Virtual Slidebox
Presented by the MGH Pathology Service

MICROSCOPIC FEATURES

• In adults, usually a nonspecific pattern of chronic hepatitis and cirrhosis
• Eosinophilic hyaline globules can be seen on H+E, predominantly in periportal hepatocytes
• Portal inflammation is variable (predominantly lymphocytic), and interface hepatitis usually mild or absent
• Bile ductular reaction seen only in endstage disease
• In neonates, there may be a picture of neonatal hepatitis, with canalicular cholestasis, giant cell transformation, ballooned hepatocytes, and loss of bile ducts

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MICROSCOPIC FEATURES

• Marked expansion of portal tracts by lymphocytic infiltrates. The extent of the infiltrate is beyond what is seen in chronic viral hepatitis, where portal tracts tend to have a relatively tight “cuff” of inflammation around them.
• The lymphocytic infiltrate is sheet-like and monotonous, rather than mixed and with a follicle-like architecture, as is usually seen in chronic viral hepatitis. In some cases, the lymphoid cells may show atypia.
• There is no interface hepatitis at the edge of the infiltrate, and there are no apoptotic hepatocytes in the lobule
• There is no associated periportal fibrosis, as is usually seen with the inflammatory infiltrates of chronic viral hepatitis

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MICROSCOPIC FEATURES

• Portal tracts are expanded by a mixed lymphoid infiltrate, which focally extends into the lobules
• The infiltrate contains lymphocytes, plasma cells, eosinophils, and scattered Reed-Stenberg cells
• The infiltrate may also involve bile ducts
• Sinusoidal dilatation and peliosis hepatis may also be present
• Epithelioid granulomas are found in ~10% of cases, usually in the portal tracts

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Female in her 40’s with abnormal LFTs.

MICROSCOPIC FEATURES

• Cords, nests, or single tumor cells embedded in myxoid matrix, with variable sclerosis and calcification
• Tumor cells may be dendritic (spindle- or stellate-shaped) or epithelioid, and have intracytoplasmic vascular lumina that may contain erythrocytes. These spaces should not be mistaken for signet-ring cells or glandular spaces
• Often multifocal or composed of confluent nodules
• At the edge, the tumor spares portal tracts and spread along sinusoids, causing atrophy of liver plates, and eventually obliterating central veins

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MICROSCOPIC FEATURES

• Nests of large polygonal cells, with abundant eosinophilic granular cytoplasm, separated by fibrous stroma
• The fibrous stroma is composed of thick, hyalinized bundles of collagen, arranged in parallel lamellae
• Cells may have cytoplasmic hyaline globules (containing alpha1-antytripsin), “ground glass”-like pale bodies (containing fibrinogen), Mallory’s hyalin, and bile
• Nuclei are large, hyperchromatic, and vesicular, with prominent nucleoli, but mitoses are uncommon

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Male in his 30’s, s/p bone marrow transplant. Liver biopsy.

• Proliferation of bland-appearing hepatocytes arranged in cords, without portal tracts or biliary epithelium
• Abnormal-appearing arteries (“unpaired arteries”) and thin-walled vessels are scattered throughout the tumor
• Cells may form pseudorosettes around canaliculi, but not acini
• Cells often contain fat or glycogen, so that the lesion looks paler than adjacent normal liver
• Bile production, hyaline globules, megamitochondria, and Mallory’s hyaline may be present
• May occasionally display focal mild atypia (especially when associated with androgenic steroid use) but mitoses are almost never seen
• May show various degenerative changes: evidence of prior hemorrhage; sinusoidal dilatation; large blood-filled (pelioid) spaces; myxoid stroma; fibrosis; necrosis; infarction
• Usually solitary but can be multi-focal; when >10, sometimes referred to as adenomatosis

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MICROSCOPIC FEATURES

• Composed of blood-filled spaces lined by a single layer of bland endothelium
• Contains variable amounts of fibrous stroma
• Vascular spaces may contain organizing fibrin or thrombi
• May undergo various degenerative changes with time, such as sclerosis, calcification, and involution

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MICROSCOPIC FEATURES

• Non-caseating epithelioid granulomas centered in portal tracts
• Lymphoplasmacytic “cuff” of inflammation surrounding granulomas
• Necrosis is uncommon, and tuberculomas are very rare
• Hepatic parenchyma is otherwise fairly normal in appearance

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MICROSCOPIC FEATURES

• May be epithelial or mixed epithelial-mesenchymal. Subclassified into six patterns:

1. Pure fetal (31% of cases): uniform cells, similar to normal hepatocytes, with slightly higher N:C ratio and variable amounts of glycogen, resulting in an alternating “light-and-dark” appearance at low power. The cells are usually arranged in trabeculae resembling normal liver, but with no portal structures. Extramedullary hematopoiesis is common.

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55 yo with adrenal nodule and large hepatic mass. Partial hepatectomy.

56 y/o M with MEN2A, FDG-avid liver and left adrenal lesions. Mildly elevated norepinephrine of 100 (nl<80). Liver biopsy.

Male in his 60’s with a history of fatty liver, ALT 97, AST 73, AIP 148

Male in his 20’s who first presented with jaundice and elevated liver enzymes at the age of 14.