Clin Liver Dis 9 (2005) 281 285

Liver Biopsy in the Diagnosis of Hepatocellular Carcinoma

Ian R. Wanless, MD, FRCPC
Department of Pathology, The Toronto Hospital, 200 Elizabeth Street, Toronto, Canada, M5G 2C4

Modern imaging techniques have allowed the discovery of many small and asymptomatic hepatic lesions that pose a new challenge to pathologists. These lesions are difficult to diagnose histologically because small lesions tend to be well differentiated, with subtle deviations from normal. Pathologists outside of referral centers do not have comprehensive experience with these lesions.

Classification and nomenclature Study of resected hepatocellular carcinoma (HCC) reveals a high prevalence of small premalignant lesions in the same liver [1,2]. These lesions have atypical features that distinguish them from normal or cirrhotic liver but are not sufficient for the diagnosis of carcinoma. They are thought to be premalignant because small regions of carcinoma can often be found within these otherwise benign lesions. Individual investigators have applied different names to these lesions, including macroregenerative nodules, adenomatous hyperplasia, and dysplastic nodules. The International Working Party of the World Congresses of Gastroenterology recommended consolidation of the nomenclature to dysplastic nodule [3].

Presentation Moderately differentiated hepatocellular carcinomas are usually hypervascular with enhancement on modalities that detect arterial flow [4]. Early malignant lesions may be isovascular or hypovascular, and become hypervascular upon
E-mail address: ian.wanless@utoronto.ca 1089-3261/05/$ see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.cld.2004.12.005

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Table 1 IWP histologic criteria to distinguish hepatocellular nodules Large regenerative nodule +b Dysplastic nodule, low grade + + Dysplastic nodule, high grade + +/ + + + + + + + + Welldifferentiated HCC + + + + + + + + + + + + + Moderately differentiated HCC + + + + + + + + + + + + + + + +

Histologic feature Clone-like populations Plates more than 3 cells wide Mitotic figures N 5/10 HPF Cell density more than twice normala Invasion of stroma or portal tracts Irregular nuclear contour, at least moderate Absence of portal tracts (arterial supply) Mitotic figures, occasional (15/10 HPF)c Cell density more than 1.3 times normal Nuclear hyperchromasia Irregular nuclear contour, at least mild Pseudogland formation Cytoplasmic basophilia Cytoplasmic clear cell change Reticulin less than normal Increased or decreased iron accumulation

Abbreviations : IWP, International Working Party; HCC, hepatocellular carcinoma; HPF, high power field (10 40). a As a measure of increased nuclear to cytoplasmic ratio. b Especially when cholestasis present. c Mitoses may occur in any lesion in the presence of cholestasis or recent necrosis. Data from Wanless IR for the International Working Party. Terminology of nodular hepatocellular lesions. Hepatology 1995;22:98393.

further growth. The portal vein supply is lost as arteries grow to supply the growing lesion. This is reflected on CT with arterioportography as a negative tumor blush during the portal venous phase. A third of early carcinomas has abundant steatosis [5].

Pathology The pathologist recognizes dysplastic nodules only when the size or texture differs from the background cirrhotic nodules. This generally occurs when the

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nodule reaches 5 mm, although for study purposes a cutoff of 10 mm has often been used. Generally, nodules greater than 1.5 cm achieve histologic criteria of HCC. However, occasionally, benign dysplastic nodules may reach a 2-cm diameter without definite malignant transformation. Aspiration cytology can be used for a reliable diagnosis of moderately differentiated HCC, but tissue sections are usually required for dysplastic nodules and well-differentiated carcinoma. The histologic features listed in Table 1 may assist in the diagnosis. Carcinoma is suggested by hepatocellular plates more than two cells in thickness. Reticulin, trichrome, or periodic acid schiff stains facilitate this assessment. Welldifferentiated HCC may have single or double plates so that other criteria must be considered. Atypical architectural features including pseudoglandular forms, and double plates with deviation of the nuclei to the sinusoidal margins are suggestive of HCC. An increased nucleus-to-cytoplasmic ratio is particularly useful. HCC should have some nuclear atypia, although this is often mild. Invasion of stroma is a useful criterion for malignancy [6,7]. However, biopsy samples seldom have this feature. There are a number of look-alike conditions where benign and nonneoplastic hepatocytes migrate into stromal areas as well as lumina of portal and hepatic veins. Therefore, this criterion should not be accepted unless there are supportive cytologic and architectural features of carcinoma. Mitotic figures are not helpful to diagnose well-differentiated HCC. Loss of reticulin may occur, especially in moderately differentiated HCC. Immunohistochemical stain for CD34 or CD31 highlights the arterial supply of a nodule; endothelial cells that line arterialized sinusoidal stain positively [8]. Although this staining is more prominent in HCC, it also occurs focally in dysplastic nodules and benign cirrhotic nodules. The hepatocytes of most HCCs are positive for glipican-3, but focal and weak staining limits its diagnostic usefulness [9]. Dysplastic nodules may be low grade or high grade. Low-grade dysplastic nodules are not suggestive of malignancy, and high-grade dysplastic nodules have atypical features but not sufficient criteria for the diagnosis of HCC. Lowgrade dysplastic nodules are difficult to distinguish from regenerative nodules because of the minimal nuclear atypia and normal nucleus/cytoplasmic (N/C) ratio in both conditions. The most useful feature is the presence of map-like areas of uniform cellular appearance especially in background cirrhotic nodules. Small clusters less than 1 mm in diameter of atypical hepatocytes have been defined as dysplastic foci. These are most often recognized as iron-free foci in patients with hemochromatosis [10]. Regenerative nodules in nonneoplastic conditions may resemble dysplastic nodules or HCC [11]. This is particularly the case in fulminant hepatic failure, severe cholestasis, and Budd-Chiari syndrome when regenerative stimuli are extreme. These regenerative nodules often have mitoses, widened plates, moderate increase in N/C ratio, and active nuclear chromatin pattern. Regenerative nodules are supplied by portal tracts, often with ductular proliferation. Clinical history is important to avoid these difficulties. Adenoma may be difficult to distinguish from well-differentiated HCC [11]. The history of exposure to oral contraceptives or anabolic steroids may be

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comforting. However, HCC can also occur in this clinical setting. Shrinkage of the lesion on cessation of the medication is one of the best diagnostic criteria for adenoma. A lesion many centimeters in diameter that has minimal abnormalities of nuclei, N/C ratio, and plate structure is usually benign. Generally adenoma does not have mitoses, and the plates are uniform and no more than two cells in thickness. Focal nodular hyperplasia can usually be diagnosed when there is a central scar, a regular arrangement of arteries, and periarterial connective tissue containing ductal elements [11]. There is a newly recognized form of adenoma in which portal elements may be found. This has been called telangiectatic hepatocellular adenoma as well as telangiectatic focal nodular hyperplasia [12]. Nonhepatocellular lesions such as angiomyolipoma may be distinguished by negative heppar-1 (hepatocyte, Dako) and Cam5.2 stains.

Interobserver variation The International Consensus Group for Hepatic Neoplasia is currently assessing the reliability of histologic diagnosis of early HCC and dysplastic nodules. This group of two dozen hepatopathologists from 10 countries met in 2002 and 2004. The results of these meetings will be published in detail elsewhere. The results indicated considerable variation in diagnoses rendered for a study set of resected lesions. It was evident that refinements of the diagnostic criteria and a teaching aid for general pathologists was needed. A new diagnostic approach is being developed, to be known as the Laennec Classification of Hepatocellular Neoplasia.

The Laennec Classification of Hepatic Neoplasia The proceedings of the The International Consensus Group for Hepatic Neoplasia indicated that there were many histologic criteria that were difficult to apply because of subjective assessment. Furthermore, some criteria were of value only in large resection specimens; a lower grade of neoplasia was often diagnosed in a biopsy from the same lesion. The proposed Laennec Classification of Hepatocellular Neoplasia system will be defined in detail elsewhere. The system can be applied to premalignant lesions and all grades of hepatocellular carcinoma. In this system, nuclear atypia, N/C ratio, and architectural atypia are graded 04 or 06 with the assistance of a standard set of photographs. The scores of these three components are summed, giving a possible range of 014. When two or more distinct regions are noted, more than one Laennec score is reported along with a comment on the percentage of the lesion occupied by each score. Stromal invasion, mitoses, and arterialization are not considered in this system because they are highly dependent on sample size.

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The advantages of this system are (1) it can be applied to both small and large samples, (2) complexity is reduced, (3) criteria are standardized, and (4) the use of a numerical score reinforces the fact that early neoplastic features form a spectrum. The clinical significance of a given Laennec score is currently being evaluated.

References
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