Orcein positive granules in the hepatocytes in chronic intrahepatic cholestasis. Morphological, histochemical and electron X-ray microanalytical examination

Collagen proportionate area correlates with histological stage and predicts clinical events in primary sclerosing cholangitis

BACKGROUND & AIMS

Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease in need of accurate biomarkers for stratification and as surrogates for clinical endpoints in trials. Quantitative liver fibrosis assessment by collagen proportionate area (CPA) measurement has been demonstrated to correlate with clinical outcomes in chronic hepatitis C, alcohol-related and non-alcoholic fatty liver disease. We aimed to investigate the ability of CPA to quantify liver fibrosis and predict clinical events in PSC.

METHODS

Biopsies from 101 PSC patients from two European centres were retrospectively assessed by two expert pathologists in tandem, using grading (Ishak and Nakanuma) and staging (Ishak, Nakanuma, Ludwig) systems recently validated to predict clinical events in PSC. CPA was determined by image analysis of picro-Sirius red-stained sections following a standard protocol. We assessed the correlations between CPA, staging and grading and their associations with three outcomes: (1) time to PSC-related death, liver transplant or primary liver cancer; (2) liver transplant-free survival; (3) occurrence of cirrhosis-related clinical manifestations.

RESULTS

CPA correlated strongly with histological stage determined by each scoring system (P < .001) and was significantly associated with the three endpoints. Median time to endpoint-1, endpoint-2 and endpoint-3 was shorter in patients with higher CPA, on Kaplan-Meier analyses (P = .011, P = .034 and P = .001, respectively).

CONCLUSION

Quantitative fibrosis assessment by CPA has utility in PSC. It correlates with established histological staging systems and predicts clinical events. CPA may be a useful tool for staging fibrosis and for risk stratification in PSC and should be evaluated further within prospective clinical trials.

Validation of the prognostic value of histologic scoring systems in primary sclerosing cholangitis: An international cohort study

Histologic scoring systems specific for primary sclerosing cholangitis (PSC) are not validated. We recently determined the applicability and prognostic value of three histological scoring systems in a single PSC cohort. The aim of this study was to validate their prognostic use and reproducibility across a multicenter PSC cohort. Liver biopsies from PSC patients were collected from seven European institutions. Histologic scoring was performed using the Nakanuma, Ishak, and Ludwig scoring systems. Biopsies were independently scored by six liver pathologists for interobserver agreement. The prognostic value of clinical, biochemical, and all three histologic scoring systems on predicting composite endpoints 1 (PSC-related death and liver transplantation), 2 (liver transplantation), and 3 (liver-related events), was assessed using univariable and multivariable Cox proportional hazards modeling. A total of 119 PSC patients were identified, and the median follow-up was 142 months. During follow-up, 31 patients died (20 PSC-related deaths), 31 patients underwent liver transplantation, and 35 patients experienced one or more liver-related events. All three staging systems were independent predictors of endpoints 2 and 3 (Nakanuma system: hazard ratio [HR], 3.16 [95% confidence interval (CI), 1.49-6.68] for endpoint 2 and HR, 2.05 [95% CI, 1.17-3.57] for endpoint 3; Ishak system: HR, 1.55 [95% CI, 1.10-2.18] for endpoint 2 and HR, 1.43 [95% CI, 1.10-1.85] for endpoint 3; Ludwig system: HR, 2.62 [95% CI, 1.19-5.80] for endpoint 2 and HR, 2.06 [95% CI, 1.09-3.89] for endpoint 3). Only the Nakanuma staging system was independently associated with endpoint 1: HR, 2.14 (95% CI, 1.22-3.77). Interobserver agreement was moderate for Nakanuma stage (κ = 0.56) and substantial for Nakanuma component fibrosis (κ = 0.67), Ishak stage (κ = 0.64), and Ludwig stage (κ = 0.62).

CONCLUSION

We confirm the independent prognostic value and demonstrate for the first time the reproducibility of staging disease progression in PSC using the Nakanuma, Ishak, and Ludwig staging systems. The Nakanuma staging system-incorporating features of chronic biliary disease-again showed the strongest predictive value. (Hepatology 2017;65:907-919).

Chronic cholestatic liver diseases: clues from histopathology for pathogenesis

Chronic cholestatic liver diseases include fibrosing cholangiopathies such as primary biliary cirrhosis or primary sclerosing cholangitis. These and related cholangiopathies clearly display pathologies associated with (auto)immunologic processes. As the cholangiocyte's apical membrane is exposed to the toxic actions of the bile fluid, the interaction of bile with cholangiocytes and the biliary tree in general must be considered to completely understand the pathogenesis of cholangiopathies. While the molecular processes involved in the hepatocellular formation of bile are well understood in both normal and pathophysiologic conditions, those in the bile ducts of normal liver and in livers with cholangiopathies lag behind. This survey highlights key mechanisms known to date that are important for the formation of bile by hepatocytes and its modification by the biliary tree. It also delineates the clinical pathophysiologic findings for cholangiopathies and puts them in perspective with current experimental models to reveal the pathogenesis of cholangiopathies and develop novel therapeutic approaches.

Evaluation of a new histologic staging and grading system for primary biliary cirrhosis in comparison with classical systems

Recently, our research team proposed a new histologic staging and grading system for primary biliary cirrhosis (PBC) that takes into account necroinflammatory activity and histologic heterogeneity. The present study aimed to confirm the usefulness of the new evaluation system. A total of 152 liver biopsy specimens and clinical data (including outcomes in patients with PBC before treatment with ursodeoxycholic acid) were analyzed with respect to the new system. Staging was evaluated on the basis of 3 histologic components (fibrosis, bile duct loss, and deposition of orcein-positive granules), and grading was assessed on the basis of chronic cholangitis activity and hepatitis activity. Concurrently, the classical systems, that is, the Scheuer and Ludwig staging systems, were also assessed and compared with our new system. PBC cases showed different distributions in each stage of the 3 systems. The new staging and grading system reflected liver dysfunctions before specific treatment. This was on a par with the results obtained using the classical systems. Development of cirrhosis-related conditions correlated well with the new staging system compared with the 2 classical staging systems, and in particular, the amount of deposition of orcein-positive granules could reflect development of cirrhosis-related conditions (scores 0-1 versus scores 2-3 groups, P < .0001). In conclusion, the new PBC staging system was demonstrated to reflect clinicolaboratory features, and its progression was associated with the development of cirrhosis-related conditions.

The role of the pathologist in diagnosing and grading biliary diseases

Pathological features of primary biliary cirrhosis (PBC) are reviewed. Immune-mediated, non-suppurative cholangitis is the initial lesion and is followed by the gradual and extensive destruction of bile ducts and development of chronic cholestasis. Simultaneously, necro-inflammatory activities of the hepatic parenchyma and limiting plates of milder form develop not infrequently. Eventually, liver fibrosis and cirrhosis develop. A new system applicable to needle liver biopsies in which staging is evaluated using a combination of three factors (fibrosis, cholestasis, and bile duct loss) and necro-inflammatory activities of the bile duct and hepatic parenchyma are graded, is proposed. The clinical and therapeutic evaluation of PBC using this system is warranted.

Application of a new histological staging and grading system for primary biliary cirrhosis to liver biopsy specimens: Interobserver agreement

Recently the authors proposed a new staging and grading system for primary biliary cirrhosis (PBC) that takes into account necroinflammatory activity and histological heterogeneity. Herein is proposed a convenient version of this system. Scores for fibrosis, bile duct loss, and chronic cholestasis were combined for staging: stage 1, total score of 0; stage 2, score 1-3; stage 3, score 4-6; and stage 4, score 7-9. Cholangitis activity (CA) and hepatitis activity (HA) were graded as CA0-3, and HA0-3, respectively. Analysis of interobserver agreement was then conducted. Digital images of 62 needle liver biopsy specimens of PBC were recorded as virtual slides on DVDs that were sent to 28 pathologists, including five located overseas. All participants were able to apply this version in all 62 cases. For staging, kappa was 0.385 (fair agreement) and the concordance rate was 63.9%. For necroinflammatory activity, the kappa and concordance rate were 0.110 (slight agreement) and 36.9% for CA, and 0.197 (slight agreement) and 47% for HA, respectively. In conclusion, this new staging and grading system for PBC seems to be more convenient and practical than those used at present, but more instruction and guidance are recommended for the grading of necroinflammatory activity in practice.

Clinicopathological study of primary biliary cirrhosis negative for antimitochondrial antibodies

Primary biliary cirrhosis (PBC) is characterized by the occurrence of antimitochondrial antibodies (AMA) and the progressive destruction of intrahepatic bile ducts, followed by biliary cirrhosis. However, there are about 5% of PBC patients who show clinicopathological features of PBC but are negative for AMA. In this study, clinicopathological features, as well as antibody reactivity against recombinant (r)-mitochondrial polypeptides, were examined in 30 AMA negative PBC patients and 38 AMA positive PBC patients, in whom the presence of AMA had been determined by indirect immunofluorescence (IF). There were few differences in the clinical and serological features between both groups. Histopathologic features, including staging, bile duct lesions and granuloma, were also similar in both groups. Among the 30 IF-tested AMA negative patients, 29 were also negative against beef heart mitochondrial proteins, but 24 reacted to one or more of the following r-polypeptides, as determined by immunoblotting: E1 alpha of pyruvate dehydrogenase complex, the E2 subunit of pyruvate dehydrogenase complex, and the branched-chain 2-oxo-acid dehydrogenase complex. The remaining six AMA-negative patients were asymptomatic, and histologically resembled having stage 1 of the disease, with relatively mild lymphocytic piecemeal necrosis. One case was positive for anti-smooth muscle antibody. The other clinicopathological features of these patients were similar to those of other AMA negative patients. The present study found that a majority of the AMA-negative patients fulfilling other clinicopathological criteria of PBC, had features similar to the AMA-positive PBC patients, and that a majority of IF AMA-negative patients were positive for r-polypeptides of the 2-oxo-acid dehydrogenase complex. It seems that nearly all the AMA negative patients possess a broad spectrum of antibody profile of AMA, in addition to clinicopathological and serological features.

Granulomatous cholangitis in chronic hepatitis C: a new diagnostic problem in liver pathology

A case of chronic hepatitis C at the pre-cirrhotic stage complicated with hepatocellular carcinoma is reported. The patient, a 64 year old female, showed elevated levels of serum alkaline phosphatase and immunoglobulin M. Antimitochondrial antibodies were negative by indirect immunofluorescence. Western blotting using beef heart mitochondria and recombinant polypeptides coding for mitochondrial antigens revealed that the patient's serum was positive only for the E2-subunit of the branched chain ketoacid dehydrogenase complex. In the non-neoplastic liver, chronic non-suppurative cholangitis surrounded by epithelioid granuloma, resembling the granulomatous destructive cholangitis of primary biliary cirrhosis, was found. The damaged bile ducts were immunohistochemically minimally positive or ambiguous for HLA-DR, and their expression of the E2-subunit of the pyruvate dehydrogenase complex E2 (PDC-E2) was diffuse or granular, and not typical of primary biliary cirrhosis. There was no bile duct loss, and orcein-positive copper binding granules reflecting chronic cholestasis were negative in periportal hepatocytes. The overall features in this case were consistent with primary biliary cirrhosis presenting an infrequent profile of antimitochondrial antibodies and atypical expression of HLA-DR and PDC-E2 on biliary epithelial cells, with late superimposition on chronic hepatitis C. However, it is also possible that this is a case of chronic hepatitis C with hepatitis-associated bile duct damage accompanied by granulomatous reaction. Either way, this case raises new diagnostic issues in the differential diagnosis of chronic liver diseases presented with granulomatous cholangitis.

Necroinflammatory changes in hepatic lobules in primary biliary cirrhosis with less well-defined cholestatic changes

Primary biliary cirrhosis (PBC) is characterized by nonsuppurative inflammation and destruction of interlobular bile ducts. In this study we examined the necroinflammatory changes in hepatic lobules in PBC in the absence of cholestatic changes secondary to bile duct destruction, viral hepatitis types B and C, and progression of histologic stages. Kupffer cell hyperplasia, mononuclear sinusoidal infiltrates, and focal hepatocellular necroses were found frequently in the hepatic lobules. Some cases also showed perivenular zonal necrosis and central to central bridging necrosis. Focal necroses and swollen Kupffer cells were associated with lymphocytes with plump eosinophilic cytoplasm, resembling epithelioid cells. Well-developed and less-defined epithelioid cell granuloma also was occasionally found. The size, number, and distribution of these intralobular necroinflammatory changes varied from case to case and also from lobule to lobule in the same case. beta-2-Microglobulin was expressed on hepatocytes in areas of intralobular necrosis, in association with activated T cells. Laboratory data reflecting necroinflammatory changes in the hepatocytes tended to be elevated in the patients with zonal necroses. It is suggested in this study that necroinflammatory changes in the hepatic lobules are constant and inherent features in PBC and easily recognizable at an earlier histologic stage, and that hepatocytes, in addition to bile duct epithelium, may be targets of the immunologically mediated destruction that characterizes PBC.

A rapid non-enzymatic method for the preparation of HMW DNA from blood for RFLP studies

AIMS

To define a new histological staging and grading system for primary biliary cirrhosis (PBC), to provide more information reflecting clinical laboratory data and the prognosis to hepatologists.

METHODS AND RESULTS

First, 17 histological lesions of PBC were scored in 188 needle liver biopsy specimens. Factor analysis yielded three independent groups of factors: factor 1 (fibrosis, fibrous piecemeal necrosis, orcein-positive granules, bile plugs, Mallory bodies, feathery degeneration, bile duct loss and atypical ductular proliferation); factor 2 (portal inflammation, eosinophilic infiltration, lymphoid follicles, epithelioid granulomas, interface hepatitis and chronic cholangitis); and factor 3 (interface hepatitis, lobular hepatitis, acidophilic bodies and pigmented macrophages). The eight findings of factor 1, but not factors 2 and 3, were significantly correlated with clinical laboratory data and scores in the Mayo Clinic's prognostic model. Factor 1 lesions may reflect histological progression (staging), while factor 2 and 3 lesions may relate to necroinflammatory activity (grading). Then, we devised a staging and grading system using three lesions (bile duct loss, fibrosis and orcein-positive granules) from factor 1 and three from factors 2 and 3 (chronic cholangitis, interface hepatitis and lobular hepatitis).

CONCLUSION

This new system might provide more pathological information on PBC patients for hepatologists.

Pathology of septum formation in primary biliary cirrhosis: a histological study in the non-cirrhotic stage

Bridging or incomplete septum formation, an important step leading to cirrhosis in various chronic progressive liver diseases, was examined in 231 liver biopsy specimens of primary biliary cirrhosis (non-cirrhotic stage. Incomplete septa from the enlarged portal tracts and portal to portal bridges were frequent and appeared first, while portal to central ones appeared subsequently and became frequent in the liver specimens with changes resembling cirrhosis. These septa were divided into four types histologically: ductular, lymphocytic, loose connective tissue and fibrous type. More than one type was usually found in the same specimen. The pathology of the first three types was similar to and frequently continuous with that of neighbouring periportal regions, suggesting that most of these septa were formed by the extension of periportal destructive processes. The fibrous type might be an advanced form of the other three types. Incomplete septa seemed to pinch off part of the hepatic parenchyma in a hepatic lobule; this was followed by an unusual enlargement of the portal tracts and an approximation of portal tracts and central veins. There were perivenular hepatocellular necroses on occasion. Progression of periportal hepatocellular damage may lead to septum formation and finally progress to cirrhosis, in primary biliary cirrhosis. The significance of perivenular necroses remains speculative.

Hepatocellular carcinoma in primary biliary cirrhosis: an autopsy study

A survey of Japanese autopsy cases of primary biliary cirrhosis disclosed that hepatocellular carcinoma is apparently becoming a better recognized complication of the advanced stage of primary biliary cirrhosis. Six autopsy cases (five women and one man) of primary biliary cirrhosis associated with hepatocellular carcinoma were obtained from several Japanese institutions and examined. All cases were in an established cirrhotic stage of primary biliary cirrhosis. Hepatocellular carcinoma was incidentally found at autopsy in four cases and, in these, the carcinomas were small in size and number. The other two cases showed advanced hepatocellular carcinoma and one case showed extrahepatic metastasis. Histologically, all cases showed well-differentiated hepatocellular carcinomas. Fatty changes or bile plugs were frequently seen within the tumors. Mallory body clusters and focal deposition of copper-binding protein were consistently found in cirrhotic liver tissues and also in the carcinoma tissues of almost all cases. The presence of atypical adenomatous hyperplasia in the peripheries of some carcinomas suggested that hepatocellular carcinoma in primary biliary cirrhosis may evolve through multiple steps.

Portal lymphadenopathy associated with lipofuscin in chronic cholestatic liver disease

To determine whether portal lymphadenopathy in primary biliary cirrhosis is caused by deposition of lipofuscin pigment in sinus histiocytes and to compare primary biliary cirrhosis with other liver diseases a retrospective study on a consecutive series of 169 livers obtained at transplantation was carried out. There were grouped into eight diagnostic categories: primary biliary cirrhosis (n = 51), primary sclerosing cholangitis (n = 10), extrahepatic biliary atresia (n = 6), chronic rejection (n = 9), cirrhosis (other causes) (n = 38), primary liver neoplasia (n = 21), acute liver disease (n = 20), and retransplantation (other) (n = 14). Lymph nodes were present in 66 specimens. Fifty of these contained granules of lipofuscin pigment. The highest incidence of lymph node enlargement and the largest amounts of pigment were present in cases of primary biliary cirrhosis. A similar pattern of lymph node enlargement was also commonly observed in other chronic cholestatic conditions (primary sclerosing cholangitis, biliary atresia, chronic rejection). Much less pigment was seen in nodes draining livers with non-cholestatic cirrhosis or primary tumours. Nodes were not found in acute liver disease. It is concluded that portal lymphadenopathy associated with lipofuscin is a common finding in various chronic cholestatic liver diseases. The pathogenesis of this lesion is uncertain. Most cases are asymptomatic with enlarged nodes which may be detected only at laperotomy or necropsy and may be wrongly attributed to neoplastic disease. Diagnostically, the finding of large amounts of lipofuscin in enlarged portal lymph nodes is a good indicator of underlying chronic cholestatic liver disease.

Survey of copper granules in liver biopsy specimens from various liver abnormalities other than Wilson's disease and biliary diseases

Copper granules in hepatocytes were examined by the p-dimethylaminobenzylidene rhodanine method in 965 liver biopsy specimens obtained from patients with various liver abnormalities other than Wilson's disease and biliary diseases. The granules were found in chronic active hepatitis (incidence of positive cases: 17.2%) and alcoholic fibrosis (22%) with lobular disarray and fibrosis, nonbiliary liver cirrhosis (28%), and drug-induced cholestasis (15%). Copper granules were present in the periportal or periseptal hepatocytes where the granules were mainly found in the perinuclear cytoplasm. These intracellular and intralobular distribution patterns of copper granules resembled those of primary biliary cirrhosis. These data suggest that hepatic fibrosis and lobular disarray with fibrosis in these chronic liver disease may lead to distortion or interruption of small biliary branches followed by disturbance of bile flow and deposition of copper granules. Copper stain seems to provide a valuable information for assessment of progression of these chronic liver diseases. Impaired biliary excretion seems important in deposition of copper granules in drug-induced cholestasis.

Pathologic study of primary biliary cirrhosis of early histologic stages presenting cholestatic jaundice

While cholestatic jaundice usually develops in the advanced stages of primary biliary cirrhosis, our series of this disease disclosed that 8 of the 88 cases presented cholestatic jaundice in the early histologic stages (stages 1 and 2). These patients frequently presented esophageal varices (57%) and showed a low incidence of positive mitochondrial antibodies compared to the non-jaundices cases in the same histologic stages. Histologic changes of livers from the jaundiced patients failed to show fundamental differences from those of the non-jaundiced patients, except for the presence of bile plugs and extensive bile duct loss in the former. Deposition of orcein-positive granules and increased hepatic copper content, suggesting prolonged cholestasis, were rather advanced, and inflammatory changes in the portal tracts and piecemeal necrosis were rather mild in the jaundiced patients. These data suggest that cholestatic jaundice occurs in a few patients in the early histologic stages on a biopsy with extensive bile duct loss and features of prolonged cholestasis; it is not clear whether such patients are a small separate cluster in PBC, or not.

Copper storage disease of the liver and chronic dietary copper intoxication in two further German infants mimicking Indian childhood cirrhosis

A severe copper storage disease of the liver with micronodular cirrhosis resembling Indian childhood cirrhosis (ICC) was found in two siblings of a German family leading to death in one infant at the age of 13 months. The fatal outcome correlated with severe ballooning of hepatocytes and excessive formation of Mallory bodies. The copper content of the liver was 698 micrograms per gramme wet weight (control 5 micrograms) in the living patient and 2154 micrograms per gramme dry weight (controls 39, 54 micrograms) in the dead infant. In both cases copper was stored not only in hepatocytes but also to a high degree in mesenchymal cells. Chronic contamination of drinking water supplied from a well via copper pipes could be verified as the cause of copper intoxication, lending further support to ICC as an environmental, acquired disorder. Accumulation of exogenic copper already very early in infancy appears most important for the development of the disease, as both the parents and one child not exposed to copper intoxication during the first 9 months of its life are clinically healthy.

An autopsy case of primary sclerosing cholangitis with sequential histologic observations of the liver

A rare autopsy case of primary sclerosing cholangitis with sequential histologic observations of the liver is described. The patient, a 62-year-old female at the time of autopsy, presented with prolonged cholestasis of about 9 years duration. Initial (at 53 years) and second (at 59 years) liver biopsies disclosed fibrous enlargement of the portal tracts with loss of interlobular bile ducts, lymphoplasmacytic infiltration, a few epithelioid granulomas, piecemeal necrosis, atypical ductular proliferation and deposition of copper granules. Hypergammaglobulinemia with elevated IgM was also noted. These clinicopathological features resembled primary biliary cirrhosis. However, no florid duct lesions were found, and absence of antimitochondrial antibodies and cholangiographic demonstration of a beaded biliary tree favored a diagnosis of primary sclerosing cholangitis. The autopsied liver disclosed sclerosis and cholangioectases of the intra- and extrahepatic biliary tree in addition to biliary cirrhosis. The histology of the biliary tree disclosed nonspecific fibrosing inflammation in the extra- and intrahepatic biliary tree. Other autopsy findings included chronic thyroiditis, sialoadenitis and pancreatitis.

Histochemical and ultrastructural study of copper-binding protein in hepatocellular carcinoma

Orcein-positive hepatocellular material (OPHM), found in 18 of 44 hepatocellular carcinomas (HCC), was compared histochemically and ultrastructurally with similar granular materials in other liver diseases. OPHM was not found in 15 control livers, 45 metastatic liver cancers or ten cholangiocellular carcinomas. OPHM in HCC was stained with orcein when the tissue sections were preoxidized. In addition, it was positively stained with rhodanine and rubeanic acid for copper. These findings were identical to the OPHM in Wilson's disease, in primary biliary cirrhosis and in neonatal livers. Seven of 12 resected HCC revealed cytoplasmic dense bodies ultrastructurally in which an x-ray microanalyzer demonstrated copper. OPHM in HCC, a granular accumulation, was concluded to be rich in copper-protein complex, and might correspond to dense bodies derived from lysosome ultrastructurally. The pathogenesis and biologic significance of this copper overload in a number of HCC are also discussed.

Fatal copper storage disease of the liver in a German infant resembling Indian childhood cirrhosis

A female child of non-consanguineous, healthy German parents fell ill at the age of 7 months with a progressive liver disease leading to irreversible hepatic failure 3 months later. Histological examination revealed severe liver cell necrosis, excessive Mallory body formation and veno-occlusive-like changes associated with massive storage of copper, similar to Indian childhood cirrhosis (ICC). Chronic copper contamination of drinking water was the only detectable aetiological factor. The study illustrates that ICC most probably is an environmental disease, also occurring outside the Indian subcontinent, and is likely to be underdiagnosed in the Western world.

A copper-sulfur complex in the liver of a patient with Wilson's disease

An asymptomatic 16-year-old boy was found to have Wilson's disease without Kayser-Fleischer rings. Liver biopsy showed chronic active hepatitis with 1025 micrograms copper/g dry weight. After 19 months of d-penicillamine therapy, the liver histology became almost normal and the copper content decreased to 238 micrograms/g dry weight. The liver specimens obtained before and after treatment were studied by X-ray probe microanalysis. After treatment, both copper and sulfur decreased in hepatocellular lysosomes. The estimated molar ratio of the decreased copper to the decreased sulfur was 32/100. These figures suggest that lysosomal copper exists in the form of metallothionein.

Dietary copper intake in artificially fed infants

Plasma concentrations of copper and zinc and leucocyte concentrations of zinc were measured in mothers during later pregnancy, at delivery, and 8-10 weeks after birth, and plasma concentrations of copper and zinc were measured in their infants at delivery and 8-10 weeks after birth. The 145 infants were either breast fed or fed one of two milk formulas supplying copper at different concentrations. None of the infants achieved the minimum copper intakes recommended by the World Health Organisation (WHO). At 2 months of age there were no major differences in growth or health detected in infants fed the different copper intakes. Infant birth weight correlated well with the ratio of maternal venous plasma zinc:maternal leucocyte zinc at delivery. Maternal venous plasma copper and zinc concentrations at birth correlated with umbilical venous plasma copper and zinc concentrations. Infants fed the higher copper content formulas had a low mean plasma zinc concentration without a significant increase in the mean plasma copper concentration. The present WHO recommendations regarding minimum copper intakes for infants fed formulas cannot be achieved with currently available formulas and are probably wrong.

Copper-binding protein in liver cells

The patterns and incidences of orcein-positive granules of copper-binding protein (CBP) in 2,531 liver biopsy specimens from children and adults with a large variety of liver diseases are reported. Fetal and neonatal livers have high physiologic levels of copper and CBP, which fall to within the adult range by the third to the sixth month of life. Therefore, in liver specimens from children less than 6 months of age, it was not possible to determine whether the orcein-positive granules present represented physiologic or pathologic deposits of CBP. In adults and in children older than 6 months of age, CBP granules were found almost exclusively in association with four main groups of liver diseases: Wilson's disease, chronic biliary disorders, cirrhosis/extensive fibrosis, and primary liver tumors. Orcein-positive granules were never found in patients with acute liver disease. The granules were extremely helpful in distinguishing chronic biliary diseases from acute cholestatic and hepatic disorders, primary biliary cirrhosis from chronic active hepatitis, and primary liver tumors from metastatic tumor deposits.

Is mallory body formation a preneoplastic change? A study of 181 cases of liver bearing hepatocellular carcinoma and 82 cases of cirrhosis

The hypothesis that Mallory body formation by hepatocytes is a sign of preneoplasia was tested. This hypothesis was based on animal experiments but has not been tested in man. The authors studied the livers of 181 human autopsies in which hepatocellular carcinoma (HCC) was present and 82 cirrhotic livers from patients with alcoholism, HB viral infection, or cryptogenic cirrhosis. The frequency of Mallory bodies in nonneoplastic hepatocytes was 40% in the HCC-bearing livers with cirrhosis (LC). In HCC-bearing livers with pre-cirrhotic changes (PC), 25% showed Mallory body formation by nonneoplastic hepatocytes. In the cases of HCC, where there was no accompanying PC or LC, Mallory bodies were never found in the nonneoplastic hepatocytes. When the 82 cirrhotic livers without HCC and the 116 cirrhotic cases with HCC were combined, it was found that HCC was present in 70% of cirrhotic livers when the nonneoplastic liver cells contained Mallory bodies. When no Mallory bodies were found in the nonneoplastic liver cells, HCC was present in 53% of cases. The difference between the two groups was significant (P less than 0.05). The difference was significant for both HB viral hepatitis and cryptogenic cirrhosis but not for alcoholic cirrhosis. Likewise, when nonneoplastic hepatocytes formed Mallory bodies in cirrhotic livers, there was a statistically significant increase in the number of HCC cells that formed Mallory bodies (P less than 0.01). When nonneoplastic hepatocytes occurred in groups of Mallory body forming cells, the hepatocellular features were atypical and characteristic of dysplastic cells. The evidence indicates that when Mallory body formation was observed in HBsAg-positive and cryptogenic cirrhotic livers, they were associated with an increased frequency of HCC formation in man.

The lysosomal copper concentration in the liver in primary biliary cirrhosis

The copper concentration in the lysosomes of periportal hepatocytes of nine patients with primary biliary cirrhosis was determined by X-ray microanalysis in ultrathin sections, the chlorine concentration of the embedding medium being taken as internal standard. A positive correlation was found between the lysosomal and the total liver copper concentration. No correlation was found between the lysosomal copper concentration and the grade of orcein staining for lysosomal copper-associated protein in paraffin sections. It is concluded that in contrast to the grade of orcein staining, the lysosomal copper concentration is a reliable measure of the total liver copper concentration in primary biliary cirrhosis.

Immunohistochemical demonstration of the cytoplasmic copper-associated protein in the liver in primary biliary cirrhosis: its identification as metallothionein

Metallothionein was isolated from the liver of rats pretreated with cadmium. Monospecific anti-metallothionein antibodies were produced in rabbits. Twenty-six primary biliary cirrhosis (PBC) liver samples and three control liver samples were stained for metallothionein by an indirect immunoperoxidase technique. Nineteen of the PBC samples and the control samples were also stained for copper by Timm's silver sulphide method. In all PBC samples the copper concentration was determined. In addition, the zinc, cadmium, and mercury concentrations were measured in some samples. Eighteen of the PBC samples stained for metallothionein showed marked diffuse cytoplasmic and nuclear staining of a varying number of periportal hepatocytes. In none of them was granular staining detected. None of the control samples showed staining. Fourteen of the PBC samples stained for copper showed diffuse cytoplasmic and granular staining of the periportal hepatocytes. In none of them was nuclear staining detected. None of the control samples showed staining. No elevated zinc, cadmium, or mercury concentrations were found but the copper concentration was increased in 21 of the 26 PBC samples. The number of cells staining for copper and metallothionein was assessed semiquantitatively. Significant correlations were found between the grade of metallothionein staining and the liver copper concentration; the grade of Timm's staining and the liver copper concentration; and the grades of metallothionein staining and Timm's staining. The data suggest that the accumulation of copper induces synthesis of cytoplasmic and nuclear metallothionein, and that the increased amount of cytoplasmic copper is bound to a similarly increased amount of metallothionein.

Value of copper-associated protein in diagnostic assessment of liver biopsy

Of 1361 consecutive liver biopsy specimens, 24% contained orcein-positive granules. The highest incidence of positivity was found in biliary disease (90.9%), long before cirrhosis had developed, whereas in chronic non-primarily biliary disease, positive results were almost exclusively in patients with well established cirrhosis. Orcein-positive granules were never found in acute liver disease. These granules were also demonstrated in tumour cells of primary hepatocellular tumours (benign 4 of 4 cases; malignant 9 of 37 cases), while all the secondary tumour deposits were negative. In our view the additional information obtained by this technique warrants its adoption as a routine procedure.