Gross examination

The examination of organs and tissues macroscopically in order to establish a diagnosis and to select relevant portions for subsequent microscopic examination and special studies is fundamental to the practice of pathology. In the autopsy room, in the surgical pathology laboratory and, very often, in the operating room, gross pathology is the essential, underlying basis of morphologic diagnosis. Diagnoses on the basis of gross examination can be accurately made in as many as 90 % of specimens (Grossman IW, A primer of gross pathology, Charles C Thomas, 1972). In the remaining 10 % the skilled pathologist can be close to the diagnosis or can, at least, construct an accurate differential diagnosis that can provide guidance for subsequent studies. Sadly the numbers of pathologists with skills in macroscopic ("gross") pathology is rapidly declining, with concomitant loss in the quality of gross examinations, lower accuracy and elegance of specimen descriptions, and lack of precision in sample selection for special studies. This clearly impacts the quality of surgical pathology practice and, inevitably, the quality of patient care. The decline of gross pathology is a result of a number of factors, including a marked decrease in the numbers of autopsies which means that there are fewer opportunities for pathologists to hone gross pathology skills and to gain proficiency in handling tissues for appropriate further study. This is compounded by an increasing reliance on pathologists' assistants (PAs) for the handling, description and sampling of gross specimens, by the expanded utilization of biopsies rather than resections prior to initiating therapy and by the reliance on highly sophisticated immunopathology, molecular and genomic methods for diagnosis and even for determination of therapy. Despite these and other changes in medical and pathology practice, careful examination of the gross specimen is still the sine qua non of surgical and autopsy pathology practice.

Primary hepatocellular carcinoma ("hepatoid" carcinoma) of the pancreas: a case report and review of the literature

Key Clinical Message

We present a case of hepatocellular carcinoma located within the pancreas. These tumors occur in the body and tail of the pancreas, with a male predominance, and at a younger age. Tumors with pure hepatocellular histopathology have better survival and recurrence rates and should be offered surgical therapy if possible.

Infective endocarditis: a history of the development of its understanding

Inflammation of the inner layer of the heart, especially the valvular endothelium, chordae tendinae and mural endocardium was first recognized almost 350 years ago. Over the years it has had many names, but is now generally designated infective endocarditis (IE) and has an associated infectious agent. A sterile vegetative process can also affect the valves and is usually referred to as Libman-Sacks endocarditis. The developments of medical science that allowed for our understanding of this entity included refinement of the autopsy, medical microscopy, microbiology, and in recent years, molecular studies. Some observations were misleading but clarification particularly followed the reports of Morgagni, Osler and Libman. As understanding of the pathobiology of infective endocarditis grew so did the effectiveness of therapy. This paper provides a detailed history of the development of the concept of Infective endocarditis citing many key morphological observations and concludes with brief comments about current concepts of pathogenesis as well as a few remarks about therapy.

Thomas Hodgkin: the "man" and "his disease": humani nihil a se alienum putabit (nothing human was foreign to him)

Thomas Hodgkin (1798-1865) was one of the leading physicians and scientists of the nineteenth century. A renowned diagnostician, he carried out pioneering work in public health, but devoted the greater part of his career to the study of pathology. His contributions transcend many fields, medical and non-medical, but his most important legacy to medical science was the recognition of the disease that bears his name. The diagnosis of Hodgkin's disease was difficult pending recognition of the "peculiar giant cells" that came to characterize the diagnosis. With identification of the Reed-Sternberg cell, it might have been expected that debate concerning the nature of Hodgkin's disease would be stilled. History proved to the contrary. A fierce controversy ignited with respect to the cellular origin of the Reed-Sternberg cell and the relationship, if any, of Hodgkin's disease to other malignant processes arising in the "absorbent glands and spleen." For a century, arguments ebbed and flowed, reflective of individual opinions and changing concepts, yielding ultimately to new methods for examining and identifying cells.

Interobserver and intraobserver variability in evaluating vascular invasion in hepatocellular carcinoma

BACKGROUND AND AIM

Hepatocellular carcinoma (HCC) is unique in that the presence of vascular invasion significantly changes tumor stage. Even though searching for vascular invasion is a common practice in surgical pathology, there appears to be a great variation among pathologists in its recognition. This study was designed to assess whether HCC could be accurately staged using vascular invasion as a staging parameter.

METHODS

The interobserver and intraobserver agreement for vascular invasion was analyzed in 126 liver resections for HCC. Selected slides were circulated twice among six pathologists for independent review using their own criteria. One to three representative images from 26 equivocal cases selected by one of the authors were re-evaluated by the pathologists. The presence or absence of vascular invasion on each slide or image was recorded as yes or no. The results were analyzed using unweighted kappa statistic analysis for multiple raters.

RESULTS

The interobserver agreement was moderate on two slide circulations with kappa values of 0.50 (95% confidence interval 0.45-0.55) and 0.43 (0.38-0.47), respectively. The kappa value dropped significantly to 0.19 (0.09-0.29) on selected images photographed from controversial cases. The intraobserver agreement was moderate, with kappa values ranging from 0.23 to 0.56 (mean = 0.45).

CONCLUSIONS

Pathologists can reproducibly recognize vascular invasion in many HCC cases but may have difficulty in equivocal cases, which may lead to either understaging or overstaging of the tumors. This may have a significant impact on prognostic assessment and therapeutic decision making. Our observations indicate the need for improved definition for vascular invasion in HCC.

Tityus: a forgotten myth of liver regeneration

The ancient Greek myth of Tityus is related to liver regeneration in the same way as the well known myth of Prometheus is. Depictions of the punishment of Prometheus are frequently used by lecturers on liver regeneration; however, Tityus remains unknown despite the fact that he received the same punishment and his myth could also be used as a paradigm for the organ's extraordinary ability to regenerate. Nevertheless, there is no convincing evidence that ancient Greeks had any specific knowledge about liver regeneration, a concept introduced in the early 19th century. We describe and analyze the myth of Tityus and compare it to the myth of Prometheus. We also explore artistic and literary links and summarize recent scientific data on the mechanisms of liver regeneration. Finally, we highlight links of the legend of Tityus with other sciences.

Surgical pathology in the 20th century at the Mount Sinai Hospital, New York

How did the education of surgical pathology, and pathology in general, differ at Mount Sinai? Passing the examination of the American Board of Pathology was never the focus of the department. Learning criteria or quoting references was de-emphasized, but mastery of macroscopic pathology was required, supported in both word and action by two brilliant surgical pathologists, Otani and Kaneko, and by two extraordinary medical pathologists, Klemperer and Popper. Meticulous microscopy emphasized pattern rather than reliance on lists of discrete features. Otani developed a regular "problem case" meeting for a community of pathologists, made up of alumni and other interested pathologists, as well as active department members. These monthly sessions provided the highest level of "continuing medical education." Otani and Kaneko unequivocally believed in learning from cases, and Mount Sinai residents were fortunate both in the one-to-one teaching and in the wealth of material, in all systems, that came to surgical pathology. Outstanding pathologists who came from Mount Sinai settled throughout the country and provided the highest level of diagnoses, but, with the exception of Bernard Wagner, Emanuel Rubin, Fiorenzo Paronetto, Richard Horowitz, Michael Gerber, Marc Rosenblum, Bruce Wenig, Jaishree Jagirdar, Swan Thung, Cesar Moran, Hideko Kamino, Philip LeBoit, Alberto Marchevsky, and others, there were relatively few academic leaders. Otani and Kaneko did not have national reputations. Klemperer, although world renowned, was relatively unassuming, and his disciples numbered almost as many nonpathologists as pathologists. Popper did establish a major center for liver pathology, with students coming from around the world, but did not particularly promote general surgical pathology. Can the Mount Sinai approach still be applied? The decline in the numbers of autopsies performed, the demands for rapid turnaround time, the de-emphasis of gross pathology as newer technologies (eg, immunohistochemistry, cytogenetics, molecular pathology) gain place, the increasing tendency to select investigators, including basic scientists, as teaching department chairs and the financial constraints requiring increasing use of nonphysician workers all speak to the relegation of the Otani-Kaneko era to history. Is this a loss to Pathology? It is certainly a style of practice that has been lost. However, there is no reason to bemoan the state of Pathology in the beginning years of the 21st century. Pathology practice is outstanding at many medical centers throughout the world, including at Mount Sinai under the very able and creative leadership of Alan Schiller, who has presided over great enhancements of the department in both anatomic and clinical pathology, including significant advances in the study of diseases by molecular methods. Surgical Pathology at Mount Sinai has been led by James Strauchen, a renowned hematopathologist recruited by Schiller's predecessor, Jerome Kleinerman, and is currently directed by Ira Bleiweiss, a student of Kaneko. Other techniques and technologies have, to a degree, compensated for some of the changes since the Otani-Kaneko years and it is almost certain that advances in molecular pathology will allow for increasing sophistication in establishing diagnoses, and likely even grading and staging, probably even on blood, rather than tissue, samples. The science of Pathology will advance, as the art declines. Those who learned at Mount Sinai during the Otani-Kaneko years will, however, very likely tell you that they were privileged to have learned Pathology there and, especially, to have learned a distinct philosophy of Pathology under the guidance of caring, thoughtful, and especially gifted pathologists.

Application of immunohistochemistry to liver and gastrointestinal neoplasms: liver, stomach, colon, and pancreas

CONTEXT

Immunohistochemistry has become an integral component of the practice of pathology. Newer antibodies allow for increasingly precise diagnoses for tumors that previously could not be easily identified. Recently, immunohistochemical evaluations have begun to allow pathologists to actively assist in determining prognosis and even in selecting therapies.

OBJECTIVE

To summarize the usefulness of currently available immunostains for the study of liver and gastrointestinal system neoplasms and to make recommendations for panels of immunostains that can be particularly helpful.

DATA SOURCES

Information has been collected from recent literature as well as from personal experience and practice.

CONCLUSIONS

Many immunostains are now available for the practicing pathologist that allow for increasing accuracy in diagnosis of liver and gastrointestinal tract neoplasms. Panels of immunostains can be used to differentiate between various tumors and also to identify site of origin in the case of a metastatic neoplasm. Immunostains that allow for prognostic determinations and for guidance in the selection of chemotherapeutic agents can also be used by pathologists to assist in the management of patients with malignant tumors affecting the liver and gastrointestinal tract.

Primary hepatic carcinoid tumor presenting as Cushing's syndrome

Hepatic carcinoid tumors are very uncommon; most are clinically non-functional and very few present with the symptoms of carcinoid syndrome. ACTH-producing carcinoid tumors most commonly originate in the lung or thymus and present insidiously with bronchospasm and/or chest mass. Occasionally, ectopic ACTH syndromes have been reported in association with pancreatic islet cell tumors, medullary thyroid cancer, pheochromocytoma, small-cell lung carcinoma, and rarely, ovarian and prostate tumors. We report here a patient with an ectopic ACTH-secreting primary hepatic carcinoid tumor who presented with cushingoid appearance, profound proximal muscle weakness, severe lower extremity edema, and markedly elevated urinary free cortisol. ACTH levels were in the low normal range. A solitary vascular hepatic lesion was found on magnetic resonance imaging, which was isodense with the surrounding liver on octreotide scan and photopenic on an 18-fluorodeoxyglucose (18FDG)-positron emission tomography (PET) scan. Following surgical resection of the hepatic tumor, histopathology confirmed an ACTH-secreting neuroendocrine tumor (NET), the patient had complete resolution of hypercortisolemic symptoms and remains in remission, now 4 yr after hepatic tumor resection. This case reports the first ACTH-secreting primary hepatic NET presenting as ectopic Cushing's syndrome. Interesting aspects of this case include the presence of a pituitary incidentaloma, the low normal ACTH, and photopenia on 18FDG-PET imaging.

Relevance of the Autopsy as a Medical Tool: A Large Database of Physician Attitudes

Context.—Autopsy rates for patients dying in hospitals have declined from approximately 50% in the 1950s to 5% or less today.

Objective.—To investigate the nature of physician attitudes about autopsy in a large and varied population and to relate these attitudes to certain physician demographic variables.

Design.—A 10-question, anonymous, multiple-choice format questionnaire was distributed to all attending physicians at 4 hospitals: 2 that were university-affiliated (1 private and 1 public), 1 military, and 1 private nonuniversity-affiliated medical center. A total of 2608 surveys were distributed.

Results.—Three hundred eighty-eight (15%) physicians responded to the survey. Respondents agreed (77%) that autopsy results could affect their future medical practice, and disagreed (73%) that the accuracy of modern diagnostic procedures makes autopsy unnecessary. Most respondents (72%) disagreed that litigation concerns play a role in the decision to request autopsy. Spearman correlation coefficients found 9 significant relationships among the survey items, with many correlations reflecting statistically significant relationships between demographic and attitudinal variables.

Conclusions.—The survey data and statistical analysis confirm that respondents value the autopsy as a relevant clinical tool, in spite of declining requests. One of the most crucial factors influencing attitudes is the physician's level of experience with autopsy in training and practice. Among other interesting results was that strength of belief in autopsy relevancy correlates significantly (P = .003) with greater prior exposure to the autopsy. In a sense, the current low autopsy rates may be self-perpetuating because of the paucity of and decreasing experience with autopsy by succeeding generations of clinicians.

Living donor liver transplantation: histological abnormalities found on liver biopsies of apparently healthy potential donors

OBJECTIVE

With the continued shortage of deceased donor grafts, living donor liver transplantation has become an option for adult liver transplant candidates. In the non-transplant setting, liver biopsy is typically carried out to evaluate clinical or biochemical hepatic dysfunction. In living donor liver transplantation, assessment of histological abnormalities that are undetectable by serological, biochemical and radiological methods might play an important role in donor and recipient outcome.

METHODS

Seventy consecutive liver biopsies carried out as part of our evaluation of potential donor candidates for adult-to-adult or adult-to-child living donor liver transplants were analyzed.

RESULTS

Of the 70 potential donor candidates who underwent liver biopsy for evaluation for living donor liver transplantation, 67% had an unexpected abnormality, of which steatosis was the most common abnormality (38.5%). A variety of other histopathological abnormalities were found including granulomas of unknown etiology (7%), chronic hepatitis (6%) and a microabscess. None of the histological abnormalities had been suspected despite extensive clinical, serological or radiological investigation.

CONCLUSIONS

Among the 70 potential donor candidates for living donor liver transplantation, 34% had unremarkable liver biopsies. The most common abnormality was steatosis (38.5%). These findings suggest that all potential candidates for living donor liver transplants should undergo screening liver biopsies. The precise significance of these changes remains to be determined, including which of these changes are contraindications to liver transplantation. These findings may also have implications in the non-transplant setting as changes ascribed to specific etiologies for liver disease might include changes occurring in apparently healthy individuals.

Imatinib (Gleevec)-induced hepatotoxicity

Imatinib (Gleevec, Novartis Pharmaceuticals Corp, East Hanover, NJ) is widely used in the treatment of chronic myelogenous leukemia and gastrointestinal stromal tumors. To our knowledge, only one case report of histologically proven Imatinib-induced hepatotoxicity has been reported. We describe another case of hepatotoxicity in a 22-year-old woman including the histopathologic changes and the clinical course after the discontinuation of Imatinib.

Early Hepatic Nodular Hyperplasia and Submicroscopic Fibrosis Associated With 6-Thioguanine Therapy in Inflammatory Bowel Disease

BACKGROUND

6-Thioguanine (6-TG) has been used as an alternative thiopurine for inflammatory bowel disease (IBD) patients not responsive to or intolerant of azathioprine (AZA) and 6-mercaptopurine (6-MP). 6-TG-related hepatotoxicity, including liver biochemistry value elevations, sinusoidal collagen deposition on electron microscopy, and veno-occlusive disease, have been described related to its use as therapy for neoplastic disease.

METHODS

We studied 38 liver biopsies from patients treated with 6-TG, almost all of whom (n = 125) received 6-TG for 1 to 3 years at the Inflammatory Bowel Disease Center at Cedars-Sinai Medical Center. All biopsies were fixed in 4% buffered formalin and prepared in the usual manner. Hematoxylin and eosin, Masson's trichrome (trichrome), and reticulin silver impregnation (reticulin) stained slides were studied. In 23 cases, tissue was also prospectively fixed in glutaraldehyde and processed for electron microscopy.

RESULTS

In 20 of the 37 patients studied (53%), nodular regeneration of varying degree was seen with reticulin. In only 4 of these 20 instances (11% of the total) were the changes seen with hematoxylin and eosin and in 3 of the 4, only in retrospect after studying the reticulin preparation. Minimal fibrosis was seen with trichrome in only 13 biopsies (34%), but sinusoidal collagen deposition was observed in 14 of the 23 cases studied with electron microscopy (60%). The biopsy from the 1 patient with nodular hyperplasia obvious with hematoxylin and eosin also demonstrated changes of venous outflow obstruction.

CONCLUSIONS

6-TG-treated IBD patients are at significant risk for nodular hyperplasia, early fibrosis and, less often, venous outflow disease (Budd-Chiari). The natural history of these changes is unknown and follow-up biopsies are needed to determine histologic and clinical sequela. Patients not demonstrating nodular hyperplasia or fibrosis who continue with 6-TG because there are no better therapeutic choices should be periodically rebiopsied.

Nomenclature of the finer branches of the biliary tree: canals, ductules, and ductular reactions in human livers

The work of liver stem cell biologists, largely carried out in rodent models, has now started to manifest in human investigations and applications. We can now recognize complex regenerative processes in tissue specimens that had only been suspected for decades, but we also struggle to describe what we see in human tissues in a way that takes into account the findings from the animal investigations, using a language derived from species not, in fact, so much like our own. This international group of liver pathologists and hepatologists, most of whom are actively engaged in both clinical work and scientific research, seeks to arrive at a consensus on nomenclature for normal human livers and human reactive lesions that can facilitate more rapid advancement of our field.

Early Nodular Hyperplasia of the Liver Occurring With Inflammatory Bowel Diseases in Association With Thioguanine Therapy

Context.—Nodular hyperplasia (also referred to as nodular regenerative hyperplasia and nodular regenerative hyperplasia of the liver) is a sequel to therapy with thioguanine in patients with hematologic malignancies. Recently, 6-thioguanine has been used to treat patients with inflammatory bowel disease who have been resistant to other forms of therapy.

Objective.—To study liver biopsies from 3 patients with inflammatory bowel disease who had received thioguanine for more than a year, and who had elevated serum liver enzyme values and underwent percutaneous liver biopsy.

Design.—Percutaneous liver biopsies and histologic examinations were performed, including staining with the reticulin silver impregnation method.

Results.—All 3 patients had foci of nodular regenerative hyperplasia, which was best seen with the reticulin silver impregnation method.

Conclusions.—Thioguanine-treated inflammatory bowel disease patients are at risk for the development of nodular hyperplasia. Reticulin-stained histologic sections are necessary to recognize this change. Further studies are needed to determine the frequency and significance of this change.

6-thioguanine can cause serious liver injury in inflammatory bowel disease patients

BACKGROUND & AIMS

Thioguanine (6-TG) has been studied as an alternative thiopurine in inflammatory bowel disease (IBD). Short-term safety and efficacy data were favorable. Experience with 6-TG in patients with acute lymphoblastic leukemia raised long-term safety concerns when implicated in nodular regenerative hyperplasia (NRH) of the liver and portal hypertension. The aim of this study was to describe the association between 6-TG and NRH in IBD.

METHODS

Liver chemistries and complete blood counts were monitored, and patients were encouraged to undergo liver biopsy. Clinical data were collected by chart review, and associations were tested by univariate and multivariable analyses. Patients were classified based on the presence (group 1) or absence (group 2) of laboratory abnormalities.

RESULTS

Laboratory abnormalities occurred in 29 of 111 patients (26%). Elevations of liver enzymes and a decrease in platelet counts (<200,000) were most commonly observed. Male gender (odds ratio, 2.9; 95% CI, 1.1-7.3; P < 0.03) and preferential 6-methylmercaptopurine production on 6-mercaptopurine/azathioprine (odds ratio, 3.0; 95% CI, 1.2-7.4; P < 0.04) were independently associated with laboratory abnormalities. No association was seen with duration of 6-TG treatment, cumulative dose, or 6-TG nucleotide levels. The median increase in alanine aminotransferase, aspartate aminotransferase, and alkaline phosphatase levels was 39, 30, and 75 U/L, respectively, in group 1, and the median decrease in platelet count was 115,000 in group 1 versus 7000 in group 2 (P < 0.001). NRH occurred in 76% of patients undergoing biopsy in group 1 and 33% in group 2.

CONCLUSIONS

NRH is a common finding in 6-TG-treated patients with IBD. The progression or reversibility of NRH remains unknown. Our findings suggest that 6-TG should not be considered as therapy for patients with IBD.

Cartilaginous metaplasia in calcified diabetic peripheral vascular disease: morphologic evidence of enchondral ossification

The mechanism of arterial calcification is not clear. We examined histological sections of major arteries from lower extremities of two patients with longstanding type II (or non-insulin-dependent) diabetes mellitus, and found morphological evidence of cartilaginous metaplasia and ectopic ossification with associated severe medial arterial calcification and atherosclerosis. Hematoxylin and eosin, alcian blue, and toluidine blue stains were applied for the demonstration of cartilage cells and their specific matrix proteins, and immunohistochemical studies for type II collagen. To our knowledge, cartilaginous metaplasia has not previously been described in medium-sized human muscular arteries. This observation supports the hypothesis that active enchondral ossification may be a pathway leading to arterial calcification in diabetic obstructive peripheral vascular disease.

Comparative immunohistochemical profile of hepatocellular carcinoma, cholangiocarcinoma, and metastatic adenocarcinoma

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.

Hepatitis B and hepatitis C

Hepatitis B and C are worldwide infectious hepatitides which are distinct in terms of epidemiology and molecular biology, but which may be quite similar in terms of clinical manifestations and histopathology, in both the acute and chronic stages. Hepatitis B virus (HBV), the human prototype of the Hepadnaviridae family of viruses is not directly cytopathic and viral hepatitis is caused by the cellular immune response to HBV. Patients infected with HBV may also have hepatitis D (delta) virus (HDV) infection, either as co-infection or a superinfection. Hepatitis D virus does not infect independently. Better control of HBV has also led to a decline in the incidence of HDV. Hepatitis C virus (HCV) is on of the Flaviviridae family of viruses, and is quite heterogeneous, with six major genotypes and more than 100 subtypes. Hepatitis C virus circulates as quasispecies that result from mutations accumulated over time, which probably enable HCV to replicate efficiently or resist immune mechanisms. Quasispecies have complicated vaccine development. Both HBV and HCV will recur in the transplanted liver. The risk of developing hepatocellular carcinoma is significantly greater in both HBV- and HCV-infected individuals.

Transmission of hepatitis B infection from hepatitis B core antibody--positive liver allografts is prevented by lamivudine therapy

Donor shortage has led to the use of hepatitis B core antibody (anti-HBc)--positive (anti-HBc(+)) liver allografts for patients in need of relatively urgent orthotopic liver transplantation (OLT). Because anti-HBc(+) allografts transmit hepatitis B virus (HBV) infection at a high rate, effective prophylaxis is required. We assessed the effectiveness of lamivudine in preventing HBV transmission by anti-HBc(+) allografts. Between March 1996 and March 2000 at Cedars-Sinai Medical Center (Los Angeles, CA), 15 of 169 patients (8.9%) received liver allografts from anti-HBc(+) donors. Six patients were hepatitis B surface antigen (HBsAg)(+) (group 1), and 9 patients were HBsAg negative (HBsAg(-); group 2) before OLT. All patients were administered lamivudine, 100 or 150 mg/d, orally after OLT. Patients who were HBsAg(+) before OLT also were administered hepatitis B immunoglobulin (HBIG) prophylaxis. Hepatitis B serological tests were performed on all patients, and HBV DNA was determined in liver tissues in 10 patients. All 15 patients remained HBsAg(-) at their last follow-up 2 to 40 months (mean, 17 months) post-OLT. All patients in group 1 had antibody to HBsAg (anti-HBs) titers greater than 250 mIU/mL post-OLT (mean follow-up, 20 months; range, 7 to 40 months). Of the 2 patients in group 1 who underwent liver biopsy after OLT, 1 patient had detectable hepatic HBV DNA despite being anti-HBs(+) and HBsAg(-). Among the patients in group 2, none acquired anti-HBc or HBsAg. Hepatic HBV DNA was undetectable in the 7 patients in group 2 who underwent liver biopsy after OLT. Anti-HBc(+) allografts can be safely used in patients who undergo OLT for chronic hepatitis B and susceptible transplant recipients if prophylaxis with combination HBIG and lamivudine or lamividine alone is administered after OLT, respectively. However, more data are needed to determine the efficacy of lamivudine monotherapy in preventing transmission of HBV infection from anti-HBc(+) liver allografts to susceptible recipients.

Primary liposarcoma of the liver: a case report and review of literature

Liposarcoma is a rare mesenchymal malignant tumor, which usually originates in the retroperitoneum and the extremities. Seven cases of primary liposarcoma of the liver have been previously reported. We present the eighth case, which occurred in an adult female patient. Primary liposarcoma of the liver, although extremely rare, must be considered in the differential diagnosis of a hepatic mass that develops in a noncirrhotic liver, especially in patients who are potential candidates for orthotopic liver transplantation. Liposarcoma is an absolute contraindication for liver transplantation.

Immortalized intrahepatic mouse biliary epithelial cells: immunologic characterization and immunogenicity

Nonsuppurative destructive cholangitis (NSDC), a process of T-cell-mediated destruction of biliary epithelia observed in primary biliary cirrhosis (PBC), graft-versus-host disease (GVHD), and hepatic allograft rejection (HAR), also occurs in the B10. D2-->BALB/c model of GVHD. To advance studies of immunopathogenesis in this murine model, we immortalized 4 BALB/c intrahepatic biliary epithelial cell (BEC) lines as a reliable source of target cells. Freshly isolated BEC, as well as each cell line, expressed cytokeratin-19 (CK-19), epithelial cell adhesion molecule (EPCAM) and cystic fibrosis transmembrane conductance regulator (CFTR). None expressed albumin. Immortalized cells also expressed SV40 large T antigen. Class I major histocompatibility complex (MHC) was expressed by >97% of immortalized cells, while class II MHC and intercellular adhesion molecule-1 (ICAM-1) expression ranged from 0% to 13% and 14% to 74%, respectively. Interferon gamma (IFN-gamma) induced aberrant class II MHC expression and increased expression of ICAM-1. Variable proportions of immortalized cells expressed B7-1/B7-2 molecules and FAS. IFN-gamma significantly reduced B7-1 expression in some lines and significantly increased B7-2 expression in others. Allografts of freshly isolated and immortalized BEC injected into subscapular fat pads spontaneously formed duct-like structures. Inflammation was absent in BALB/c recipients. In contrast, inflammatory lesions in B10.D2 recipients were reminiscent of NSDC. Our results indicate that BALB/c-immortalized intrahepatic biliary cells: 1) retain the phenotype of mouse BEC; 2) can be induced to express aberrant class II MHC and increased ICAM-1; 3) express costimulatory B7-1/B7-2 molecules and FAS; and 4) spontaneously form duct-like structures after in vivo injection that are immunogenic in B10.D2 mice. These cell lines should facilitate future studies of the immunopathogenesis of NSDC in the B10. D2-->BALB/c murine model.

Estimation of tumor stage and lymph node status in patients with colorectal adenocarcinoma using probabilistic neural networks and logistic regression

Staging colorectal adenocarcinoma on the basis of biopsy specimens could identify patients who might benefit from neoadjuvant therapy without undergoing resection first. In this study, we evaluated the ability of artificial neural networks with genetic algorithms and multivariate logistic regression to predict the stage of 99 patients with primary colorectal adenocarcinoma by analyzing age, tumor grade, and immunoreactivity to p53 and bcl-2 with use of endoscopically obtained biopsy specimens. We correlated results with regional lymph node status and tumor stage, identified in subsequent colectomy specimens. bcl-2 and p53 protein expression were demonstrated by immunohistochemical methods, using formalin-fixed, paraffin-embedded biopsy tissues. Tumor grade was evaluated in hematoxylinand eosin-stained sections. Patients were divided into training (n = 75) and testing cases (n = 24). Several probabilistic neural networks with genetic algorithm models were trained, using the four prognostic features as input neurons and regional lymph node status or stage as output neurons. Data were analyzed with univariate statistics and multivariate logistic regression. The cases were divided into training (n = 40) and testing (n = 59). The best two models classified correctly the lymph node status of 20 of 24 test patients (specificity, 80%; sensitivity, 85%; positive predictive value, 86%) and the tumor stage of 21 of 24 test patients (specificity, 82%; sensitivity, 92%; positive predictive value, 85%), respectively. Tumor grade and p53 protein were statistically significant (P < .05) by analysis of variance for lymph node status and tumor stage. Logistic regression models with these two independent variables correctly estimated the probability of lymph node metastases in 44 of 59 test cases and the tumor stage of 43 of 59 test cases, respectively. Results indicated the usefulness of probabilistic neural networks in the population studied, but the findings should be validated with large groups of patients.

Hepatocellular carcinoma with fibrolamellar pattern in a patient with autoimmune cholangitis

A 75-year-old woman with a 15-year history of autoimmune cholangitis underwent orthotopic liver transplantation because of progressive liver decompensation. A clinically unsuspected hepatocellular carcinoma was found. A portion of the tumor showed fibrolamellar differentiation. Hepatocellular carcinoma, either with the usual pattern or with a fibrolamellar pattern, is rare in the setting of primary biliary cirrhosis, but has been seen in the setting of autoimmune hepatitis. Autoimmune cholangitis is a relatively recently recognized form of autoimmune liver disease whose association with hepatocellular carcinoma has yet to be determined.

Novel human malignancy-associated gene (MAG) expressed in various tumors and in some tumor preexisting conditions

We have identified a novel human malignancy-associated gene (MAG) expressed in various malignant tumors including glioblastomas and hepatocellular carcinomas (HCCs) and in tumor preexisting conditions such as hepatitis C virus- and hepatitis B virus-induced liver cirrhosis. The expression of MAG was characterized using reverse transcription-PCR (RT-PCR), rapid amplification of cDNA ends PCR, RNA dot blotting, RNase protection assay, and Northern blot analysis. Rapid amplification of cDNA ends PCR yielded a 536-bp MAG fragment in HCC, macroregenerative liver nodules with dysplasia, and liver cirrhosis but not in normal liver or placenta. By RT-PCR, MAG expression was not found in 12 different normal tissues but found in 46 of 51 (90%) premalignant and malignant tissues of various sites. Embryonic liver and brain were positive for MAG expression together with tumors from the same organs, but the corresponding normal adult tissues were negative. By RNase protection assay, MAG mRNA was expressed in the HepG2 liver tumor cell line and in an ovarian carcinoma but not in normal liver. The estimated transcript size from Northern blot analysis was 8.8 kb. This novel gene may play a role in the progression of premalignant conditions and in the development of HCC and other cancers.

Terbinafine hepatotoxicity: case report and review of the literature

We report a patient who developed significant liver dysfunction following therapy with terbinafine. At the end of a 3 1/2-wk course of terbinafine, he developed progressive jaundice and pruritus. His serum bilirubin peaked at 30.9 mg/dl 3 wk after discontinuing terbinafine. A liver biopsy revealed mild to moderate mixed cellular infiltrate in the portal tracts, and hepatocellular and canicular cholestasis. His liver tests normalized 100 days after stopping terbinafine.