The ultrastructural features of aflatoxin B1-induced lesions in the rat liver

Hepatocellular carcinoma was induced in rats by administering aflatoxin B1 (AFB1) for 6 weeks. Malignant tumours were preceded by foci and nodules of altered hepatocytes. The ultrastructural characteristics of the nodular lesions have been studied and compared with those of the hepatocellular carcinoma cells. Alterations in the endoplasmic reticulum, junctional complexes and nuclei were common to both the basophilic and eosinophilic nodular cells and the carcinoma cells. These most likely represent hyperplastic changes rather than malignant alterations. The eosinophilic nodules were distinguished from other lesions by the abundance of concentric, membranous whorls in the cytoplasm of nodular cells. These cytoplasmic structures were also present in some hepatocellular carcinoma cells. The observations provided further evidence suggesting that the eosinophilic nodule, rather than the basophilic nodule, may play a role in the development of malignancy in the rat liver.     

The way we teach general pathology in Oslo, Norway

Hepatocellular carcinoma was induced in rats by administering aflatoxin B₁ (AFB₁) for 6 weeks. Malignant tumours were preceded by foci and nodules of altered hepatocytes of three histological types, composed of basophilic, eosinophilic, and vacuolated cells. In addition, there were areas of altered hepatocytes that were considered as hyperplastic. Lectins were used as histochemical markers to compare the expression of membrane glycoproteins in hepatocellular carcinomas and hepatic nodules with non-nodular or control hepatocytes. There were marked changes in the lectin-binding patterns of the hepatocellular carcinoma cells and the eosinophilic nodules. The lectin-binding patterns of basophilic nodules, vacuolated nodules, and hyperplastic areas were similar to non-nodular or untreated hepatocytes. The similarity in the lectin-binding changes of the eosinophilic nodules and hepatocellular carcinomas suggests that the eosinophilic nodules may be an early stage in the development of carcinoma.     

Iron-negative foci in siderotic macroregenerative nodules in human cirrhotic liver. A marker of incipient neoplastic lesions

Resistance to iron accumulation is known as a phenotypic marker of neoplasia and preneoplasia in experimental hepatocarcinogenesis in rodents overloaded by iron. This study was aimed to evaluate whether such iron-free foci are present and valuable for identification of preneoplastic and incipient neoplastic lesions in human cirrhotic livers, especially within macroregenerative nodules in which hepatocellular carcinoma is known to arise. Iron-free foci were found in siderotic macroregenerative nodules in liver cirrhosis. These foci were classic and overt carcinoma or borderline lesions showing an expansive growth pattern. Borderline lesions were composed of hyperplastic or small basophilic hepatocytes with hyperchromasia and distinct nuclear membrane showing pseudoglandular, trabecular, compact, and scirrhous patterns. These data suggest that iron stain is valuable for identification of neoplastic or borderline lesions representing a transition from hyperplastic nodule to carcinoma in human liver cirrhosis.     

Gastrointestinal hepatoid adenocarcinoma: venous permeation and mimicry of hepatocellular carcinoma, a report of four cases

Aims : Four cases of hepatoid adenocarcinoma, three in the stomach, and one in the sigmoid colon, are presented to emphasize venous permeation and mimicry of hepatocellular carcinoma by metastatic liver nodules. Methods and results : Tumour cells in all cases extensively invaded veins, and intravenous tumour thrombi in two cases were grossly observed as anastomosing, worm-like cords up to 10 mm in diameter in the lesser omentum and mesentery in continuity with the primary mucosal lesions. The cytological features and trabecular architecture of the metastatic liver nodules in these subjects mimicked primary hepatocellular carcinoma. In a third case the tumour contained grossly visible bile in a metastatic lung nodule, but there was no evidence of bile production in the primary gastric or metastatic liver lesions. In the fourth case, detailed histopathological study revealed a gastric origin of the hepatoid adenocarcinoma, rather than primary hepatocellular carcinoma metastatic to the stomach, the initial diagnosis. Conclusions : These cases are reported here to draw attention to this rare variant of gastrointestinal adenocarcinoma, its mimicry of hepatocellular carcinoma when metastatic to the liver and other sites, and its propensity for venous permeation.     

Synchronous hepatocellular carcinoma and cholangiocarcinoma arising in two different dysplastic nodules.

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.     

Focal nodular hyperplasia-like areas in cirrhosis

AIMS: Focal nodular hyperplasia-like lesions have rarely been described in cirrhotic livers. We describe five cases of such lesions. METHODS AND RESULTS: Between 1998 and 2001, 146 liver transplants were performed at the Royal Free Hospital for cirrhosis of the liver. Nodular lesions identified in the livers removed at transplantation were defined histologically according to the International Working Party classification (Hepatology 1995; 22; 983). They were present in 63 of these livers, as follows: 36 dysplastic nodules, 121 macroregenerative nodules, and 71 hepatocellular carcinomas. In five patients, an additional 12 nodules (size range 4-23 mm, median 10.5 mm) showed histological features suggestive of focal nodular hyperplasia including mildly inflamed vascular fibrous septa, and ductular proliferation. Pre-transplantation imaging showed features suspicious for hepatocellular carcinoma, in three of these lesions (12, 23 and 23 mm diameter) from two different patients. These lesions were histologically indistinguishable from focal nodular hyperplasia occurring in non-cirrhotic livers, with fibrous scars and septa which contained vascular and ductular structures. CONCLUSIONS: It is important to recognize that these lesions may occur in the context of cirrhosis and that they should be considered in the differential diagnosis with hepatocellular carcinoma, dysplastic nodules and macroregenerative nodules.     

Morphology of foci of altered hepatocytes and naturally-occurring hepatocellular tumors in F344 rats

Summary The morphology of liver tumors of F344 rats used as controls in carcinogenesis bioassays were studied. Foci of cellular alteration composed of hepatocytes with basophilic cytoplasm were found commonly in F344 rats, 2 years of age. Eosinophilic and vacuolated foci were considerably less common. The morphology of 67 nodular hepatic lesions indicated that 54 were neoplastic nodules and 13 hepatocellular carcinomas. The majority of these tumors were composed of basophilic hepatocytes. Some of the carcinomas appeared to arise within neoplastic nodules. No tumors metastasized.     

Evidence for the stem cell origin of hepatocellular carcinoma and cholangiocarcinoma.

A review of the morphologic, autoradiographic, and phenotypic analysis of the cellular changes seen during induction of cancer of the liver in rats by chemical carcinogens is used to develop an alternative to the established hypothesis that chemically induced hepatocellular carcinoma arises from premalignant nodules. The authors propose that hepatocellular and ductular carcinomas arise from a pluripotent liver stem cell and that enzyme-altered foci and nodular changes are adaptive non-oncogenic responses to the toxic effects of carcinogens. It is further postulated that persistent nodules may provide an environment that nurtures development of neoplastic cells other than the altered hepatocytes that originally form the nodule. It is possible, however, that there may be more than one cellular lineage to hepatocellular cancer and that persistent nodules contain these different lineages.     

Osteocartilaginous metaplasia of the right atrium in male domestic sheep

Among 53 clinically healthy male sheep with epididymitis, nine had minimal to severe firm nodular thickening of the right atrial wall at necropsy. The two most severely affected atria were about three times normal size. Histologically, the atrial masses consisted of partly mineralized cartilage nodules with lipid-filled cavities and basophilic to eosinophilic trabeculae. Further investigation failed to reveal clues as to etiopathogenesis of these lesions.     

Hepatocarcinogenesis in liver cirrhosis: imaging diagnosis.

Hepatocellular carcinoma (HCC) frequently occurs in association with liver cirrhosis, as chronic liver disease is one of the most important factors in carcinogenesis. In addition to HCCs, recent reports of pathologic studies of resected specimens from cirrhotic liver describe associated small nodular lesions such as regenerative nodule, dysplastic nodule (adenomatous hyperplasia), and dysplastic nodule with subfocus of HCC (early HCC). In hepatocarcinogenesis of the cirrhotic liver, a regenerative nodule might be the first step in the development of HCC, going through phases of dysplastic nodule, early HCC and early advanced HCC in a multistep fashion. Fortunately, recent advances in various imaging techniques have facilitated the verification of these nodules. In this review, new nomenclature of small hepatocellular nodules, and detection and characterization of hepatic nodules in carcinogenesis with various imaging techniques are described with focus on the premalignant lesions and early stage of HCC. In addition, the efficacy of various imaging techniques for diagnosing them is discussed. Although the terms and definitions of these nodules are still variable and controversial, familiarity with the concept of these borderline lesions is important.     

The histology and development of hepatic nodules and carcinoma in C3H/He and C57BL/6 mice following chronic phenobarbitone administration.

Male C3H/He and C57BL/6 mice were given diets containing sodium phenobarbitone (PB) to allow a daily intake of 85 mg/kg. Control and treated animals were killed at 5, 30, 40, 60, and 80 wk. Other mice were killed in extremis or at the end of the respective experiments: 91 wk for C3H/He and 100 wk for the C57BL/6 animals. A basophilic nodule was found in 1/5 control C3H/He mice at 30 wk; these nodules increased in number with time so that nodules of this type were found in approximately 70% of animals by 91 wk. Nodules were not found in control C57BL/6 mice until 80 wk, when they were found in 4% of mice. PB treatment markedly increased the number of hepatic nodules in both strains of mice. The additional nodule burden was due to the development of a second nodule type formed of large cells with a predominantly eosinophilic cytoplasm. C3H/He animals given PB for 60 wk and then returned to a control diet bore fewer nodules at 91 wk than treated mice killed at 60 or 91 wk. The cumulative incidence of carcinoma in control C3H/He and C57BL/6 mice was 28 and 4%, respectively. The incidence of carcinoma was not increased by PB treatment in either strain. It is concluded that both strains of mice behave in a qualitively similar way to PB administration, although they show considerable quantitative differences in terms of the time and number of nodules that develop. Furthermore, the increased nodule numbers associated with PB treatment were not accompanied by an increase in the number of carcinomas.     

ATYPICAL ACINAR CELL NODULES OF THE HUMAN PANCREAS

The earliest morphological evidence of altered growth potential of pancreatic acinar cells of the rats treated with carcinogen, such as azaserine, is the development of nodules of atypical acinar cells, some of which are considered to appear, eventually, as acinar cell carcinomas. On the other hand, there exist nodular lesions in the human pancreas, which are similar to atypical acinar cell nodules of the rats, in the sense of nodularity, multiplicity, size, and cytological features, such as pale cytoplasm. To clarify the plausibility of the human nodular lesions as a precursor of acinar cell carcinoma of the pancreas, light and electron microscopical studies were performed, using pancreases of 115 semi-consecutive series of autopsy cases and 20 surgical cases. Multiple nodular lesions were found in 3 autopsy cases and one surgical cases. Ultrastructurally, markedly dilated cysterna of rough-surfaced endoplasmic reticulum and intracisternal granules were the most prominent characteristics of the atypical cells of the nodules. These features are neither reported in chemically induced atypical acinar cell nodules and carcinomas nor in human acinar cell carcinomas. The human lesions were considered to be of degenerative nature rather than neoplastic.     

Atypical acinar cell nodules of the human pancreas

The earliest morphological evidence of altered growth potential of pancreatic acinar cells of the rats treated with carcinogen, such as azaserine, is the development of nodules of atypical acinar cells, some of which are considered to appear, eventually, as acinar cell carcinomas. On the other hand, there exist nodular lesions in the human pancreas, which are similar to atypical acinar cell nodules of the rats, in the sense of nodularity, multiplicity, size, and cytological features, such as pale cytoplasm. To clarify the plausibility of the human nodular lesions as a precursor of acinar cell carcinoma of the pancreas, light and electron microscopical studies were performed, using pancreases of 115 semi-consecutive series of autopsy cases and 20 surgical cases. Multiple nodular lesions were found in 3 autopsy cases and one surgical cases. Ultrastructurally, markedly dilated cysterna of rough-surfaced endoplasmic reticulum and intracisternal granules were the most prominent characteristics of the atypical cells of the nodules. These features are neither reported in chemically induced atypical acinar cell nodules and carcinomas nor in human acinar cell carcinomas. The human lesions were considered to be of degenerative nature rather than neoplastic.     

Arterial elements and perisinusoidal cells in borderline hepatocellular nodules and small hepatocellular carcinomas

Borderline hepatocellular nodule in the human cirrhotic liver is considered a preneoplastic lesion of hepatocellular carcinoma (HCC). However, the angiogenetic process and changes in perisinusoidal cells (fat-storing cells or Ito cells) during the borderline nodule-HCC sequence have not been investigated. We have investigated intraparenchymal arterial elements and perisinusoidal cells in normal livers, chronic hepatitis, borderline nodules and small HCC, using an immunohistochemical staining for α-smooth muscle actin. In normal livers, chronic hepatitis, cirrhotic nodules and large regenerative nodules, no or few arterial elements were present in the parenchyma, and α-smooth muscle actin-positive perisinusoidal cells were not increased. In borderline nodules, however, there were many intranodular arterial elements, and perisinusoidal cells were significantly increased. In small HCC, there were much more arterial elements, and perisinusoidal cells were increased further. These data suggest that angiogenesis first occurs in borderline hepatocellular nodules and it gradually proceeds during the nodule to HCC sequence along with an increase in perisinusoidal cells. The demonstration of arterial elements and perisinusoidal cells may be useful for the differential diagnosis of large regenerative nodule, borderline hepatocellular nodule and small HCC.     

Focal hyperplastic hepatocellular nodules in hepatic venous outflow obstruction: a clinicopathological study of four patients and 24 nodules

AIMS: In hepatic venous outflow obstruction (Budd-Chiari syndrome), focal hepatocellular nodules are occasionally discovered showing variable morphology. These could be interpreted either as neoplastic (adenoma), regenerative (large regenerative nodule) or reactive to abnormal vasculature (focal nodular hyperplasia). The aim of this study was to investigate their histogenesis and to determine their morphological characteristics in order to provide diagnostic criteria. MATERIAL AND METHODS: Twenty-four hepatocellular nodules were studied, which were found in three explanted livers and in one additional autopsied liver from four patients with Budd-Chiari syndrome. As controls, we employed three explanted livers without nodules from patients who also suffered from Budd-Chiari syndrome. We attempted to classify the nodules morphologically as either adenoma-like, large regenerative nodule or focal nodular hyperplasia-like, using criteria from the literature. RESULTS: Out of the four cases, we observed two nodules in each of two livers, five in the third one and up to 15 in the remaining one. The size of the nodules ranged from 4 to 25 mm. Eleven nodules could be categorized as large regenerative nodules (two of them with a central scar), seven as focal nodular hyperplasia-like and six as adenoma-like. Some large regenerative nodules showed proliferated arteries with muscular hyperplasia similar to that seen in focal nodular hyperplasia. In the individual livers we could find nodules of various categories. Patchy or diffuse monoacinar regeneration was seen in most cases (six out of seven cases) in the macroscopically non-nodular liver parenchyma. In addition, thrombotic obstruction of portal vein branches was present in all except one of the nodular cases, but in none of the controls. Thus, it appears that portal venous obstructions are frequently, but not invariably associated with the development of nodules. CONCLUSIONS: The hepatocellular nodules seen in livers from patients with Budd-Chiari syndrome share morphological characteristics with large regenerative nodules, focal nodular hyperplasia and hepatocellular adenomas. Their multiplicity, the existence of mixed lesions, the frequent hepatocellular regenerative background as well as the frequently associated portal venous obstructions suggest that these nodules are regenerative in nature and conditioned by an uneven blood perfusion throughout the liver. In their differential diagnosis, the clinicopathological context in which they occur is of paramount importance and should allow recognition that those resembling adenomas may not be true neoplasms.     

Severe cytological atypia (large cell change) in focal nodular hyperplasia with numerous mallory bodies. A benign (adaptive) change?

Focal nodular hyperplasia (FNH) is a benign hepatocellular lesion composed of hyperplastic appearing hepatocytes arranged in nodules separated by fibrous septa that usually form a central stellate scar. Rare lesions that show unusual cytological or architectural features were reported as variants of focal nodular hyperplasia. We present the morphological features of a case of FNH with severe cytological atypia (so-called large cell change) in a 73-year-old man. In addition to diffuse cytological atypia, Mallory hyaline bodies were found in almost all lesional cells. This rare variant of FNH should be differentiated from other neoplastic lesions, in particular from the fibrolamellar variant of hepatocellular carcinoma.     

An immunohistochemical study of calcitonin-containing cells in benign and malignant thyroid lesions

Parafollicular cells (C-cells) in benign and malignant thyroid lesions were studied immunohistochemically with a polyclonal anti-calcitonin (CT) antibody. The C-cells were seen most frequently in the middle third of the lateral lobes in the thyroid gland of normal individuals and patients with Graves' disease and chronic thyroiditis, although in the latter the number of such cells was significantly decreased (p less than 0.05). In adenomatous goiter, C-cells were present in nodular lesions from an early stage of nodule development (frequency about 19%), whereas in the later stage these cells were rarely observed inside type 1 nodules, which were generally characterized by an admixture of follicles with considerably different sizes. However, C-cells were not observed inside type 2 nodules, which were composed of similar-sized follicles, or in the parenchyma of 56 cases of benign and malignant thyroid tumors. These findings suggest that since C-cells are present in nodular lesions, the histogenesis of adenomatous goiter is quite different from that of follicular adenoma; thyroid neoplasms generally contain no C-cells in the parenchyma.     

Adenomatoid nodules are the main cause for discrepant histology in 234 thyroid fine-needle aspirates reported as follicular neoplasm

According to several large studies, the surgical pathologist renders a non-neoplastic diagnosis in ～20-40% of thyroid fine-needle aspiration (FNA) cases reported as follicular neoplasm. This study analyzes the cause of this poor correlation between cytology and histology. Cases consisting of oncocytic (Hurthle) cells were excluded from study. During the study period from January 1996 to April 2010, histologic follow-up was available for 234 of 670 cases (34.9%) reported as follicular neoplasm on ultrasound-guided thyroid FNA. Sonographic and Doppler data were available in all cases and included nodule location, size, echogenicity, and vascularity. Of the 234 aspirates with follow-up, surgical pathology reported 130 cases (55.6%) of follicular adenoma, 15 cases (6.4%) of follicular carcinoma, 14 cases (6.1%) of follicular variant of papillary carcinoma, and 75 cases (32.3%) of nodular goiter. Recuts of those index nodules reported as nodular goiter were examined independently by two pathologists using the 2× objective lens. Adenomatoid nodule was defined as an insufficiently encapsulated "blue" nodule of increased nuclear density when compared with the surrounding thyroid. Of the 75 cases reported as nodular goiter, 60 index nodules (80%) fulfilled the described criteria for adenomatoid nodule, while 15 did not. In conclusion, adenomatoid nodules are the main cause of poor histologic correlation with follicular neoplasm reported by FNA. If "increased nuclear density at scanning magnification" were adopted by surgical pathologists as the major diagnostic criterion for follicular adenoma rather than encapsulation, noncorrelated cases would be reduced from 32 to 6.4%.     

Histopathological and morphometric analysis of atypical adenomatous hyperplasia of human cirrhotic livers

Atypical adenomatous hyperplasia (AAH) is a hyperplastic parenchymal nodular change in the cirrhotic liver, in which overt hepatocellular carcinoma (HCC) occasionally arises. AAH is defined as a sizable hepatocellular nodule with a variable degree of hepatocellular atypia not regarded as HCC, and is different from ordinary adenomatous hyperplasia in which hepatocellular atypia is absent. In the present study, we attempted to evaluate carcinogenetic processes and to find histological variables which indicate malignant transformation in AAH, using 49 surgically resected or autopsied nodules. AAH frequently showed morphological heterogeneity. Atypical lesions within AAHs were divisible into the following three categories from overall histopathological appearances: malignant (A), equivocal (B), or non-malignant (C) lesions. Analysis of combination of these three lesions, which were frequently intermixed in a given AAH, suggested that B lesions appear subsequent to C lesions, and A lesions finally appear in AAH nodules. Among the 14 histological variables, enlargement, hyperchromasia and irregular contour of nuclei were found to correlate well with A lesions. Increased nuclear density, iron resistance, reduction of reticulin fibres, clear cell change, sinusoidal dilatation and presence of abnormal arteries were suggestive of A or B lesions. Nuclear deviation toward the sinusoids, acinar and compact arrangements, fatty change and Mallory's hyaline alone were not useful indicators of A or B lesions. These results indicate that AAH is a preneoplastic or borderline lesion in which overt HCC is likely to evolve through several steps. Although a needle liver biopsy is a useful tool for diagnosis of benign, equivocal and malignant hepatocellular nodular lesions, the needle biopsy specimen should be carefully evaluated by considering the morphological heterogeneity of the AAH and a variable combination of 14 histological variables.     

ADENOMA WITH MULTIPLE HYPERPLASTIC NODULES IN NONCIRRHOTIC LIVER POSSIBLY RELATED TO LONG-TERM ADMINISTRATION OF A HYPOLIPIDEMIC DRUG

Described here is an autopsy case of a 76-year-old woman with preneoplastic and other adenomatous hepatocellular lesions. Multiple small hyperplastic liver foci with PAS positive reaction and adenomatous nodular lesions were noted in a non-cirrhotic liver. These lesions resembled altered foci or neoplastic nodules which are currently regarded as premalignant changes in experimental animal models. It is suggested that the liver lesions of this woman may be related to long-term administration of hypolipidemic drug cloflbrate for hypercholesteremia and the lesions could be one of the precursor changes of human hepatocellular carcinoma.