alcoholism are the main culprits. Several mechanisms have been hypothesized to account for the neoplastic transformation. Because of the association of HBV infection, vaccination programs for children have dramatically decreased the infection rates.
The tumor may present with upper abdominal pain, malaise, weight loss, and fatigue. Depending upon the degree of liver involvement as well as the presence of cirrhosis, there may be jaundice, gastrointestinal bleeding, and fever. Serum alpha-feto protein is elevated in 60-75% of cases. The disease is progressive and death usually occurs within 10 months of initial diagnosis from cachexia, gastrointestinal bleeding, liver failure, or rupture of the tumor with massive hemorrhage.
The tumor may present as a solitary, multiple, or diffusely infiltrative cancer. HCCs have a marked propensity for vascular invasion, especially the portal vein or inferior vena cava. Under the microscope, the tumor grows in seveal patterns ranging from trabecular to an acinar pseudoglandular pattern.
OUTLINE
PATHOGENESIS CHARACTERIZATION GENERAL
Michael Torbenson, MD, etal.
Recent models suggest that hepatocellular carcinoma (HCC) develops through several independent pathways marked by key mutations in the b-catenin or p53 gene. An additional pathway potentially is marked by aberrant expression of a-fetoprotein (AFP).
To see whether these potential markers are expressed independently, we immunostained sequential sections from 55 HCCs. Of the cases, 30 (55%) were positive for 1 or more proteins: AFP, 19 cases (35%); p53, 12 cases (22%); and b-catenin, 9 cases (16%). Seven tumors (13%) were positive for more than 1 protein, with 4 of 7 positive in the same area of tumor and 3 of 7 positive in different areas of the carcinomas. By statistical analysis, expression of the markers was independent of one another and of tumor size.
Concurrent evaluation of p53, b-catenin, and AFP protein expression showed no associations, supporting models in which these proteins might serve as markers of independent pathways in the development of HCC.AFLATOXINS Produced by molds and activated by hepatocytes
Products are intercalated into DNA to form mutagenic adducts with guanosine of p53 gene
Microsomal enzymes responsible for detoxifying aflatoxins are mutated in high risk areas
Acts synergistically with HBV infectionCAVEOLIN Caveolin and Thrombospondin Expression During Hepatocellular Carcinogenesis
Yerian, Lisa M MD; Anders, Robert A MD, PHD; Tretiakova, Maria MD, PHD; Hart, John MD
From the Department of Pathology, University of Chicago Hospitals, Chicago IL.
The American Journal of Surgical Pathology : Volume 28(3) March 2004 pp 357-364 Abstract quote Macroregenerative and dysplastic nodules (MDNs) are hepatocellular carcinoma (HCC) precursor lesions and exhibit distinct vascular profiles relative to adjacent cirrhotic liver. Recent microarray analysis of MDN identified aberrant expression of caveolin-1 and thrombospondin-1, genes suspected to play a role in tumorigenesis at other sites.
We used immunohistochemistry to localize caveolin and thrombospondin expression in 14 MDNs from livers with hepatitis C cirrhosis and in tissue arrays that included samples of MDNs, HCC, and nonneoplastic liver. Hepatocytes were uniformly negative for caveolin. Sinusoidal endothelial cells exhibited increased caveolin expression in MDNs relative to adjacent cirrhotic liver in most (28 of 36, 78%) MDNs evaluated. However, few HCCs showed increased caveolin expression as compared with nonneoplastic liver (5 of 19, 26%). Unpaired arteries showed strong positive endothelial cell staining. Thrombospondin staining was weak or negative in hepatocytes in nearly all (77 of 92, 84%) MDNs and in 46 of 49 HCCs evaluated (94%). Sinusoidal endothelial cells were negative for thrombospondin, but hepatic arteries and MDNs showed positive mural staining; portal veins were positive both in vessel walls and in endothelial cells. The altered expression profiles of these genes identified in microarray analysis are not likely related directly to malignant transformation of hepatocytes but rather to an alteration in the vascular supply to these lesions.
The results illustrate the critical role of histologic techniques in interpretation of microarray data.FHIT FHIT mRNA and protein expression in hepatocellular carcinoma.
Kannangai R, Sahin F, Adegbola O, Ashfaq R, Su GH, Torbenson M.
1Department of Pathology, The Johns Hopkins Hospital, Baltimore, MD, USA.
Mod Pathol. 2004 Jun;17(6):653-9. Abstract quote
Loss of fragile histidine triad (FHIT) gene expression is seen in approximately 50% of hepatocellular carcinomas in China. However, little information is available on FHIT expression in hepatocellular carcinoma in the United States, where carcinogen exposure is generally lower.
Investigations of FHIT mRNA in hepatocellular neoplasms and paired non-neoplastic tissues demonstrated normal-sized FHIT transcripts in all non-neoplastic tissues and in all neoplasms including 11 hepatocellular carcinomas, two fibrolamellar carcinomas, and four benign proliferative lesions. In addition, all but one malignant and all benign neoplasms showed aberrant smaller transcripts. The smaller aberrant transcripts were overexpressed in 6/11 hepatocellular carcinomas and 1/2 fibrolamellar carcinomas. An additional 79 hepatocellular carcinomas, 12 fibrolamellar carcinomas and 15 hepatic adenomas were examined for FHIT expression by immunohistochemistry. No loss of immunostaining was seen in 67/79 (85%) of hepatocellular carcinomas, while a moderate or marked decrease was seen in 12/79 (15%). Fibrolamellar carcinomas and hepatic adenomas showed no loss of FHIT expression.
In conclusion, hepatocellular carcinomas retained expression of normal FHIT mRNA transcripts, but also showed universal expression of smaller sized aberrant transcripts and commonly overexpressed these aberrant transcripts. Loss of FHIT protein expression is relatively uncommon in this cohort from the United States, where exposure to hepatic carcinogens is generally low.FIBRONECTIN
Hepatocellular carcinomas show abnormal expression of fibronectin protein.Torbenson M, Wang J, Choti M, Ashfaq R, Maitra A, Wilentz RE, Boitnott J.
Departments of Pathology (MT, AM, REW, JB) and Surgery (MC), The Johns Hopkins Hospital, Baltimore, Maryland.
Mod Pathol 2002 Aug;15(8):826-30 Abstract quote Fibronectin plays an important role in cell-to-cell adhesion, cell migration, and cell signaling. In the liver, fibronectin expression has been studied primarily as a component of the extracellular matrix, but little information is available on the expression of fibronectin protein in the neoplastic cells of hepatocellular carcinomas (HCCs).
Twenty-four surgically resected HCCs were immunostained with fibronectin. Tumor and normal liver tissues were concurrently analyzed in all cases, and expression in the tumor was evaluated in comparison to the nonneoplastic liver. The average age at resection was 54 +/- 18 years for the 18 men and 6 women. Twenty-one of the cases were classic HCCs including 6 cases that were well differentiated, 12 cases moderately differentiated, and 3 cases poorly differentiated. The remaining 3 cases were moderately differentiated fibrolamellar carcinomas. In the normal liver, fibronectin labeled the sinusoids and weakly to moderately stained the cytoplasm of hepatocytes. In HCCs, 15/24 showed overexpression of fibronectin in the cytoplasm, 8/24 showed no change from the nonneoplastic liver, and one case showed decreased cytoplasmic staining. In addition, an abnormal membranous staining pattern was noted in 16/24 HCCs. In contrast to the HCCs, none of the three fibrolamellar carcinomas showed increased cytoplasmic or membranous staining. Excluding fibrolamellar carcinoma, increased cytoplasmic staining and/or an abnormal membranous staining was noted in 19/21 (90%) of HCCs.
Fibronectin shows abnormal cytoplasmic and/or membranous staining in the majority of HCCs. The implications of fibronectin overexpression are uncertain but may reflect a critical step in tumor genesis.
HBV INFECTION Viral DNA integrated into the host cell genome
Tumors are clonal with respect to these insertions
Viral integration induces genomic instability
HBV X protein acts as a transactivator of cellular and viral promoters and binds to tumor suppressor gene p53Full-length genomic analysis of hepatitis B virus isolates in a patient progressing from hepatitis to hepatocellular carcinoma.
Lin X, Qian GS, Lu PX, Wu L, Wen YM.
Department of Molecular Virology, Shanghai Medical University, Shanghai, China
Med Virol 2001 Jul;64(3):299-304 Abstract quote
In hepatitis B virus (HBV)-endemic countries, the majority of hepatocellular carcinoma (HCC) arises in HBV carriers. High frequency of mutations at nucleotides 1762(A-->T) and 1764(G-->A) in the core promoter region have been described in HCC. Due to the differences in genetic backgrounds, environmental risk factors and random cellular insertion sites, it is difficult to analyze the possible roles of HBV variants detected in different HCC patients.
In a follow-up cohort study, an HBsAg-positive asymptomatic carrier was diagnosed HCC within 4 years. Eleven full-length HBV isolates, three from the first serum sample obtained 4 years pre-HCC, and eight from serum sample, peri-tumor and tumor tissue post-HCC of this individual were sequenced and used to transfect HepG2 cells. When sequences were compared between pre- and post-HCC isolates, no single mutation common to all post-HCC isolates that differed from pre-HCC isolates was found.
Among all 11 isolates, there were 20 predicted amino acid substitutions shared by two or more post-HCC isolates. These were located in the S(5), X(4), core(4), polymerase(4), pre-S1(2) and pre-S2(1) proteins. Possible roles of amino acid substitutions and enhanced replication efficiency in cells transfected by post-HCC isolates are discussed.
CHROMOSOMAL ABNORMALITIES
Allelic alterations in nontumorous liver tissues and corresponding hepatocellular carcinomas from chinese patients.Ho MK, Lee JM, Chan CK, Ng IO.
Hum Pathol. 2003 Jul;34(7):699-705. Abstract quote Allelic imbalance may play an important in tumor progression in hepatocarcinogenesis, but the genetic background of the corresponding nontumorous liver in hepatocellular carcinoma (HCC) is not well defined.
We studied the incidence of loss of heterozygosity (LOH) and microsatellite instability (MSI) by microsatellite analysis in both nontumorous livers and the corresponding tumors, by comparing them with the normal DNA from Chinese patients with resected primary HCCs. We also evaluated the pathologic significance of the alterations. We used 18 highly polymorphic microsatellite markers on chromosomes 1, 3, 4, 7, 8, 9, 13, 16, 17, and 18.
Our results showed that 70.6% (24 of 34) of the HCCs exhibited LOH at 1 or more loci, and that the overall fractional allelic loss (FAL) was 0.169. MSI was observed in only 1 tumor. In contrast, the nontumorous livers of the HCCs showed a very low incidence of LOH, with only a single LOH detected in 1 of 34 (2.9%) of the nontumorous livers, with an overall FAL index of 0.005.
Tumors with LOH at 1 or more loci had significantly more frequent venous invasion (P = 0.019). Allelic loss at locus D9S199 (9p23) was seen more frequently in larger tumors (P = 0.031), and, less significantly, allelic loss at locus D16S516 (16q24.1) was seen more frequently in larger tumors (P = 0.059). LOH was common in predominantly hepatitis B virus-associated HCCs from Chinese patients. However, LOH or MSI in the corresponding cirrhotic or noncirrhotic livers was uncommon.
Genomic instability in chronic viral hepatitis and hepatocellular carcinoma
Maria Pina Dore, MD Giuseppe Realdi, MD Daniela Mura, MD Angela Onida, MD Giovanni Massarelli, MD Giuseppe Dettori, MD David Yates Graham, MD Antonia Rogado Sepulveda, MD, PhD
Hum Pathol 2001;32:698-703. Abstract quote
Chronic hepatitis may progress to cirrhosis and hepatocellular carcinoma (HCC). Progressive accumulation of mutations and genomic instability in chronic viral hepatitis might flag an increased risk of HCC development.
Genomic instability at dinucleotide microsatellite loci in chromosomes 2, 13, and 17 and at 2 mononucleotide repeat loci was examined in liver tissues from 41 patients, including 30 without HCC (18 patients with chronic hepatitis and 12 with cirrhosis) and 11 with HCC. Genomic instability was detected in 51% of the 41 cases. Allelic imbalance at informative dinucleotide loci occurred in 37% of the cases. In 14 cases (34%), allelic imbalance was detected in chronic hepatitis or cirrhosis without HCC. Allelic imbalance at the chromosome 13 locus was detected in 50% of the cases of chronic hepatitis C. Allelic imbalance at the TP53 chromosome locus and/or at the chromosome 13 locus was significantly more frequent than alterations at the chromosome 2 locus (P = .026). Low-level microsatellite instability was found in 20% of all cases examined and high-level microsatellite instability in 3 patients (7.5%), including 2 cases of chronic hepatitis and 1 case of cirrhosis.
Our results show that allelic imbalance occurs frequently in hepatitis-related HCC as well as in chronic hepatitis in patients without HCC. Allelic imbalance at the D13S170 chromosome 13 locus (13q31.2) occurs frequently in chronic hepatitis, suggesting that genomic alterations affecting the long arm of chromosome 13 might be used to monitor the natural progression of chronic hepatitis-associated liver carcinogenesis.
Detection of chromosomal aberrations in well-differentiated hepatocellular carcinoma by bright-field in situ hybridization.Wilkens L, Bredt M, Flemming A, Mengel M, Klempnauer J, Kreipe H, Flemming P.
Department of Pathology, Medizinische Hochschule, Hannover, Germany.
Mod Pathol 2002 Apr;15(4):470-5 Abstract quote Differentiation between well-differentiated hepatocellular carcinoma (HCC) and nonmalignant lesions with increased cellular proliferation may be difficult in needle biopsies. Based on recurrent chromosome aberrations known for HCC, we developed a nonfluorescent in situ hybridization technique that allows combination with morphological analysis in bright-field microscopy.
Fourteen biopsies of HCC and 31 samples of regenerative nodules (n = 10), chronic hepatitis (n = 10), fibrosis or cirrhosis of unknown origin (n = 5), focal nodular hyperplasia (n = 2), primary biliary cirrhosis (n = 2), steatosis (n = 1), and adenomatous hyperplasia (n = 1) were analyzed with probes specific for the centromeric regions of chromosomes 1, 6, 7, and 8. After microwave pretreatment and in situ hybridization, signals were detected using a tyramine-based system and AEC as substrate. Evaluation of signals was done by conventional bright-field microscopy. Using this approach, aberrant counts were seen for at least one chromosome in 12/14 cases of HCC. In contrast, none of the nonmalignant lesions revealed aberrant counts for any of the chromosomes analyzed.
In conclusion, this new combination of in situ hybridization and tyramine amplification allows fast and reliable evaluation of chromosome aberrations in a histomorphological context similar to paraffin immunohistochemistry. Registration of imbalances contributes to a reliable differentiation between malignant and nonmalignant lesions of the liver.
Identification of four distinct regions of allelic imbalances on chromosome 1 by the combined comparative genomic hybridization and microsatellite analysis on hepatocellular carcinoma.Leung TH, Wong N, Lai PB, Chan A, To KF, Liew CT, Lau WY, Johnson PJ.
Department of Clinical Oncology, Sir Y.K. Pao Centre for Cancer, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong.
Mod Pathol 2002 Nov;15(11):1213-20 Abstract quote Frequent chromosome 1 abnormalities detected in human hepatocellular carcinoma have been implicated in early genetic events of liver carcinogenesis. Recurrent loss of 1p with a common deleted region 1p36-p34 has been reported from microsatellite analysis, whereas common gain of the whole chromosome q-arm was described from several comparative genomic hybridization studies. The relationships between copy number changes and allelic status however remains unclear.
In this study, we have conducted a simultaneous comparative genomic hybridization and microsatellite analysis study on chromosome 1 in 31 hepatocellular carcinoma cases. Microsatellite analysis revealed frequent loss of heterozygosity on 1p at loci D1S468 (74%), D1S450 (67%), D1S2667 (65%), D1S2697 (75%), D1S199 (52%), and D1S234 (67%) corresponded to the distal 1p36 region and coincided with 12 cases (86%) that presented losses on 1p by comparative genomic hybridization analysis. Although comparative genomic hybridization indicated a common deleted region of 1p36-p35 in the current series, microsatellite analysis has refined the smallest overlapping region (SOR) to 1p36.13-p36.22. Gain of 1q as revealed by comparative genomic hybridization suggested low and high-level gains, and cases that displayed an amplicon below the heterochromatic region 1q21-q25.
Common allelic imbalances of polymorphic markers D1S2635 (64%), D1S484 (67%), D1S2878 (65%), D1S196 (70%), D1S249 (64%) D1S2785 (75%), D1S2842 (73%) and D1S2836 (74%) that corresponded to the regions 1q23.1-q24.2, 1q32.1 and 1q43-q44 were detected. Three distinct regions of allelic imbalances were thus suggested on recurring 1q gain found in hepatocellular carcinoma. Furthermore, microsatellite analysis has enabled a mapping of common overrepresented regions and suggested SOR on 1q23.1-q23.3 (D1S2635-D1S2878), 1q25.1-q31.1 (D1S452-D1S238), and 1q43 (D1S2785-D1S2842).
Our current study has refined chromosome 1 aberrations in hepatocellular carcinoma to four regions of allelic imbalances. The SORs delineated should provide basis for further molecular investigation in hepatocarcinogenesis on genes residing on these chromosomal regions.
CIRRHOSIS Stimulation of hepatocellular division with ongoing necrosis and inflammaiton Occurrence of hepatocellular carcinoma and decompensation in western European patients with cirrhosis type B. The EUROHEP Study Group on Hepatitis B Virus and Cirrhosis.
Fattovich G, Giustina G, Schalm SW, Hadziyannis S, Sanchez-Tapias J, Almasio P, Christensen E, Krogsgaard K, Degos F, Carneiro de Moura M, et al.
Istituto di Semeiotica e Nefrologia Medica, University of Verona, Italy.
Hepatology 1995 Jan;21(1):77-82 Abstract quote
To examine the morbidity of compensated cirrhosis type B, a cohort of 349 Western European, white patients (86% men; mean age, 44 years) with biopsy-proven cirrhosis was followed up for a mean period of 73 months and was studied for occurrence of hepatocellular carcinoma (HCC) and decompensation.
At entry into the study all patients were tested for hepatitis B e antigen (HBeAg; 34% of patients were HBeAg-positive) and antibody to hepatitis delta virus (anti-HDV; 20% of patients were anti-HDV-positive); 48% of 252 patients tested were hepatitis B virus (HBV)-DNA-positive. During follow-up HCC developed in 32 (9%) of the 349 patients and decompensation was observed in 88 (28%) of 317 tumor-free patients. Five years after diagnosis, the probability of HCC appearance was 6% and the probability of decompensation was 23%. After the first episode of decompensation the probability of survival was 35% at 5 years. Cox's regression analysis identified three variables that independently correlated with HCC: age, serum levels of platelets, and liver firmness on physical examination. HBV (HBeAg or HBV-DNA) and HDV (anti-HDV) markers at presentation had no prognostic value for the development of HCC. In conclusion, a high proportion of patients with HBsAg-positive compensated cirrhosis do not experience worsening of their condition for several years, but once decompensation occurs life expectancy is poor. European, white patients with compensated cirrhosis type B are at consistent risk for HCC.
Prognostic factors for HCC reflect an advanced stage of cirrhosis and support the hypothesis that development of a tumor could be the likely consequence of long-standing hepatic disease.
FAS Expression of Fas and Fas-related molecules in human hepatocellular carcinoma
Sug Hyung Lee, etal.
Hum Pathol 2001;32:250-256.
Many tumor cells, including hepatocellular carcinoma (HCC), express both Fas and its ligand on their surfaces, and it has remained a mystery why such cells do not spontaneously become apoptotic.
In the current study, we analyzed the alterations of Fas structure and the expression of Fas and Fas ligand (FasL) and of Fas pathway inhibitors, including soluble Fas (sFas), Fas-associated phosphatase-1 (FAP-1), and bcl-2, in 50 cases of human HCC.
Monoallelic loss of the Fas gene, as determined by loss of heterozygosity with intragenic polymorphisms, was observed in 5 of the 34 informative cases (15%), but none of the 50 cases showed Fas gene mutation. Expression of Fas and FasL was detected in 44 (88%) and 50 (100%) cases, respectively. sFas messenger RNA, as analyzed by in situ reverse-transcription polymerase chain reaction was expressed in 42 of the 50 cases (84%), and FAP-1 expression was observed in 40 of the 50 cases (80%).
In contrast, none of the 50 cases showed bcl-2 expression.
Our results showed that the majority of the HCCs (88%) coexpressed a death receptor, Fas and its cognate ligand, FasL, but all HCCs showed one or more alterations of the Fas pathway molecules known to inhibit Fas-mediated apoptosis.
These findings suggest that the expression of sFas and FAP-1 and, in part, loss of Fas expression, rather than Fas gene alteration or bcl-2 expression, may be involved in the Fas resistance of HCC in vivo and that these mechanisms may play important roles in the pathogenesis of human HCC.
METALLOPRO-TEINASES
- Association of E-cadherin, matrix metalloproteinases, and tissue inhibitors of metalloproteinases with the progression and metastasis of hepatocellular carcinoma.
Gao ZH, Tretiakova MS, Liu WH, Gong C, Farris PD, Hart J.
1Department of Pathology and Laboratory Medicine, University of Calgary and Calgary Laboratory Services, Calgary, AB, Canada.
Mod Pathol. 2006 Apr;19(4):533-40. Abstract quote
Molecular markers can provide additional information to traditional histomorphological evaluation for the assessment of tumor progression and predicting the likelihood of invasion and metastasis in various types of malignancies.
We studied the association of E-cadherin, matrix metalloproteinases (MMPs), and tissue inhibitors of metalloproteinase with the progression and metastasis of hepatocellular carcinoma. Tissue microarray including six normal livers, 14 cirrhotic livers, 39 macroregenerative nodules, 16 dysplastic nodules, 22 grade I hepatocellular carcinomas, 43 grade II hepatocellular carcinomas, seven grade III hepatocellular carcinomas, and 10 metastatic hepatocellular carcinomas were stained immunohistochemically with antibodies against MMPs -1, -2, -3, -7, -9, tissue inhibitors of metalloproteinase-1, -2, -3, and E-cadherin. The intensities of staining were scored manually by two pathologists and verified by the Chromavision Automated Cellular Imaging System. Compared with normal liver, cirrhotic liver had significantly lower E-cadherin and tissue inhibitors of metalloproteinase-1 but higher MMP-1 and -7, which suggest a more favorable environment for tumor invasion and metastasis. Grade I and grade II hepatocellular carcinomas demonstrated high E-cadherin and decreased MMP-3 and -9, which may explain the rarity of extrahepatic metastasis in low-grade hepatocellular carcinomas despite the high circulatory volume of the liver.
The histological progression from dysplastic nodule to well-differentiated hepatocellular carcinoma and to less differentiated tumors was associated with a gradual decrease in tissue expression of E-cadherin, tissue inhibitors of metalloproteinase-2 and -3. Metastatic hepatocellular carcinomas showed significantly lower level of tissue inhibitors of metalloproteinase-1, -2, -3 but higher level of MMP-7.
These data suggest that tissue expression of E-cadherin, certain MMPs, and tissue inhibitors of metalloproteinases could be useful markers to predict the progression and metastasis of hepatocellular carcinoma.METASTATIC TUMOR ANTIGEN I
Overexpression of metastatic tumor antigen 1 in hepatocellular carcinoma: Relationship to vascular invasion and estrogen receptor-alpha.
Moon WS, Chang K, Tarnawski AS.
Department of Medicine, Veterans Administration Medical Center, Long Beach, California, USA.
Hum Pathol. 2004 Apr;35(4):424-9. Abstract quote
The morbidity and mortality experienced by cancer patients is mainly due to the invasion and metastasis of the primary tumor.
Recently, a potential metastasis-associated gene and its product, the metastatic tumor antigen 1 (MTA1), were identified; this gene has been found to be overexpressed in a variety of cancers. MTA1 is also known as a potent co-repressor of estrogen receptor element transcription in breast cancer cells. The expression of MTA1 in hepatocellular carcinoma (HCC) and its potential relationship to metastasis and to estrogen receptor alpha (ER-alpha) expression has not been examined, forming the basis for this study. Paraffin sections of 45 HCC specimens, 4 different HCC cell lines, and normal hepatocyte cell line (h NHeps) were immunostained with MTA1 and ER-alpha antibodies. In addition, we examined, by Western blotting, the MTA1 and ER-alpha expression levels in 4 human HCC lines (HepG2 [wild p53], HLE, HLF, and HuH-7 [mutant p53]). MTA1 was overexpressed in HCC cells versus nonmalignant hepatocytes in 31 of 45 HCC specimens (69%). Its expression was predominantly localized to the nucleus or cytoplasm of HCC cells. Nineteen of 20 HCC (95%) specimens with vascular invasion displayed strong MTA1 expression.
Overexpression of MTA1 also significantly correlated with large tumor size. The cytoplasmic and nuclear immunoreactivity for ER-alpha was present in HCC specimens in 46% and 12%, respectively. Expression of MTA1 inversely correlated with the nuclear localization of ER-alpha. There was no marked difference in MTA1 and ER-alpha expression levels between HCC cell line expressing wild-type p53 and cell line with mutated p53 HCC.
In conclusion, these findings indicate that overexpression of MTA1 is associated with HCC growth and vascular invasion. Nuclear translocation of ER-alpha inversely correlated with MTA1 expression, suggesting negative regulatory mechanisms.METHYLATION
Expression of DNA methyltransferases in multistep hepatocarcinogenesis.Choi MS, Shim YH, Hwa JY, Lee SK, Ro JY, Kim JS, Yu E.
Departments of Pathology, Internal Medicine, and Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea and Department of Biological Sciences and Bio/Molecular Informatics Center, Konkuk University, Seoul, Korea.
Hum Pathol 2003 Jan;34(1):11-7 Abstract quote Hypermethylation of cell cycle regulators and increased DNA methyltransferase 1 (Dnmt1) mRNA level have been reported in hepatocarcinogenesis. However, the expression of Dnmts has not yet been examined in hepatocellular carcinomas (HCCs).
We examined 13 cases of HCCs in dysplastic nodules (DNs) and 28 cases of advanced HCCs for Dnmt1 and Dnmt3a, and compared the results with those of 9 cases of low-grade DNs, 24 cases of high-grade DNs, and 59 cases of nonneoplastic liver tissues from 59 cases of surgically resected livers by immunohistochemical staining.
Nuclear expression of Dnmt1 was increased significantly in all HCCs in DNs and advanced HCCs compared with those of nonneoplastic livers, low-grade DNs, and high-grade DNs (P <0.05). Nuclear expression of Dnmt3a was not detectable in nonneoplastic liver and low-grade DN, whereas it was observed in high-grade DNs (7 of 24, 29.2%), HCCs in DNs (7 of 13, 53.8%), and advanced HCCs (11 of 28, 39.3%). Different from Dnmt1 immunostaining, cytoplasmic immunoreactivity for Dmnt3a was significantly decreased or absent in 13 of 24 cases of high-grade DNs (54.1%), 12 of 13 cases of HCCs in DNs (92.3%), and 22 of 28 cases of advanced HCCs (78.6%), compared with nonneoplastic livers and low-grade DNs (P <0.05).
Our data suggest that Dnmt1 and Dnmt3a play a role in the early stage of hepatocarcinogenesis and that dysregulation of Dnmt3a may be involved in the progression of HCC. Furthermore, the significantly decreased cytoplasmic immunoreactivity for Dnmt3a in high-grade DNs and HCCs can be used as a diagnostic adjunct.
PROTEASES
HGF, MET, and Matrix-Related Proteases in Hepatocellular Carcinoma, Fibrolamellar Variant, Cirrhotic and Normal Liver.Schoedel KE, Tyner VZ, Kim TH, Michalopoulos GK, Mars WM.
Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
Mod Pathol 2003 Jan;16(1):14-21 Abstract quote Fibrolamellar variant is an uncommon subcategory of hepatocellular carcinoma with a better prognostic outcome. Proteinases and growth factors that are involved in the remodeling of extracellular matrix may influence the behavior of cancers.
To determine whether these factors contribute to the distinct etiologies of fibrolamellar hepatocellular carcinoma and traditional hepatocellular carcinoma, we assayed hepatocyte growth factor, the hepatocyte growth factor receptor, and two hepatocyte growth factor activators, hepatocyte growth factor activator and urokinase-type plasminogen activator, in hepatocellular carcinoma, fibrolamellar hepatocellular carcinoma, cirrhotic liver and normal liver. In addition, we examined the urokinase-type plasminogen activator receptor, the type 1 plasminogen activator inhibitor, plasmin, fibrinogen, and the type IV matrix metalloproteinases.
Eighteen hepatocellular carcinomas and 11 fibrolamellar hepatocellular carcinomas were obtained as paraffin embedded sections from the University of Pittsburgh Department of Pathology. Frozen tissues from a subset of cases (9 hepatocellular carcinomas, 4 fibrolamellar hepatocellular carcinomas, 12 cirrhotic livers and 2 normal livers) were also available for analysis. Antibodies against urokinase-type plasminogen activator, urokinase-type plasminogen activator receptor, hepatocyte growth factor and hepatocyte growth factor receptor were used to analyze immunoperoxidase stained slides from the paraffin blocks. Western blot analyses using antibodies against hepatocyte growth factor, hepatocyte growth factor receptor, phosphotyrosine, hepatocyte growth factor activator, urokinase-type plasminogen activator receptor, urokinase-type plasminogen activator, plasminogen activator inhibitor-1, fibrinogen and plasmin were performed on membrane-enriched fractions from the frozen tissue, as was collagen zymography for matrix metalloproteinase-2 and matrix metalloproteinase-9.
The most notable findings are as follows: hepatocyte growth factor activator was only detected in malignant tissue but not cirrhotic liver or normal liver. Although hepatocyte growth factor was detected in most samples, it was significantly elevated in 5/9 hepatocellular carcinomas. Furthermore, 8/9 fibrolamellar hepatocellular carcinomas demonstrated hepatocyte growth factor receptor levels similar to normal, whereas 8/9 hepatocellular carcinomas and 11/12 cirrhotic livers exhibited either an increase or decrease. In contrast, active matrix metalloproteinase-2, which was absent in normal liver, was elevated in fibrolamellar hepatocellular carcinoma as compared to cirrhotic liver and conventional hepatocellular carcinoma. Surprisingly, 10/12 cirrhotic livers and 2/4 fibrolamellar hepatocellular carcinomas but only 1/9 hepatocellular carcinomas were enriched for plasmin.
The combined data suggest that the hepatocyte growth factor and plasmin systems tend to be operative in hepatocellular carcinoma and cirrhotic liver, more than fibrolamellar hepatocellular carcinoma. Furthermore, matrix turnover appears to be a more prominent feature of fibrolamellar hepatocellular carcinoma.
These findings provide insight into the behavioral differences between hepatocellular carcinoma and the fibrolamellar variant.
p21
High expression of p21 is correlated with human hepatocellular carcinoma in patients with hepatitis C virus-associated chronic liver diseases.Wagayama H, Shiraki K, Sugimoto K, Ito T, Fujikawa K, Yamanaka T, Takase K, Nakano T.
First Department of Internal Medicine, Mie University School of Medicine, Tsu 514-8507, Japan.
Hum Pathol 2002 Apr;33(4):429-34 Abstract quote p21(WAF1/CIP1) (p21) protein is a universal inhibitor of cyclin-dependent kinases and is regulated transcriptionally by p53, which is activated by DNA stress. Hepatocytes in chronic hepatitis receive several DNA stresses by lymphocytes and Kupffer cells.
Therefore, we analyzed p21 expression of hepatocytes in hepatitis C virus (HCV)-associated chronic liver diseases and investigated the possible involvement of p21 in hepatocarcinogenesis. We examined p21 expression in 35 cases of HCV-associated chronic hepatitis and 25 cases of HCV-associated liver cirrhosis by immunohistochemical analysis. The p21 labeling index (LI) was calculated as the ratio of positive cells to total cells. p21-positive hepatocytes were more numerous in areas of intense inflammation and spotty necrosis and areas close to fibrosis, and were increased according to the degrees of grading and staging. The p21 LI with liver cirrhosis was significantly higher than that with chronic hepatitis (14.4 +/- 5.9 versus 11.1 +/- 4.2, P = 0.014). The cumulative incidence of hepatocellular carcinoma (HCC) was significantly higher in the p21 LI >/=14% group than in the p21 LI <14% group (P = 0.0079). Multivariate analysis demonstrated that p21 expression can be recognized as an independent significant factor for HCC development (relative risk 5.00, P = 0.039). p21 LI decreased significantly after interferon therapy.
These results suggested that p21 is up-regulated by the stress of inflammation and fibrosis in HCV-associated chronic liver diseases and that high p21 expression might be related to hepatocarcinogenesis in cirrhotic patients.
SURVIVIN
Nuclear translocation of survivin in hepatocellular carcinoma: a key to cancer cell growth?
Moon WS, Tarnawski AS.
Department of Medicine, Veterans Administration Medical Center, Long Beach, CA 90822, USA.
Hum Pathol. 2003 Nov;34(11):1119-26. Abstract quote
Survivin is a recently described anti-apoptosis protein and regulator of cell division. Its expression and localization in hepatocellular carcinoma (HCC) and in normal liver tissue has not been fully elucidated.
We examined the expression of survivin, Fas, proliferating cell nuclear antigen (PCNA), and apoptosis in 47 specimens of hepatocellular carcinoma (HCC) and surrounding nonmalignant hepatic tissues. To further determine the relationship between survivin expression and cell proliferation and apoptosis, we performed double immunostaining for survivin and PCNA TUNEL staining in the same HCC specimens. Positive immunostaining for survivin was present in 35 of 47 (74%) HCCs. Twenty-two of 35 survivin-positive HCCs (63%) showed punctate nuclear staining in HCC cells, and the remaining 13 showed predominant cytoplasmic staining. In contrast, nonmalignant hepatocytes showed only cytoplasmic staining. HCC cells had significantly higher PCNA-labeling and apoptotic indices compared with the case of nonmalignant hepatic tissue (P<0.001). Furthermore, nucleus-positive HCC specimens for survivin showed the highest PCNA labeling index. The nuclear localization of survivin in HCC cells correlated with tumor cell de-differentiation with the exception of the HepG2 cell line. Survivin expression was inversely associated with apoptosis and was strongly associated with Fas expression (P=0.01). All 4 HCC cell lines examined showed survivin expression and punctate nuclear localization.
Our results indicate that survivin is localized to the cytoplasm in quiescent nonmalignant liver cells to suppress apoptosis and translocates into the nucleus in HCC cells. In conclusion, translocation of survivin from the cytoplasm to the nucleus may constitute an important regulatory mechanism for cell proliferation and differentiation in HCC.TRANSFORMING GROWTH FACTOR BETA II
Expression of Transforming Growth Factor-beta1 and Transforming Growth Factor-beta Receptors in Hepatocellular Carcinoma and Dysplastic Nodules.Paik SY, Park YN, Kim H, Park C.
Department of Pathology and Brian Korea 21 Project for Medical Science, Yonsei University, College of Medicine, Seoul, South Korea.
Mod Pathol 2003 Jan;16(1):86-96 Abstract quote In this study we analyzed by immunohistochemistry the expression of TGF-beta1 protein and TGF-beta receptors I and II in 4 low-grade dysplastic nodules, 2 high-grade dysplastic nodules, 6 early, 22 small, and 62 advanced hepatocellular carcinomas.
The expression of TGF-beta1 protein by hepatocytes was decreased in advanced hepatocellular carcinoma compared with small or early hepatocellular carcinoma(P <.05). Frequent and intense staining of TGF-beta1 protein was noted in the sinusoidal endothelium of advanced hepatocellular carcinomas despite of its decreased staining in hepatocellular carcinoma cells. Reduced expression of TGF-beta receptors I and II compared with surrounding nontumorous tissue were noted from the early hepatocellular carcinoma stage suggesting that down-regulation of TGF-beta receptors is correlated with progression from premalignant to malignant phenotype. Reduced expression of both TGF-beta1 and TGF-beta receptor II in neoplastic hepatocytes were also significantly correlated with increased tumor size and increased proliferative activity(P <.05).
These findings suggest that during hepatocarcinogenesis, the inhibitory effects of TGF-beta1 protein on hepatocellular carcinoma cells is outweighed by its effects on stromal elements, which, overall, contributes indirectly to a tumor growth stimulatory environment. Also, the growth-inhibitory effects of TGF-beta1 may have been further negated by reduced TGF-beta receptors on hepatocellular carcinoma cells.
Smad4 overexpression in hepatocellular carcinoma is strongly associated with transforming growth factor beta II receptor immunolabeling.Torbenson M, Marinopoulos S, Dang DT, Choti M, Ashfaq R, Maitra A, Boitnott J, Wilentz RE.
Departments of Pathology, Internal Medicine, and Surgery, The Johns Hopkins Hospital, Baltimore, MD, and Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX
Hum Pathol 2002 Sep;33(9):871-6 Abstract quote In the normal liver, the transforming growth factor beta (TGF-beta) signaling pathway plays an important role in inhibiting hepatocyte growth. This effect is mediated through Smad4 (or Dpc4), a tumor-suppressor gene that affects gene transcription and controls cell growth. A loss of Smad4 is associated with carcinoma in a number of other organs, including the pancreas and colon. Despite these facts, several recent studies using cDNA microarrays have surprisingly shown overexpression of Smad4 in hepatocellular carcinoma (HCC). Because Smad4 plays a central role in the TGF-beta signaling pathway, we hypothesized that activation of the TGF-beta signaling pathway may explain Smad4 overexpression.
To investigate this, 21 surgically resected HCCs were immunostained with antibodies to Smad4 and TGF-beta receptor II. Tumor and normal liver tissues were stained in all cases, and expression in the tumor was scored in comparison to the nonneoplastic liver. Thirteen hepatic adenomas were also immunostained as a control group. The average age at resection was 58 +/- 16 years for the 17 men and 4 women with HCC. TGF-beta receptor II was weakly expressed in the hepatocyte cytoplasm of all normal livers and was overexpressed in 10 of 21 HCCs. Of these 10 HCCs increased Smad4 immunolabeling was also present in 10 of 10 cases.
In contrast, of the 11 of HCCs that did not show TGF-beta overexpression, only 1 showed increased Smad4 immunolabeling. Increased TGF-beta receptor II and Smad4 labeling was associated with a worse nuclear grade and increased mitotic activity. For the hepatic adenomas, the 13 women had an average age at resection of 36 +/- 10 years. Whereas 2 adenomas showed over expression of TGF-beta receptor II, there was no Smad4 overexpression in any case. In conclusion, increased Smad4 protein expression in HCC is tightly linked to overexpression of TGF-beta II receptors and is associated with increased mitoses and a worse nuclear grade. Hepatic adenomas only rarely show overexpression of TGF-beta II receptors and did not show increased Smad4 labeling.
The results from this study indicate that Smad4 protein overexpression is present in a subset of HCCs and is strongly correlated with immunostaining for TGF-beta II receptor, findings that may represent activation or dysregulation of the TGF-beta signaling pathway.
VASCULAR ENDOTHELIAL GROWTH FACTOR
Overexpression of VEGF and angiopoietin 2: a key to high vascularity of hepatocellular carcinoma?Moon WS, Rhyu KH, Kang MJ, Lee DG, Yu HC, Yeum JH, Koh GY, Tarnawski AS.
Department of Pathology and Institute for Medical Sciences, Chonbuk National University, Medical School, Chonju, Korea.
Mod Pathol. 2003 Jun;16(6):552-7. Abstract quote Hepatocellular carcinoma (HCC) is becoming one of the most common malignant tumors worldwide and is characterized by a high vascularity. Angiogenesis, formation of new microvessels, is critical for the growth and progression of various human solid tumors. Vascular endothelial growth factor (VEGF) and angiopoietins (Ang1 and Ang2) are endothelial cell-specific vasculogenic and angiogenic growth factors, but their expression and roles in HCC have not been extensively explored.
The aim of this study was to determine the expression and cellular localization of VEGF, Ang1, and Ang2 in specimens of resected human HCC using in situ hybridization and immunohistochemical staining and to examine their relationship to microvessel density (MVD) and tumor size.
We also investigated whether mutation of p53 protein might affect the expression of the above angiogenic growth factors. VEGF and Ang2 were strongly expressed and localized predominantly to cancer cells, whereas Ang1 was detected in supportive cells of large blood vessels, stromal cells, endothelial cells, and tumor cells. Expression of the VEGF protein and the Ang2 (but not Ang1) mRNA were strongly correlated with MVD (P <.05, P =.001) and tumor size (P <.05). There was also a strong correlation between VEGF protein and Ang2 mRNA expression (P <.001). However, no significant correlation was found between overexpression of p53 and the expression of VEGF, angiopoietins, or MVD.
These findings suggest that overproduction of the angiogenic growth factors VEGF and Ang2 by HCC cells may increase vascularity and tumor growth in a paracrine manner. Our findings also suggest that interaction between VEGF and Ang2 may play a critical role in tumor angiogenesis in HCC.
CLINICAL VARIANTS CHARACTERIZATION MULTIPLE TUMOR NODULES
- Clonal relationship of tumor nodules in hepatocellular carcinoma: a hierarchical clustering analysis of comparative genomic hybridization data.
Wong QW, Wong N, Lai PB, To KF, Wong N.
Department of Anatomical and Cellular Pathology, The Chinese University of Hong Kong, Shatin, NT, SAR Hong Kong, China.
Hum Pathol. 2005 Aug;36(8):893-8. Abstract quote
Information on the clonal relationship between tumor nodules in patients diagnosed with hepatocellular carcinoma (HCC) holds prognostic significance in the prediction of recurrence and postoperative treatment.
Here, we investigated the clonal relationships in 11 focal nodules from 5 patients with HCC by comparative genomic hybridization (CGH) and spectral karyotyping. CGH analysis indicated tumor nodules in 5 (100%) of 5 cases to share similar patterns of genomic imbalances, suggesting nodules to be clonally related. This clonal relationship was further substantiated in 2 cases, where spectral karyotyping analysis indicated identical structural rearrangements between focal tumors. Few studies have attempted to differentiate multicentric growth from intrahepatic dissemination in HCC using CGH analysis; however, data interpretation remained subjective. In this study, we have extended our data to include published CGH findings on 57 nodules derived from 19 HCC cases.
Simulation of CGH findings by unsupervised 2-way hierarchical clustering indicated tumor nodules in 20 (83.3%) of 24 cases to cluster concordantly, signifying a high incidence of clonal similarity.
In sum, bioinformatic analysis of genomic profiles may represent a reliable research tool in analyzing clonal relationships among tumor nodules.
HISTOLOGICAL TYPES CHARACTERIZATION GENERAL The pathologist has the additional difficult task of differentiating several precursor lesions from hepatocellular carcinoma (HCC). These dysplastic nodules were once referred to as adenomatous hyperplasia. The most important message is fully developed malignant change even in a focus of less than 1 mm is diagnostic for HCC in the setting of a cirrhotic liver
Mallory bodies present in 20% of tumors, indistinguishable from alcoholic hyaline
Non-Mallory cytoplasmic globules present in 20%, usually PAS positive and diastase resistant (globules of alpha-1-antitrypsin)
- Vascular invasion and herniation by hepatocellular carcinoma in cirrhosis: A wolf in sheep's clothing?
Quaglia A, Etessami N, Sim R, Difford J, Dhillon AP.
Department of Histopathology, Royal Free Hospital, London, United Kingdom.
Arch Pathol Lab Med. 2005 May;129(5):639-44. Abstract quote
CONTEXT: Vascular invasion is an important diagnostic and prognostic feature of hepatocellular carcinoma (HCC) in cirrhosis. Intravascular free-floating tumor clusters (IvCs) of HCC are found histologically in the vicinity of HCC. Thrombus formation is not seen morphologically in association with these IvCs, which are usually covered by endothelium.
OBJECTIVE: Our hypothesis is that these IvCs are the result of a nondestructive form of vascular invasion by HCC, and we tried to define this aspect of microvascular invasion more accurately.
DESIGN: Tissue sections were stained with hematoxylin-eosin, and consecutive sections were stained for fibrin (Martius scarlet blue, fibrinogen), platelets (factor XIIIa), smooth muscle actin, and endothelium (CD34). We studied cirrhotic livers removed at transplantation between 1997 and 1999. Of the livers studied, 35 of 81 consecutive cirrhotic livers contained HCC, and 17 showed microscopic vascular invasion. Five of these 17 cases showed IvCs and were subjected to the study.
MAIN OUTCOME MEASURE: Presence or absence of thrombus formation in association with IvC.
RESULTS: Usually, IvCs were covered by endothelium, and no associated thrombus formation was seen. In 1 case of HCC, thrombus formation was seen focally in association with disruption of the endothelial coating.
CONCLUSIONS: We propose that the endothelial-lined trabecular structure of HCC everts, frondlike, via vascular structures within the tumor capsule into peritumoral vascular lumens without destruction of the endothelial coating. This may protect these HCC tumor projections from thrombus formation but may also act as a barrier to tumor extravasation, and this may be exploited from a therapeutic point of view.Primary Liver Carcinoma in Genetic Hemochromatosis Reveals a Broad Histologic Spectrum
Mohib Morcos, MD
Sylvie Dubois, MSc
Marie-Pierre Bralet, MD
Jacques Belghiti, MD
Claude Degott, MD
Benoît Terris, MDAm J Clin Pathol 2001;116:738-743 Abstract quote
Hepatocellular carcinoma (HCC) is a well-known complication of genetic hemochromatosis (GH). However, the frequency of primary liver carcinoma (PLC) with biliary differentiation, such as cholangiocarcinoma (CC) and combined hepatocholangiocarcinoma (CHCC), in GH remains unclear. We analyzed the histologic type of 20 PLCs occurring in the background of GH; all patients were homozygotic for the C282Y mutation. Ten were depleted of iron by successive phlebotomies, while the remaining 10 were untreated. Histologically, 13 cases were classified as HCC, 3 as CC, and 4 as CHCC. Immunohistochemical detection of Hep Par 1, cytokeratin 19 (CK19), and MUC1 supported this classification; PLC with biliary differentiation was immunoreactive for MUC1 in 86% (6/7) of cases and for CK19 in 100% (7/7) of cases. The nontumoral liver exhibited no cirrhosis or extensive fibrosis in 6 cases. Von Meyenburg complexes were present in 11 cases and intraparenchymal bile duct adenomas in 3.These data suggest that PLCs in patients with GH present a wide histologic spectrum, with tumors showing frequent biliary differentiation; may arise on a nonfibrotic or a cirrhotic liver; and often are associated with Von Meyenburg complexes and to a lesser extent with bile duct adenomas.
VARIANTS Must distinguish from metatastatic renal cell carcinoma Combined (HCC with cholangiocarcinoma)
Combined Hepatocellular-Cholangiocarcinoma: A Histopathologic, Immunohistochemical, and In Situ Hybridization Study
Satish K. Tickoo, M.D.; Sui Y. Zee, M.D.; Sam Obiekwe, M.D.; Hong Xiao, B.S.; Jonathan Koea, M.D.; Christian Robiou, M.D.; Leslie H. Blumgart, M.D., F.A.C.S.; William Jarnagin, M.D.; Marc Ladanyi, M.D.; David S. Klimstra, M.D.
Am J Surg Pathol 2002; 26(8):989-997 Abstract quote
Combined hepatocellular-cholangiocarcinoma (CHC) forms a small but significant proportion of primary liver carcinomas. However, its diagnostic features are not well established, and this has possibly contributed to the variability in its reported clinical outcome in the literature. Many such tumors with features intermediate between hepatocellular carcinoma and cholangiocarcinoma (CC) may have been considered CC in the past based on positivity for "biliary differentiation" cytokeratins and the lack of availability of highly sensitive and specific hepatocellular markers. The utility of in situ hybridization for albumin mRNA, a recently available sensitive and specific hepatocellular marker, has not been reported in CHC.
We investigated 27 CHCs with regard to their histomorphologic spectrum and association of these morphologies with immunohistochemical staining for different cytokeratins (CK7, CK19, and CK20; AE1; Cam 5.2), epithelial membrane antigen, polyclonal carcinoembryonic antigen and alpha-fetoprotein, and in situ hybridization for albumin mRNA. All 27 tumors contained areas morphologically intermediate between hepatocellular carcinoma and CC (transitional-type tumors), and in each case such areas formed at least 25% of the tumor. Nine (33%) tumors showed areas with "antler-like" morphology, a feature not previously described in CHC. Twenty-two of 23 tumors (96%) showed positive signals on in situ hybridization for albumin mRNA. Positivity for both hepatocellular (albumin mRNA) and biliary (keratin immunohistochemical profile) markers confirmed the light microscopic impression of biphenotypic differentiation in these tumors. Immunohistochemical positivity for all cytokeratins (except CK7) and epithelial membrane antigen, as well as the expression of albumin mRNA by in situ hybridization, did not show significant differences between hepatocellular carcinoma and CC-like areas.Based on the cytokeratin profile and results on polyclonal carcinoembryonic antigen/alpha-fetoprotein alone, many such tumors would be classified as CC. However, the positivity for albumin mRNA by in situ hybridization proves that such an interpretation would not have been accurate. Clinically, CHCs showed many differences from pure hepatocellular carcinoma, including the absence of cirrhosis (0 of 27), rarity of serum hepatitis B or C marker positivity (4 of 27), and normal to only mildly elevated serum alpha-fetoprotein levels (median 187 ng/mL). The tumor followed an aggressive clinical course, with overall 3-and 5-year survival rates of 30% and 18%, and in the resected cases of 38% and 24%, respectively.
Trabeculae grow together compressing sinusoids and forming sheets Young adults (20-40 yrs)
No association with HBV or cirrhosis risk factors
Large tumor with fibrous bands coursing throughout
Well differentiated polygonal cells rowing in nests and cords separated by parallel lamellae of dense collagen bundles
- Epidermal growth factor receptor expression and gene copy number in fibrolamellar hepatocellular carcinoma.
Buckley AF, Burgart LJ, Kakar S.
Department of Pathology, Veteran Affairs and UCSF Medical Center, San Francisco, CA 94143, USA.
Hum Pathol. 2006 Apr;37(4):410-4 Abstract quote.
Increased expression of epidermal growth factor receptor (EGFR), a transmembrane tyrosine kinase, is associated with tumor progression in many carcinomas. Epidermal growth factor receptor inhibitors have shown promise in treating some of these tumors.
Fibrolamellar hepatocellular carcinoma (FL-HCC) is an aggressive neoplasm that occurs in young patients with no history of cirrhosis. This study examines the expression and gene copy number of EGFR in FL-HCC. Formalin-fixed, paraffin-embedded FL-HCC (n = 13) sections were stained with a monoclonal antibody against EGFR. Fluorescence in situ hybridization analysis was performed using probes against EGFR gene and centromeric region of chromosome 7 (CEP 7). Epidermal growth factor receptor and CEP 7 signals were counted in 50 tumor nuclei per case as well as 300 normal hepatocyte nuclei. The EGFR to CEP 7 signal ratio was calculated for each case. Most (92%, 12/13) of FL-HCC showed strong and diffuse staining with anti-EGFR antibody. Fluorescence in situ hybridization was informative in 11 cases, 10 of which showed extra EGFR gene copy numbers (mean, 3.69; range, 3.13-5.0). Epidermal growth factor receptor was overexpressed in all these cases. The mean number of EGFR signals per cell in FL-HCC was double that of normal hepatocytes (3.69 versus 1.80); the mean EGFR/CEP 7 ratio in tumor cells was 1.05.
In conclusion, EGFR is strongly overexpressed on the cell membrane in nearly all cases of FL-HCC. Similar gains of chromosome 7 are observed, indicating that the extra EGFR gene copies are due to polysomy rather than gene amplification. The strong expression of EGFR in FL-HCC tumors suggests that they may respond to treatment with EGFR antagonists.
Clinicopathologic features and survival in fibrolamellar carcinoma: comparison with conventional hepatocellular carcinoma with and without cirrhosis.
Kakar S, Burgart LJ, Batts KP, Garcia J, Jain D, Ferrell LD.
1Department of Anatomic Pathology, UCSF/VA Medical Center, San Francisco, CA, USA.
Mod Pathol. 2005 Nov;18(11):1417-23 Abstract quote.
Fibrolamellar carcinoma arises in noncirrhotic livers of young individuals and has been considered to be less aggressive than conventional hepatocellular carcinoma.
This study compares survival and clinicopathologic features of fibrolamellar carcinoma with hepatocellular carcinoma arising in noncirrhotic and cirrhotic livers. Clinical and pathologic features including age, gender, tumor size, stage and survival were recorded in 20 resected cases of fibrolamellar carcinoma.
Survival was compared with resected hepatocellular carcinoma without (n=32) and with cirrhosis (n=30). Proliferative activity was determined by immunohistochemistry for Ki-67. In all, 12 (60%) patients with fibrolamellar carcinoma died during follow-up; the 5-year survival was 45%. Mortality in fibrolamellar carcinoma was higher with metastatic disease at presentation (6/7, 86% vs 5/13, 39%, P=0.06). Age, gender and tumor size did not correlate with survival. The 5-year (45 vs 56%, P=0.4) as well as overall survival (40 vs 56.3%, P=0.3) was similar in fibrolamellar carcinoma and hepatocellular carcinoma without cirrhosis. The 5-year and overall survival in hepatocellular carcinoma with cirrhosis was 27 and 23.3%, respectively, which was not significantly different compared to fibrolamellar carcinoma (P=0.2). Among the cases without metastases at presentation, 5-year survival in fibrolamellar carcinoma (62%) and hepatocellular carcinoma without cirrhosis (57%) was significantly better (P=0.03) than hepatocellular carcinoma with cirrhosis (27%). The mean Ki-67 index was similar in all three groups (P=0.1). In conclusion, fibrolamellar carcinoma is an aggressive neoplasm with 45% 5-year survival and overall mortality of 60%. Nearly half the patients develop lymph node or distant metastasis.
The prognosis of fibrolamellar carcinoma is similar to conventional hepatocellular carcinoma. Among nonmetastatic cases, the prognosis is better in fibrolamellar carcinoma and hepatocellular carcinoma without cirrhosis compared to hepatocellular carcinoma with cirrhosis. The better outcome in fibrolamellar carcinoma appears to be due to the absence of cirrhosis rather than its distinct clinicopathologic features.
Adult-type hepatocellular carcinoma in the center of a fibrolamellar hepatocellular carcinoma.Seitz G, Zimmermann A, Friess H, Buchler MW.Department of Visceral and Transplantation Surgery and the Institute of Pathology, University of Berne, Berne, Switzerland.
Hum Pathol 2002 Jul;33(7):765-9 Abstract quote A large hepatic tumor was detected in the noncirrhotic liver of a 27-year-old female patient. The tumor was radiologically characterized by a peripheral mass encircling a central ovoid tumor, and was resected by an extended right hemihepatectomy. Histologic examination revealed that the peripheral and major component of the tumor represented a fibrolamellar hepatocellular carcinoma, whereas the central, well-demarcated tumor was a less well-differentiated adult-type hepatocellular carcinoma completely encircled by the former. Cells of the peripheral tumor mass abundantly expressed cytokeratin-7, typically present in the fibrolamellar variant, whereas no cytokeratin-7 immunoreactivity was found in the central tumor.
To our knowledge, this is the first reported case of a not admixed but clearly separated evolution of these 2 histologic patterns within the same tumor, and suggests that the 2 types of hepatocellular carcinoma may share a common pathogenic pathway.
Blood filled cystic spaces within the tumor Centers of trabeculae with dilated canaliculus
(Carcinosarcoma)
Departments of *Hepatobilliary Surgery †Department of Pathology of Sun Yat-sen University and Department of Pathology of the First Affiliated Hospital of Sun Yat-sen University, Guangdong, China ‡Pathology, Cancer Center and State Key Laboratory of Oncology in South China, Sun Yat-sen University.
Carcinosarcoma of the liver is very rare worldwide. The terminology and pathogenesis of hepatic carcinosarcoma remain controversial issues. In this article, we studied the clinicopathologic features of 5 cases of hepatic carcinosarcomas (matching the World Health Organization definition), analyzed the clinical data, histologic and immunohistochemical (IHC) results, and discussed the terminology, pathologic differential diagnoses, pathogenesis, and prognosis.
The patients were 40 to 68 years old, and included 4 males and 1 female. All patients were Hepatitis B surface antigen positive with para-tumorous cirrhosis. The largest dimensions of the neoplasms ranged from 6.0 to 14.0 cm. Satellite nodules, portal vein tumor thrombi, direct invasion into local tissues (right diaphragm, right adrenal gland, and gastric wall) as well as metastatic foci in lungs and abdominal lymph nodes were identified.
Pathologically, the neoplasms consisted of carcinomatous and sarcomatous components. The carcinomatous components were exclusively conventional hepatocellular carcinomas in all 5 cases, whereas the sarcomatous components exhibited complex features. Confirmed by IHC studies, the sarcomatous elements in different cases included rhabdomyosarcomas, malignant fibrous histiocytomas, fibrosarcoma, and poorly differentiated spindle cells without distinctive differentiation. Furthermore, the sarcomatous elements in these 5 neoplasms stained negative for all the epithelial markers we applied for IHC staining, which support the pathologic diagnosis of carcinosarcoma rather than sarcomatoid carcinoma. The presence of transitional zones between carcinomatous and sarcomatous components may support the transformation theory. Four patients with palliative hepatectomy died within 6 months, whereas 1 patient is still alive 21 months after radical resection.
The poor prognosis of hepatic carcinosarcoma may be due to their highly invasive and metastatic features. Radical resection of early stage hepatic carcinosarcoma may contribute to a relatively optimistic prognosis.Occurs in cirrhotic liver with considerable fibrous tissue
Lacks lamellar fibrosis and pleomorphic cytology of fibrolamellar typeAssociated with hypercalcemia
Extensive fibrosis
Cirrhotic and non-cirrhotic liversSynchronous (Hepatocellular and cholangiocarcinoma)
Synchronous hepatocellular carcinoma and cholangiocarcinoma arising in two different dysplastic nodules.Kwon Y, Lee SK, Kim JS, Ro JY, Yu E.Departments of Pathology and Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
Mod Pathol 2002 Oct;15(10):1096-101 Abstract quote We present the first reported case of explant cirrhotic liver that had synchronous cholangiocarcinoma and hepatocellular carcinoma arising in two different high-grade dysplastic nodules. The patient was a 55-year-old woman who had hepatitis B virus-associated liver cirrhosis for 3 years. The moderately differentiated cholangiocarcinoma occurred in high-grade dysplastic nodule with a 1.7-fold cell density compared with that of cirrhotic nodule. The hepatocellular carcinoma arose in a nodule-in-nodule pattern within a peripherally low-grade and centrally high-grade dysplastic nodule and had a 2.7-fold cell density compared with that of cirrhotic nodule. By immunohistochemistry, the tumor cells of the cholangiocarcinoma as well as bile ductular cells in dysplastic nodule were diffusely positive for cytokeratin 7, whereas hepatocellular carcinoma cells and dysplastic hepatocytes were negative for cytokeratin 7. The c-kit-positive hepatic progenitor cells were singly scattered between hepatocytes, and their number was highest in cirrhotic nodule and decreased in dysplastic nodule, whereas they were absent in cholangiocarcinoma and hepatocellular carcinoma arising in dysplastic nodules. Proliferation indices were progressively increased in cirrhotic nodule, dysplastic nodule, and cholangiocarcinoma or hepatocellular carcinoma, sequentially.
These observations indicate that cholangiocarcinoma as well as hepatocellular carcinoma can develop in dysplastic nodule and that hepatic progenitor cells might play a role in the early stage of cholangiocarcinogenesis and hepatocarcinogenesis.
Thickened trabeculae numbering up to 10-20 cells thick
SPECIAL STAINS/
IMMUNO-
HISTOCHEMISTRYCHARACTERIZATION GENERAL Immunohistochemical Detection of Hepatocellular Carcinoma in the Setting of Ongoing Necrosis after Radiofrequency Ablation
Tomoo Itoh, M.D., Yasuko Orba, C.T., Hidehiro Takei, M.D., Yusuke Ishida, M.D., Makoto Saitoh, M.D., Hideaki Nakamura, M.D., Takashi Meguro, M.D., Shoichi Horita, M.D., Miri Fujita, M.D. and Kazuo Nagashima, M.D.
Laboratory of Molecular and Cellular Pathology (TI, YO, HT, YI, MS, KN), Hokkaido University School of Medicine, Hokkaido; Hokkaido Gastroenterology Hospital (HN, TM, SH), Hokkaido; Department of Pathology, Shin-Nittetsu Muroran General Hospital (MF), Muroran; and Core Research for Evolutional Science and Technology (KN), Tokyo, JapanMod Pathol 2002;15:110-115 Abstract quote
After radiofrequency ablation (RFA), hepatocellular carcinoma undergoes complete necrosis and an ongoing necrosis that is irreversible and characterized histologically by disrupted cell outlines, homogenous cytoplasmic eosinophilia, and preserved nuclear staining, with the cells appearing quite distinct from viable cancer cells. Antibody to detect single-stranded DNA (ssDNA) specifically labeled nuclei in the setting of ongoing necrosis, but not viable tumor cells, whereas human mitochondrial antibody labeled the cytoplasm of viable cells but not cells of ongoing necrosis.The results demonstrate that RFA causes denaturation of both DNA and proteins and that the immunohistochemistry of ssDNA and mitochondrial protein is useful in detection of ongoing necrosis after RFA and provides pathological information on the validity of this procedure.
Comparison of Thyroid Transcription Factor-1 and Hepatocyte Antigen Immunohistochemical Analysis in the Differential Diagnosis of Hepatocellular Carcinoma, Metastatic Adenocarcinoma, Renal Cell Carcinoma, and Adrenal Cortical Carcinoma
Tad J. Wieczorek, MD, Jack L. Pinkus, PhD, Jonathan N. Glickman, MD, PhD, and Geraldine S. Pinkus, MDAm J Clin Pathol 2002;118:911-921 Abstract quote
We compared the effectiveness of thyroid transcription factor-1 (TTF-1, cytoplasmic reactivity) and hepatocyte antigen (HPA) as markers for characterization of hepatocellular carcinoma (HCC) and as discriminators to distinguish HCC from its histologic and cytologic mimics. Formalin-fixed, paraffin-embedded sections of 258 specimens, including 76 HCCs, 85 metastatic adenocarcinomas, 75 renal cell carcinomas (RCCs), and 22 adrenal cortical carcinomas (ACCs), were evaluated. Specimens included tissue sections and cytologic material (cell blocks). Following heat-induced epitope retrieval, immunohistochemical studies were performed using an indirect immunoperoxidase technique. Cytoplasmic reactivity for TTF-1 was noted for 54 (71%) of 76 HCCs, 3 (4%) of 85 adenocarcinomas, none of 72 RCCs, and none of 22 ACCs. Cytoplasmic reactivity for HPA was observed for 50 (66%) of 76 HCCs, 1 (1%) of 83 adenocarcinomas, none of 74 RCCs, and none of 21 ACCs. Cytoplasmic reactivity for TTF-1 and HPA is highly specific for HCC, although a minority of HCCs, particularly poorly differentiated tumors, may be nonreactive.Thus, these markers are useful for the characterization of HCC in tissue sections and cell blocks and are highly effective for distinguishing these tumors from other neoplasms included in the differential diagnosis.
Comparative immunohistochemical profile of hepatocellular carcinoma, cholangiocarcinoma, and metastatic adenocarcinoma.Lau SK, Prakash S, Geller SA, Alsabeh R.
Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA.
Hum Pathol 2002;33:1175-1181 Abstract quote Distinguishing hepatocellular carcinoma (HCC) from cholangiocarcinoma (CC) and metastatic adenocarcinoma (MA) involving the liver can be problematic, often requiring the use of immunohistochemistry to facilitate diagnosis. Hep Par 1, a monoclonal antibody with expression confined primarily to benign and malignant hepatocytes, has recently become commercially available. We evaluated Hep Par 1 along with other immunohistochemical markers used to differentiate HCC, CC, and MA, including AE1/AE3, CAM 5.2, B72.3, monoclonal carcinoembryonic antigen (mCEA), polyclonal CEA (pCEA), alpha-fetoprotein (AFP), factor XIIIa, inhibin, CD10, villin, MOC-31, cytokeratin (CK) 7, CK 19, and CK 20, to determine the markers most useful in differentiating these entities. Forty-two cases of HCC, 9 cases of CC, and 56 cases of MA (24 colon, 15 pancreas, 8 ovary, 5 breast, and 4 stomach) were studied. Hep Par 1 was sensitive and specific for HCC, with 38 of 42 (90%) cases staining positively, whereas reactivity was observed in only 8 of 56 (14%) MAs and 0 of 9 CCs. Though limited somewhat by poor sensitivity, a bile canalicular pattern of staining with pCEA, CD10, and villin was specific for HCC and was not observed in the other tumors. Lack of mCEA and MOC-31 immunoreactivity was also characteristic of HCCs. CK 19 positivity favored CC over HCC, but was not useful in differentiating CC from MA.
Expression of AFP, although observed in only about one third of the cases, favored HCC over CC and MA. CK 7 and CK 20 were also useful in this differential diagnosis, particularly when dealing with MA of colonic origin. AE1/AE3, CAM 5.2, B72.3, inhibin, and factor XIIIa were noncontributory in differentiating these entities.
CD10 Canalicular Immunostaining of Neprilysin (CD10) as a Diagnostic Marker for Hepatocellular Carcinomas Nicole Borscheri, M.D.; Albert Roessner, M.D., Ph.D.; Christoph Röcken, M.D., Ph.D.
From the Department of Pathology, Otto-von-Guericke-University, Magdeburg, Germany.
Am J Surg Pathol 2001;25:1297-1303 Abstract quoteNeprilysin (CD10) is expressed in both normal and neoplastic liver tissue, where it exhibits a characteristic canalicular pattern (CD10 can ) similar to the one observed when antibodies cross-react with biliary glycoprotein I (p-CEA). The aim of this retrospective study was to investigate the use of CD10 can in differentiating between hepatocellular carcinomas (HCCs; 63 specimens) and nonhepatocellular carcinomas (non-HCCs) metastatic to the liver (non-HCC; 25 specimens). Immunostaining was performed with antibodies directed against CD10, p-CEA, and -fetoprotein (AFP). Albumin mRNA was detected by nonradioactive in situ hybridization (ISH albumin ). In the HCC group a canalicular staining pattern for CD10 was found in 43 (68.3%) specimens, AFP was found in 15 (23.8%) specimens, and a canalicular staining pattern for p-CEA was present in 60 (95.2%) specimens. ISH albumin was performed in 35 HCC specimens and showed labeling of tumor cells in 30 (85.7%) specimens. In the non-HCC group, CD10 can , and p-CEA, immunostaining for AFP and labeling for ISH albumin were confined to non-neoplastic liver tissue. Sensitivity and specificity were, respectively, 68.3% and 100% for CD10 can , 23.8% and 100% for AFP, 95.2% and 100% for canalicular p-CEA, and 86.4% and 100% for ISH albumin .
Our results demonstrate that canalicular staining for CD10 is a highly specific marker of hepatocytic differentiation. Although it does not differentiate between benign and malignant lesions, CD10 can is clearly useful in differentiating between HCC and non-HCC.
CD117 (c-kit)
Eung Seok Lee, MD, etal.
Progenitor cells, termed oval cells, are involved in the pathogenesis of hepatocellular carcinoma (HCC) in animal models. By immunolabeling for c-kit and CD34 in human hepatitis B virus–associated cirrhosis with HCC (50 cases) and those with cirrhosis alone (10 cases), we found c-kit+ tumor cells in tumor tissue in 40 of 50 HCCs. The proportion was less than 0.1% of total tumor cell volume in most HCCs. Immunostaining for c-kit also was detected in sinusoidal endothelial cells in 43 of 50 HCCs.
The incidence of oval cell occurrence in the adjacent nonneoplastic tissue in cases of HCC was high (44/50). The occurrence of oval cells, c-kit+ tumor cells, and c-kit+ sinusoidal cells in cases of human hepatitis B virus–associated HCC suggests that oval cell proliferation might be associated with the development of human hepatitis B virus–associated HCC.
Furthermore, the c-kit+ sinusoidal cells might have a role in angiogenesis and progression of human hepatitis B virus–associated HCC.ENDOTHELIAL CELL MARKERS Novel endothelial cell markers in hepatocellular carcinoma.
Chen X, Higgins J, Cheung ST, Li R, Mason V, Montgomery K, Fan ST, Rijn Mv M, So S.
1Department of Biopharmaceutical Sciences, University of California San Francisco, San Francisco, CA, USA.
Mod Pathol. 2004 Oct;17(10):1198-21 Abstract quote
Hepatocellular carcinoma is characterized by hypervascularity and a propensity for vascular invasion. Detailed analysis of complementary DNA (cDNA) microarray global gene expression data and further validation on a smaller independent sample set by reverse transcription-polymerase chain reaction established the presence of two endothelial gene clusters in hepatocellular carcinoma.
Cluster I, consists of 20 cDNA clones, representing 15 unique genes. Cluster II consists of nine unique genes. The expression of the cluster I genes appeared to be significantly upregulated in hepatocellular carcinoma compared with normal liver, cirrhotic liver, or nontumor liver tissues adjacent to the hepatocellular carcinoma. The pattern of gene expression of cluster I genes correlated positively with the 'proliferation gene cluster' and 'stromal cells cluster 2'. Expression of cluster II genes, in contrast, was not significantly different between hepatocellular carcinoma and non-neoplastic liver tissues. Studies conducted to localize the protein products of these genes by immunohistochemical staining of tissue arrays with up to 350 cores of tissues, and by in situ hybridization led to the discovery of novel sinusoidal endothelial cell markers in hepatocellular carcinoma: podocalyxin-like and regulator of G protein signaling-5.
Our results underscore fundamental differences not only between neoplastic vs non-neoplastic liver cells but also between the hepatic sinusoidal endothelium of hepatocellular carcinoma and normal liver.HEPATOCYTE ANTIGEN (HEP PAR1) Immunoreactivity of Hep Par 1 in Hepatic and Extrahepatic Tumors and Its Correlation With Albumin In Situ Hybridization in Hepatocellular Carcinoma
Sanjay Kakar, MD, Trudie Muir, MD, Linda M. Murphy, HT(ASCP), Ricardo V. Lloyd, MD, PhD, and Lawrence J. Burgart, MDAm J Clin Pathol 2003;119:361-366 Abstract quote
We evaluated the expression of Hep Par 1 (hepatocyte paraffin 1 monoclonal antibody) in 42 hepatocellular carcinomas (HCCs), 25 cholangiocarcinomas, 18 tumors metastatic to the liver, and 87 primary extrahepatic tumors. Albumin in situ hybridization (ISH) was performed in the HCC cases. Of 42 cases of HCC, 39 (93%) were positive for Hep Par 1. All cases of cholangiocarcinoma, renal cell carcinoma, adrenocortical carcinoma, and islet cell tumors were negative; 1 case each of primary urinary bladder (n = 10) and pancreatic (n = 10) adenocarcinoma and 3 of 11 cases of primary pulmonary adenocarcinoma showed focal positivity; 7 of 10 gastric and 6 of 8 esophageal adenocarcinomas were strongly positive. Albumin ISH was positive in 39 (93%) HCC cases. All cases of HCC were positive for Hep Par 1 or albumin ISH. Hep Par 1 immunoreactivity has high sensitivity in the diagnosis of HCC. Strong positive staining also occurs in gastroesophageal adenocarcinomas. Cholangiocarcinoma and carcinomas from most other sites are negative for Hep Par 1.Hep Par 1 immunoreactivity shows high correlation with albumin ISH; their combined use for diagnosis of HCC had a sensitivity of 100% in this population.
Hep par 1 antibody stain for the differential diagnosis of hepatocellular carcinoma: 676 tumors tested using tissue microarrays and conventional tissue sections.Fan Z, Van De Rijn M, Montgomery K, Rouse RV.Deparent of Pathology, Stanford University Medical Center, Stanford, California.
Mod Pathol 2003 Feb;16(2):137-44 Abstract quote A well-characterized positive marker for hepatocellular differentiation would be a useful tool for the diagnosis of hepatocellular carcinoma (HCC). The recently commercially available Hep Par 1 antibody (clone OCH1E5.2.10) has been reported to be a sensitive marker for HCC in paraffin embedded sections. Of non-hepatocellular tumors, occasional carcinomas have been reported to stain, most frequently gastric adenocarcinomas. This study further evaluated the staining of this antibody on a large number of neoplasms using tissue microarray technology as well as conventional tissue sections. Six hundred seventy-six tumors, including 19 cases of HCC, were tested. Eighteen of 19 cases of HCC were positive, 3 showing <5% staining. Two cases negative on the array showed focal staining when whole tissue sections from the same tumors were used. 16 of 34 cases of gastric carcinomas gave positive reactions, 4 of these showed less than 5% staining. Staining of gastric carcinomas was not limited to signet ring-type carcinomas or to areas of hepatoid differentiation. Only 1 of 11 cases of cholangiocarcinoma showed focal staining. We also noted several other tumors to stain occasionally, including adrenal cortical carcinoma (3/13), yolk sac tumor (2/9), colonic adenocarcinoma (8/106), lung carcinoma (3/52), ovarian carcinoma (5/48), and endocervical adenocarcinoma (1/5). We did not observe staining in pancreatic carcinoma (11), renal cell carcinoma (36), breast carcinoma (85), melanoma (25), or mesothelioma (5).
This study supports Hep Par 1 as a useful marker in the differential diagnosis of HCC, but with significant limitations. Cautious use of this antibody in a panel with other positive (alpha fetoprotein, CD10, polyclonal carcinoembryonic antigen) and negative (epithelial membrane antigen, monoclonal carcinoembryonic antigen, CD15) markers of hepatocellular differentiation may aid in the accurate diagnosis of HCC.
Hepatocyte Antigen as a Marker of Hepatocellular Carcinoma: An Immunohistochemical Comparison to Carcinoembryonic Antigen, CD10, and Alpha-Fetoprotein
Peiguo G. Chu, M.D., Ph.D.; Shin Ishizawa, M.D.; Emerald Wu, B.S., HT (ASCP); Lawrence M. Weiss, M.D.
Am J Surg Pathol 2002; 26(8):978-988 Abstract quote
Hepatocyte monoclonal antibody (Hep) (alternatively Hep Par 1 for Hep paraffin 1) has been reported to stain normal hepatic tissue and hepatocellular carcinoma (HCC) with high specificity. We have studied the Hepatocyte expression in 96 cases of HCC and 311 cases of nonhepatic epithelial tumors. All cases of HCC were also stained with CEA-Gold 5, CD10, and alpha-fetoprotein. Hep, CEA-Gold 5, CD10, and alpha-fetoprotein immunostains were performed on formalin-fixed, paraffin-embedded tissue sections. Hep immunoreactivity was detected in 88 of 96 cases of HCC (92%), with a cytoplasmic and granular pattern of staining. The level of Hep expression in HCC corresponded to the nuclear grade and growth pattern. All 50 cases of nuclear grade 1 and nuclear grade 2 HCC were positive (100%), whereas 37 of 44 nuclear grade 3 (84%) and 1 of 2 nuclear grade 4 (50%) were positive. Sixty-seven of 68 cases of HCC with a trabecular, pseudoglandular, or scirrhous growth pattern were positive (98%), whereas 22 of 27 cases of HCC with a compact growth pattern were positive (81%). CEA-Gold 5, CD10, and alpha-fetoprotein immunoreactivity was detected in 76% (73 of 96), 52% (50 of 96), and 31% (30 of 96) cases of HCC, respectively. The positive predictive value of the combination of all four antibodies was 97%. Three cases of HCC were negative for all four antibodies; these cases had a high nuclear grade or a sarcomatoid or compact growth pattern. Twenty of 311 cases of nonhepatic tumors were positive for Hep (6%): 15 were adenocarcinomas and five were neuroendocrine tumors. The negative predictive value of Hep in HCC was 94%. The Hep-positive nonhepatic epithelial tumors were easily distinguished from HCC by the expression of keratin 7 or keratin 20 for adenocarcinoma and chromogranin and synaptophysin for neuroendocrine tumors because HCC does usually not express these markers.With the exception of two cases of hepatoid gastric carcinoma, all Hep-positive nonhepatic epithelial tumors were negative for alpha-fetoprotein, CEA-Gold 5, and CD10. Our study demonstrates that Hep is a relatively specific marker for HCC. It is useful in differentiating HCC from primary hepatic cholangiocarcinoma and metastatic tumors when combined with other immunomarkers.
A Comparison of CD10 to pCEA, MOC-31, and Hepatocyte for the Distinction of Malignant Tumors in the Liver
Carl Morrison, M.D., D.V.M., William Marsh, Jr, M.D. and Wendy L. Frankel, M.D.
Department of Pathology, The Ohio State University, College of Medicine, Columbus, Ohio
Modern Pathology 2002;15:1279-1287 Abstract quote The distinction of hepatocellular carcinoma (HCC) from metastatic adenocarcinoma (MA) and cholangiocarcinoma (CC) in some cases requires the use of immunohistochemistry. CD10 has recently been suggested as a useful stain for HCC. We directly compared CD10 with other immunohistochemical markers, Hepatocyte, pCEA, and MOC31, that have previously shown to be useful for the distinction between tumors in the liver to help define the current panel of stains that most readily distinguishes HCC from CC and MA. One hundred previously well-characterized tumors in the liver were evaluated and included 25 HCC, 15 CC, and 60 MAs (15 each from breast, esophageal/gastric, pancreatic, and colorectal origin). Tumors were immunostained with the commercially available antibodies Hepatocyte, pCEA, MOC31, and CD10. CD10 stained 13 of 25 HCC and was rarely positive in MA and CC (3/75). Hepatocyte stained 24 of 25 HCC and was negative in all 75 MA and CC. pCEA stained 24 of 25 HCC and 71 of 75 MA and CC with the proper pattern of immunoreactivity, but the pattern of staining was difficult to interpret in several cases. MOC31 stained 1 of 25 HCC and 65 of 75 MA and CC. Hepatocyte was the most sensitive and specific single marker for HCC. CD10 is not a useful addition or substitution to the panel of Hepatocyte, MOC31, and pCEA.
The combination of Hepatocyte, MOC31, and pCEA correctly classified 99 of 100 tumors in this study and is our proposed panel of immunostains for the initial workup of malignant tumors in the liver.
p53
Loss of p53 transcriptional activity in hepatocellular carcinoma evaluated by yeast-based functional assay: Comparison with p53 immunohistochemistry.
Mitsumoto Y, Nakajima T, Marutani M, Kashiwazaki H, Moriguchi M, Kimura H, Okanoue T, Kagawa K, Tada M.
Hum Pathol 2004;35:350-356 Abstract quote
We studied the transcriptional activity of p53 protein in 50 tissues of hepatocellular carcinoma (HCC) using a yeast functional assay. In this assay, red yeast colonies indicate that p53 protein cannot bind to its specific domain and has lost its transcriptional activity.
We also clarified whether mutant p53 protein could inactivate wild-type p53 protein in a transdominant manner using a modified yeast assay. In addition, we examined whether immunohistochemically detectable p53 protein was functionally inactive. The incidence of p53 inactivation was significantly higher in tumors with capsular invasion. Out of 21 tumors diagnosed with p53 mutations, 11 exhibited >75% red colonies, and all contained missense mutations. In these tumors, p53 function was lost because there was supposedly no intact p53 gene on either allele. One missense mutant produced <60% red colonies, but it was also considered inactive as a p53 protein heterotetramer because of its transdominant activity. In 7 of the remaining 9 tumors, p53 was considered to be mutated on one allele and intact on the other. All of these 7 tumors contained nonsense or frameshift mutations and had no transdominant activity, which suggested that p53 function remained intact. Alternately, immunohistochemical analysis demonstrated that all of the tumors with missense mutations were positively immunostained, whereas those that contained nonsense or frameshift mutations were negatively stained. Consequently, positively immunostaining tumors mostly coincided with p53-inactive tumors.
These yeast-based assays suggested that p53 function was retained in some mutant cases. Immunohistochemistry was helpful in screening functionally inactive p53 protein in HCCs.THYROID TRANSCRIPTION FACTOR (TTF-1)
Jun-Yi Lei, MD, PhD, Patricia A. Bourne, P. Anthony diSant'Agnese, MD, and Jiaoti Huang, MD, PhD
The cytoplasmic