Liver-and-Pancreas 2022 by IHC001

Liver and Pancreas Pathology FRCPath Part 1 Course 19/07/2022

Dr Rohit Tewari Consultant Histopathologist Royal Lancaster Infirmary

Pla n

• MCQs and EMQs • Based on past papers • Certain topics keep coming up.....

1. A 46 year old male presents with jaundice and worsening liver function tests. A cholangiography reveals beaded appearance of the bile ducts. A liver biopsy is performed, which shows portal inflammation. Periduct oedema and concentric ‘onion skin’ fibrosis is also noted. Which of the following underlying conditions is the patient most likely to have? A. B. C. D. E.

Angiodysplasia of the colon Ulcerative colitis Primary biliary cirrhosis Wilson’s disease Haemochromatosis

Primary sclerosing cholangitis

• Typically associated with ulcerative colitis • Less commonly Crohn’s disease • Also in children and in the absence of inflammatory bowel disease.

2. A 52 year old male presents with multiple nodules in the right lobe of the liver showing enhancement in the arterial phase on CT scan. A needle biopsy of the mass shows a moderately differentiated adenocarcinoma with a tubular pattern of growth and focal clear cell change. It has the following immunoprofile: CK7 –ve, CK20 –ve, AFP –ve, mCEA –ve, canalicular positive staining for CD10 and pCEA, cytoplasmic positive staining for TTF1 and Hep Par 1 positive. What is the most likely diagnosis? A. B. C. D. E.

Fibrolamellar carcinoma Metastatic clear cell renal carcinoma Primary hepatocellular carcinoma Metastatic pulmonary carcinoma Cholangiocarcinoma

Immunohistochemistry in liver tumour biopsies

3. A 52 year old female presents with abdominal pain and vomiting. A CT scan demonstrates a cystic lesion in the tail of the pancreas, which is excised. On gross examination the cyst is multilocular and contains seromucinous fluid. On histology, the wall of the cyst shows focal calcification and contains a cellular ovary like stroma. The surface epithelium is extensively denuded. Which of the following is the cyst most likely to represent? A. B. C. D. E.

Serous cystadenoma Mucinous cystadenoma Intraductal mucinous neoplasm Lymphoepithelial cyst Pancreatic pseudocyst

•

Cysts of the pancreas Non neoplastic cysts – – – – – –

Pseudocysts Lymphoepithelial cysts Retention cysts Enterogenous cysts Parasitic cysts Endometrial cysts

• Neoplastic cysts – – – –

Serous cystic neoplasm Mucinous cystic neoplasm Intraductal mucinous neoplasm Solid-cystic pseudopapillary neoplasm

Serous cystadenoma

• Most common type of cystic neoplasm • Body/Tail • Predominantly in females

Mucinous cystadenoma

• Macrocystic • Almost exclusively in females • Tail

Mucinous cystadenoma

Other hepatobiliary/p ancreas topics

• Paeds (again) – Biliary atresia – Reye’s syndrome – Cystic fibrosis • Normal liver histology (zones) • Alcohol related liver disease – Ketoacidosis in autopsy cases • (Causes of cirrhosis) • (Hepatitis) • (Hepatic nodules and

Normal liver histology

Alcohol related liver disease

• Steatosis

– Fatty change – Perivenular fibrosis

• Hepatitis – Liver cell necrosis – Inflammation – Mallory bodies – Fatty change

Alcohol related liver disease

• Cirrhosi s

– Fibrosis – Hyper plastic nodule

• Ketoaci dosis • Autopsy case – normal blood

Causes of cirrhosis

• V WASH CABS – – – – – – – –

Viral hepatitis (10%) Wilson's disease Alcoholic liver disease (60-70%) Secondary biliary cirrhosis (gall stones, stricture) Hemochromatosis (Iron overload) Cryptogenic cirrhosis (Rare) α- antitrypsin deficiency (Rare) Biliary disease- primary biliary cirrhosis and secondary (stones, stricture) biliary cirrhosis – Sclerosing cholangitis

Hepatit is

• Types and transmission

– Health worker risks?

• Hep B antigens • Ischak grading

Hepatitis risks

• Following a single hollow needle stick innoculum :• HIV – • Hep B – • Hep C –

0.9 % 30 % 3%

• Wearing gloves reduces risk by x 10 – 100 • Mucous membrane or broken skin splash - risk is 0.09% for HIV, higher for Hep B

Hepatitis B antigens

Ischak scoring in hepatitis

Hepatic nodules and tumours

• Focal nodular hyperplasia • Nodular regenerative hyperplasia • Cirrhosis • Adenoma • Hepatocellular carcinoma • Metastasis

EXTRA QUESTIONS • Taken from all the resources I could find • GI definitely ‘under represented’ • Hopefully this should cover most topics

EMQ • Match the findings of liver biopsy with the correct diagnosis. • A IVDU, interface hepatitis, orcein granules in hepatocytes • Answer: Hepatitis B • B Female with biopsy showing numerous plasma cells within the portal tracts • Answer: Autoimmune hepatitis

EMQ • C Middle aged female with biopsy showing granulomas and lymphocytic infiltrates in portal tract • Answer: Primary biliary cirrhosis • D Man with history of alcohol excess. Macro and microvesicular steatosis and Mallory bodies • Answer: Alcoholic hepatitis

EMQ • E Young patient with cirrhosis and diabetes. PERLs positive material in hepatocytes. • Answer: Haemochromatosis

MCQ • A 32 year old intravenous drug user is admitted to hospital with jaundice. An ultrasound demonstrates a cirrhotic liver. • Identify the most likely cause. • A Hepatitis B • B Hepatitis C • C HIV • D Budd Chiari syndrome • E Idiopathic • (What is alcohol was in there?)

MCQ • A 3 month old boy presents with progressive jaundice and pale stool. A liver biopsy shows ductular proliferation with accumulation of bile in the hepatocytes. • Identify the most likely diagnosis. • A Cholelithiasis • B Hirschsprungs disease • C Biliary atresia • D Primary sclerosing cholangiitis • E Primary biliary cirrhosis

MCQ • A 52 year old alcohol dependent male is found dead at home. At autopsy he has a fatty liver but no cause of death is found. Toxicology shows a blood alcohol level of zero but elevated butyric acid levels. • Identify the correct cause of death • A Gastrointestinal haemorrhage • B Cirrhosis of the liver • C Alcohol related ketoacidosis • D Acute intoxication of alcohol

MCQ • A 3 year old child presents with a febrile illness. They are prescribed aspirin. They represent 6 days later with liver failure. • Identify the most likely change seen on liver biopsy. • A Fatty change • B Centrilobular necrosis • C Ductular proliferation and bile accumulation • D Interface hepatitis

MCQ • GIST IHC • Colorectal TNM staging • Cystic fibrosis gene product – Chloride channel • Zones of liver • IVDU with varices - ?test (Hep C) • Suspicious of GIST – CD117 negative ?other IHC (DOG1 or CD34)

MCQ • Baby born to type 1 diabetic mother becomes hypoglycaemic soon after birth. Why? – Islets continue to produce increased insulin

• Child with recurrent chest infection and failure to thrive. Diagnosis? – Cystic fibrosis

GOOD LUCK