surgical pathology of hepatobiliary tree and pancreas

Surgical Pathology of LIVER, BILIARY TREE

and PANCREASBY: NOEL C. SANTOS, MD

LEARNING OBJECTIVES

• Know the indications of doing biopsy, types of biopsy• Familiarize with the conditions that needed a biopsy for definitive

diagnosis and predict the clinical outcome• Familiarize with the terms used in the assessment of various

conditions• Know the approach in diagnosing masses

LIVER

• Involved in wide variety of non-neoplastic and neoplastic conditions• Indications for doing biopsy• Assess severity of liver disease - medical• Assess the nature of space occupying lesion - surgical• Evaluate prior to transplantation

• Types of biopsy• NEEDLE BIOPSY (Fine or Core), usually guided biopsy• TISSUE BIOPSY – during laparotomy

MEDICAL LIVER DISEASES

• Grading and Staging in Chronic Viral Hepatitis, Cirrhosis• Metabolic Disorders: Hemochromatosis, Wilson, Reye’s syndrome,

Acute Fatty Liver of Pregnancy, Alpha 1-Antitrypsin deficiency• Obstructive Jaundice

Viral hepatitis, liver, gross

• Grossly, there are areas of necrosis and collapse of liver lobules seen here as ill-defined areas that are pale yellow. Such necrosis occurs with hepatitis.

Viral hepatitis, liver, gross

• The necrosis and lobular collapse is seen here as areas of hemorrhage and irregular furrows and granularity on the cut surface of the liver.

Viral hepatitis B, liver, low power microscopic

• Viral hepatitis leads to liver cell destruction. A mononuclear inflammatory cell infiltrate extends from portal areas and disrupts the limiting plate of hepatocytes which are undergoing necrosis, the so-called "piecemeal" necrosis of chronic active hepatitis.

Viral hepatitis B, liver, high power microscopic

• Individual hepatocytes are affected by viral hepatitis. A large pink cell undergoing "ballooning degeneration" is seen below the right arrow. At a later stage, a dying hepatocyte is seen shrinking down to form an eosinophilic "councilman body" below the arrow on the left.

Viral hepatitis C, liver, high power microscopic

• The extent of chronic hepatitis can be graded by the degree of activity (necrosis and inflammation) and staged by the degree of fibrosis. In this case, necrosis and inflammation are prominent, and there is some steatosis. Regardless of the grade or stage, the etiology of the hepatitis must be sought, for the treatment may depend upon knowing the cause, and chronic liver diseases of different etiologies may appear microscopically and grossly similar.

Viral hepatitis C, liver, low power microscopic

• A case of viral hepatitis which is at a high stage with extensive fibrosis and progression to macronodular cirrhosis.

Alpha-1-antitrypsin deficiency, liver, PAS stain, microscopic

• The periportal red hyaline globules seen here with periodic acid-Schiff (PAS) stain are characteristic for alpha-1-antitrypsin (AAT) deficiency. The globules are collections of alpha-1-antitrypsin not being excreted from hepatocytes. This may eventually lead to chronic hepatitis and cirrhosis.

MRI Cirrhosis

Micronodular cirrhosis

Micronodular cirrhosis:

Macronodular Cirrhosis

Hemochromatosis of liver, gross

• The dark brown color of the liver, as well as the pancreas (bottom center) and lymph nodes (bottom right) on sectioning is due to extensive iron deposition in a middle-aged man with hereditary hemochromatosis (HHC).

Hemochromatosis Prussian blue stain for Iron

Alcoholic Fatty Liver

Alcoholic Fatty Liver

SURGICAL LIVER DISEASES

• Space occupying lesions• Primary Tumors• Metastatic Lesions

Examples:- Focal Nodular Hyperplasia (FNH)- Adenoma- Hepatocellular Carcinoma- Cholangiocarcinoma- Metastatic Carcinoma/Sarcoma- Pediatric Tumors: Hepatoblastoma- Bile Duct Hamartomas and Adenomas

GALL BLADDER

• Commonly removed with Cholelithiasis• Acute obstruction, distention, perforation/rupture• Tumors – uncommon• benign (polyps)• malignant (cholangiocarcinoma)

• Documentation: legal, insurance

Pancreas pseudocystLocal accumulation of pancreatic juice - occur after

pancreatitis

Pancreas - abscess

Occur after pancreatitis, Cause : colliquation necrosis Sterile, in case, no secondary infection occurs

Tumors of the pancreas

BenignMalignant

Causative agents

smoking

alcohol

high energy diet

Benign tumors of the pancreas

Serous cystadenomaCystic teratomaLymphangiomaInsulomaMesenchymal tumors

Pancreas carcinoma – symptoms(head-tail)Jaundice - Curvoisier signWeight lossPainPassage disturbancesMigrating thrombophlebitis (Trousseau)PancreatitisMetastasis

• Incidence has increased since 1950s• Smoking tobacco is the strongest associated feature;

weak alcohol effect• Coffee is not shown to increase risk• Genetics: BRCA and hereditary pancreatitis• Survival: 1 year – 10%; 5 years – 2.5%

Pancreatic Carcinoma

HEAD~70%

BODY5-10%

TAIL10-15%

Pancreatic Carcinoma

Islet cell tumors

Hormone production in 50% of the casesUncertain biological behaviourRound, well circumscribed lesions

InsulinomaGlucagonomaVIP-omaGastrinomaSomatostatinoma