liver



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  • Normal

    • segments
    • zones
      • periportal = zone 1 = around portal tract
      • midlobular = zone 2
      • centrilobular = zone 3 = around central vein
    • portal tracts
      • portal vein: ~5x size of artery or duct
      • hepatic artery
      • bile duct: always present. 10% of small tracts can lack it. Ductopenia if otherwise.
    • parenchyma
      • architecture: cords or plates of hepatocytes, 2-3 cells thick.
      • hepatocytes
      • sinusoids: lined by endothelial cells, Kupffer cells, stellate cells.
      • bile canaliculi
      • canals of Herring
    • central vein
    • aging changes: lipofuscin, atrophy

  • Patterns

  • Non-neoplastic

  • WHO neoplasms

  • Grading

    • HCC (descriptive)
      • well differentiated: early lesions, usually < 2 cm
      • moderately differentiated: 3+ cell thick trabeculae, looks similar to normal hepatocytes
      • poorly differentiated: later lesions, pleomorphism
      • undifferentiated: contains little cytoplasm, solid growth
      • use highest grade found
    • HCC (Edmonson and Steiner, not widely used)
      • G1: rarely used
      • G2: looks similar to normal hepatocytes
      • G3: different from normal, but not overtly ugly
      • G4: ugly
      • use highest grade found
    • biliary carcinoma
      • G1: >95% glands
      • G2: >=50% glands
      • G3: >=5% glands
      • G4: <5% glands
    • Chronic hepatitis (Batts-Ludwig)
      • 0: none
      • 1: portal - patchy inflammation. Lobular - minimal necrosis.
      • 2: portal - mild inflammation, in some or all tracts. Lobular - mild hepatocellular damage
      • 3: portal - moderate inflammation in all portal tracts. Lobular - noticeable hepatocellular damage
      • 4: portal - severe inflammation, bridging necrosis. Lobular - diffuse hepatocellular damage
    • fibrosis/cirrhosis stage (Batts-Ludwig)
      • 0: none
      • 1: portal fibrosis
      • 2: periportal fibrosis, rare portal-portal septa
      • 3: septal fibrosis
      • 4: cirrhosis (nodules)
    • NAFLD activity score
      • fat
        • 0: minimal < 5%
        • 1: mild <= 33%
        • 2: moderate <= 66%
        • 3: marked 67+
      • balloon cells
        • 0: none
        • 1: few
        • 2: many
      • lobular inflammation
        • 0: none
        • 1: 1 foci per 20x field
        • 2: 2-4 foci per 20x field
        • 3: 5+ foci per 20x field

  • TNM (useful for grossing)

    • liver
      • T1: solitary tumor
      • T2: multiple tumors or vascular invasion
      • T3a: multiple and >5cm
      • T3b: portal/hepatic vein major branch involvement
      • T4: adjacent organ (non-gallbladder) invasion or visceral peritoneum perforation
    • biliary
      • Tis: intraductal
      • T1: solitary tumor
      • T2a: vascular invasion
      • T2b: multiple tumors
      • T3: visceral peritoneum perforation or extrahepatic invasion
      • T4: periductal invasion

  • Staging

    • liver
      • I: T1
      • II: T2
      • IIIA: T3a
      • IIIB: T3b
      • IIIC: T4
      • IVA: N1
      • IVB: M1
    • intrahepatic biliary
      • I: T1
      • II: T2
      • III: T3
      • IVA: T4 or N1
      • IVB: M1

  • Stains

    • trichrome: fibrosis
    • PASD: alpha1 antitrypsin deficiency globules
    • iron: hemosiderosis
    • copper: cholestasis, Wilson disease
    • reticulin: plate thickness
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