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Wen KW, Kakar S. Hepatic Precancerous Lesions and Early Hepatocellular Carcinoma. Gastroenterol Clin North Am 2024; 53:109-132. [PMID: 38280744 DOI: 10.1016/j.gtc.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
This review discusses the diagnostic challenges of diagnosing and treating precursor lesions of hepatocellular carcinoma (HCC) in both cirrhotic and non-cirrhotic livers. The distinction of high-grade dysplastic nodule (the primary precursor lesion in cirrhotic liver) from early HCC is emphasized based on morphologic, immunohistochemical, and genomic features. The risk factors associated with HCC in hepatocellular adenomas (precursor lesion in non-cirrhotic liver) are delineated, and the risk in different subtypes is discussed with emphasis on terminology, diagnosis, and genomic features.
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Affiliation(s)
- Kwun Wah Wen
- 505 Parnassus Avenue, M545, Box #0102, San Francisco, CA 94143, USA.
| | - Sanjay Kakar
- 505 Parnassus Avenue, M545, Box #0102, San Francisco, CA 94143, USA
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2
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Zhang SL, Wang HL. Ancillary tests for hepatobiliary neoplasms: what we know and what we need to know. Hum Pathol 2023; 141:183-200. [PMID: 36775105 DOI: 10.1016/j.humpath.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/29/2023] [Accepted: 02/04/2023] [Indexed: 02/12/2023]
Abstract
Ancillary tests are commonly used in the surgical pathology setting for diagnosing challenging neoplastic diseases of the liver and biliary tract, while histology and clinical correlation remain to be critically important. With continuous discoveries, more and more useful ancillary tests have become available, which can help distinguish between malignant and benign hepatocellular neoplasms, malignant and benign biliary tract entities, and intrahepatic and metastatic carcinomas. This review will focus on existing and emerging biomarkers (such as glutamine synthetase, organic anion transporting polypeptide 1B3, insulin-like growth factor-II mRNA binding protein-3, S100P, SMAD4, enhancer of zeste homolog 2, albumin, hepatocyte nuclear factor-1β, etc.) that can be used for the diagnosis, classification and prognostication of hepatobiliary neoplasms.
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Affiliation(s)
- Sarah L Zhang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine and Ronald Reagan Medical Center, University of California at Los Angeles, Los Angeles, CA, 90095, USA
| | - Hanlin L Wang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine and Ronald Reagan Medical Center, University of California at Los Angeles, Los Angeles, CA, 90095, USA.
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3
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Jornet-Rius O, Agulla B, López MC, Viñeta C, García-Ferrer A, Serrano B, Marco A, Palomares A, Novellas R, Espada Y, Roura X, Solano-Gallego L. Needle tract seeding and malignant transformation of hepatocellular adenoma into well-differentiated hepatocellular carcinoma in a dog. Vet Clin Pathol 2023; 52:507-513. [PMID: 37202832 DOI: 10.1111/vcp.13221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/26/2022] [Accepted: 11/08/2022] [Indexed: 05/20/2023]
Abstract
An 11-year-old neutered female Golden Retriever was referred for investigation of marked increases in liver enzyme activities. Abdominal ultrasound revealed a large pedunculated liver mass. Diagnosis of hepatocellular adenoma (HCA) was made when the mass was excised after a first unsuccessful attempt through ultrasound-guided core-needle biopsy. One and a half years after presentation, a nodule embedded between muscles of the abdominal wall appeared. The mass was first diagnosed as a well-differentiated hepatocellular carcinoma (HCC) through cytologic examination, which was later confirmed with histopathology. Ki 67 immunostaining of the abdominal wall nodule showed an increased immunoreactivity compared with the liver mass. Therefore, the present case documents the first needle-tract seeding of a hepatocellular epithelial tumor with possible malignant transformation of HCA into a well-differentiated HCC in a dog.
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Affiliation(s)
- Oriol Jornet-Rius
- Departament de Medicina i Cirurgia Animals, Facultat de Veterinària, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Beatriz Agulla
- Departament de Medicina i Cirurgia Animals, Facultat de Veterinària, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Claudia Viñeta
- Hospital Clínic Veterinari, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Bárbara Serrano
- Servei de Diagnòstic de Patologia Veterinària, Facultat de Veterinària, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alberto Marco
- Servei de Diagnòstic de Patologia Veterinària, Facultat de Veterinària, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Anna Palomares
- Hospital Clínic Veterinari, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Rosa Novellas
- Departament de Medicina i Cirurgia Animals, Facultat de Veterinària, Universitat Autònoma de Barcelona, Barcelona, Spain
- Hospital Clínic Veterinari, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Yvonne Espada
- Departament de Medicina i Cirurgia Animals, Facultat de Veterinària, Universitat Autònoma de Barcelona, Barcelona, Spain
- Hospital Clínic Veterinari, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Xavier Roura
- Hospital Clínic Veterinari, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Laia Solano-Gallego
- Departament de Medicina i Cirurgia Animals, Facultat de Veterinària, Universitat Autònoma de Barcelona, Barcelona, Spain
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Poté N, Caruso S, Caderaro J, Cauchy F, Lagadec F, Couchy G, Raffenne J, Augustin J, Vernuccio F, Vilgrain V, Hercent A, Theou-Anton N, Zucman-Rossi J, Paradis V. Borderline Hepatocellular Adenomas: A Practical Diagnostic Approach Based on Pathologic and Molecular Features. Mod Pathol 2023; 36:100211. [PMID: 37169258 DOI: 10.1016/j.modpat.2023.100211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 04/24/2023] [Accepted: 05/03/2023] [Indexed: 05/13/2023]
Abstract
Borderline hepatocellular adenomas (BL-HCA) are characterized by focal architectural/cytologic atypia and reticulin loss, features that are insufficient for a definitive diagnosis of hepatocellular carcinoma (HCC). The diagnosis and management of BL-HCA are challenging as their biological behavior, especially in terms of malignant potential, is still debated. We aimed to compare the clinicopathologic and molecular features of BL-HCA with those of typical HCA (T-HCA), HCA with malignant transformation (HCC on HCA), and HCC to assess the risk of malignancy. One hundred six liver resection specimens were retrospectively selected from 2 reference centers, including 39 BL-HCA, 42 T-HCA, 12 HCC on HCA, and 13 HCC specimens. Somatic mutations, including TERT promoter mutations associated with HCA malignant transformation and the gene expression levels of 96 genes, were investigated in 93 frozen samples. Additionally, TERT promoter mutations were investigated in 44 formalin-fixed, paraffin-embedded samples. The clinical features of patients with BL-HCA were similar to those of patients with T-HCA, patients being mainly women (69%) with a median age of 37 years. The median tumor size was 7.5 cm, 64% of patients had a single nodule, and no recurrence was observed. Compared with T-HCA, BL-HCA was significantly enriched in β-catenin-mutated HCA in exon 3 (41% vs 6%; P < .001). Unsupervised statistical analysis based on gene expression showed that BL-HCA overlapped with T-HCA and HCC on HCA, favoring a molecular continuum of the tumors. TERT promoter mutations were observed only in HCC on HCA (42%) and in HCC (38%). In conclusion, these results suggest that despite their worrisome morphologic features, the clinicopathologic and molecular features of BL-HCA are much closer to those of T-HCA than those of HCC on HCA or HCC. This strongly supports the usefulness of combining morphologic and molecular analyses in a practical diagnostic approach for guiding the management of BL-HCA.
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Affiliation(s)
- Nicolas Poté
- Université Paris Cité, INSERM UMR-1149, Paris, France; Department of Pathology, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Clichy, France.
| | - Stefano Caruso
- Centre de Recherche des Cordeliers, Sorbonne Université-Université Paris Cité, INSERM, Paris, France; Team Fungest, Equipe labellisée Ligue Nationale Contre le Cancer, Labex immuno-Oncology, Paris, France
| | - Julien Caderaro
- Department of Pathology, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France; Team 18, Faculté de Médecine, Université Paris-Est Créteil, INSERM UMR-955, Institut Mondor de Recherche Biomédicale, Créteil, France
| | - François Cauchy
- Department of Hepatobiliary Surgery and Liver Transplantation, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Clichy, France
| | - Floriane Lagadec
- Department of Pathology, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Clichy, France
| | - Gabrielle Couchy
- Centre de Recherche des Cordeliers, Sorbonne Université-Université Paris Cité, INSERM, Paris, France; Team Fungest, Equipe labellisée Ligue Nationale Contre le Cancer, Labex immuno-Oncology, Paris, France
| | | | - Jeremy Augustin
- Department of Pathology, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Federica Vernuccio
- Department of Radiology, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Clichy, France
| | - Valérie Vilgrain
- Université Paris Cité, INSERM UMR-1149, Paris, France; Department of Radiology, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Clichy, France
| | - Agathe Hercent
- Department of Genetics, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Nathalie Theou-Anton
- Department of Genetics, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jessica Zucman-Rossi
- Centre de Recherche des Cordeliers, Sorbonne Université-Université Paris Cité, INSERM, Paris, France; Team Fungest, Equipe labellisée Ligue Nationale Contre le Cancer, Labex immuno-Oncology, Paris, France; Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Valérie Paradis
- Université Paris Cité, INSERM UMR-1149, Paris, France; Department of Pathology, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Clichy, France
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Umetsu SE, Kakar S. Evaluating Liver Biopsies with Well-Differentiated Hepatocellular Lesions. Surg Pathol Clin 2023; 16:581-598. [PMID: 37536890 DOI: 10.1016/j.path.2023.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Needle core biopsies of liver lesions can be challenging, particularly in cases with limited material. The differential diagnosis for well-differentiated hepatocellular lesions includes focal nodular hyperplasia, hepatocellular adenoma, and well-differentiated hepatocellular carcinoma (HCC) in noncirrhotic liver, while dysplastic nodules and well-differentiated HCC are the primary considerations in cirrhotic liver. The first part of this review focuses on histochemical and immunohistochemical stains as well as molecular assays that are useful in the differential diagnosis. The second portion describes the features of hepatocellular adenoma subtypes and focuses on the differential diagnoses in commonly encountered clinicopathologic scenarios.
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Affiliation(s)
- Sarah E Umetsu
- Department of Pathology, University of California San Francisco, 505 Parnassus Avenue, Box 0102, San Francisco, CA 94143, USA.
| | - Sanjay Kakar
- Department of Pathology, University of California San Francisco, 505 Parnassus Avenue, Box 0102, San Francisco, CA 94143, USA
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González IA, Torbenson M, Sharifai N, Byrnes K, Chatterjee D, Kakar S, Yeh MM, Wu TT, Zhang X, Jain D. Clinicopathologic characterization of hepatocellular adenomas in men: a multicenter experience. Hum Pathol 2023; 138:24-33. [PMID: 37245629 DOI: 10.1016/j.humpath.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/18/2023] [Accepted: 05/22/2023] [Indexed: 05/30/2023]
Abstract
Hepatocellular adenomas (HCAs) are benign liver neoplasms which most commonly present in women in their reproductive age. In men, they are rare and have a higher risk of malignant transformation to hepatocellular carcinoma (HCC). Here we present our multicenter experience with HCA in men in the United States. A total of 27 HCA cases were included, with a mean age of presentation of 37 years (range, 9-69 years) and a mean size of 6.8 cm (range, 0.9-18.5 cm). Based on the 2019 World Health Organization classification, the most common subtype identified was inflammatory HCA (IHCA; 10 cases, 37.0%) followed by unclassified HCA (UHCA; 7 cases, 25.9%), HNF1A-inactivated HCA (H-HCA; 6 cases, 22.2%), β-catenin-activated IHCA (b-IHCA; 3 cases, 11.1%), and β-catenin-activated HCA (b-HCA; 1 case, 3.7%). Six additional cases diagnosed as hepatocellular neoplasm of uncertain malignant potential (HUMP) were also included in the study. These cases presented in a mean age of 46 years (range, 17-64 years) and a size of 10.8 cm (range, 4.2-16.5 cm). We evaluated the significance of androgen receptor (AR) expression by immunohistochemistry (IHC); of the 16 cases with materials available, 8 were considered positive using the Allred score system (2 IHCA, 2 H-HCA, 1 UHCA, and 3 HUMP). Of the total cases, 12 were diagnosed on biopsies, for which follow-up information is available for 7, and none of them show evidence of malignant transformation. Of the 21 resection cases, a concomitant well-differentiated HCC within the same lesion was identified in 5 cases (23.8%), which were diagnosed as HCA (n = 4) or HUMP (n = 1). Overall, 15% of cases in our entire cohort of HCA and HUMP showed concomitant HCC, while none of the 7 biopsy cases showed any malignant transformation on follow-up (range, 22-160 months; mean, 61.8 months).
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Affiliation(s)
- Iván A González
- Department of Pathology, Yale University, New Haven, CT, 06520, USA
| | - Michael Torbenson
- Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, 55901, USA
| | - Nima Sharifai
- Department of Pathology & Immunology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Kathleen Byrnes
- Department of Pathology & Immunology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Deyali Chatterjee
- Department of Pathology & Immunology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Sanjay Kakar
- Department of Pathology, University of California, San Francisco, San Francisco, CA, 94143, USA
| | - Matthew M Yeh
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, WA, 98195, USA
| | - Tsung-Teh Wu
- Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, 55901, USA
| | - Xuchen Zhang
- Department of Pathology, Yale University, New Haven, CT, 06520, USA
| | - Dhanpat Jain
- Department of Pathology, Yale University, New Haven, CT, 06520, USA.
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Duodenal Mucosal Barrier in Functional Dyspepsia. Clin Gastroenterol Hepatol 2022; 20:1019-1028.e3. [PMID: 34607017 PMCID: PMC8975906 DOI: 10.1016/j.cgh.2021.09.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 08/25/2021] [Accepted: 09/22/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS In addition to gastric sensorimotor dysfunctions, functional dyspepsia (FD) is also variably associated with duodenal micro-inflammation and epithelial barrier dysfunction, the pathogenesis and clinical significance of which are unknown. Our hypothesis was that miRNAs and/or inflammation degrade epithelial barrier proteins, resulting in increased duodenal mucosal permeability in FD. METHODS We compared the duodenal mucosal gene expression and miRNAs, in vivo permeability (lactulose-mannitol excretion between 0 and 60 and 60 and 120 minutes after saccharide ingestion), ex vivo assessments (transmucosal resistance, fluorescein isothiocyanate [FITC]-dextran flux, and basal ion transport), and duodenal histology (light and electron microscopy) in 40 patients with FD and 24 controls. RESULTS Compared with controls, the mRNA expression of several barrier proteins (zonula occludens-1, occludin, claudin-12, and E-cadherin) was modestly reduced (ie, a fold change of 0.8-0.85) in FD with increased expression of several miRNAs (eg, miR-142-3p and miR-144-3-p), which suppress these genes. The urinary lactulose excretion and the lactulose:mannitol ratio between 60 and 120 minutes were greater in FD than in controls (P < .05). The FITC-dextran flux, which reflects paracellular permeability, was inversely correlated (r = -0.32, P = .03) with transmucosal resistance and directly correlated (r = 0.4, P = .02) with lactulose:mannitol ratio. Other parameters (mucosal eosinophils, intraepithelial lymphocytes, and mast cells, transmucosal resistance, FITC-dextran flux, average intercellular distance, and proportion of dilated junctions) were not significantly different between groups. CONCLUSIONS In FD, there is a modest reduction in the expression of several duodenal epithelial barrier proteins, which may be secondary to up-regulation of regulatory miRNAs, and increased small intestinal permeability measured in vivo.
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Bioulac-Sage P, Gouw ASH, Balabaud C, Sempoux C. Hepatocellular Adenoma: What We Know, What We Do Not Know, and Why It Matters. Histopathology 2021; 80:878-897. [PMID: 34856012 DOI: 10.1111/his.14605] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/21/2021] [Accepted: 11/25/2021] [Indexed: 11/27/2022]
Abstract
In the last 2 decades there has been significant progress in research and diagnosis of hepatocellular adenoma (HCA), resulting in the establishment of a molecular and immunohistological HCA classification. This review aims to fine-tune the current expertise in order to enhance the histopathological diagnostic possibilities, by refining issues that are already known, addressing diagnostic difficulties and identifying still unknown aspects of HCA. We will discuss novel methods to identify HCA subtypes, in particular the sonic hedgehog HCAs and the interpretation of glutamine synthetase patterns for the recognition of beta-catenin mutated HCAs. The major complications of HCAs, bleeding and malignant transformation, will be considered, including the dilemmas of atypical and borderline lesions. Paragraphs on HCAs in different clinical and geographical settings, e.g. pregnancy, cirrhosis and non-western countries are included. The natural history of the different HCA subtypes in relation with age, sex and risk factors is a feature still insufficiently investigated. This is also true for the risks of clinical bleeding and malignant transformation in association with HCA subtypes. As HCA is a relatively rare tumor, a multicenter and multidisciplinary approach across geographical boundaries will be the appropriate method to establish prospective programs to identify, classify and manage HCAs, focusing on several aspects, e.g. etiology, underlying liver disease, complications, regression and growth. Updating what we know, identifying and addressing features that we do not know matters to warrant optimal patient management.
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Affiliation(s)
| | - Annette S H Gouw
- Departement of Pathology and Medical Biology, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Christine Sempoux
- Service of Clinical Pathology, Institute of Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Jiang W, Wu T, Shi X, Xu J. Overexpression of EWSR1 (Ewing sarcoma breakpoint region 1/EWS RNA binding protein 1) predicts poor survival in patients with hepatocellular carcinoma. Bioengineered 2021; 12:7941-7949. [PMID: 34612781 PMCID: PMC8806985 DOI: 10.1080/21655979.2021.1982844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the most prevalent malignant neoplasms with high relapse and mortality rate. It is of great importance to identify novel and effective molecular markers to predict prognosis for the treatment of HCC. The Ewing sarcoma breakpoint region 1 (EWSR1) gene is well known to fuse with various partner genes and involved in promoting the development of multiple sarcomas, especially the Ewing sarcoma family of tumors. Nevertheless, seldom studies have focused on the role of EWSR1 in cancers of epithelial origin, let alone in HCC. In the current study, the transcriptional and clinical data of EWSR1 in HCC patients were obtained from TCGA and GEO databases, as well as 124 cases from the department of Pathology of Sichuan Jianyang People's Hospital. Kaplan-Meier and Cox regression analysis were used to assess patient prognosis. EWSR1 mRNA levels were significantly upregulated in HCC tissues than in normal liver tissues (P < 0.001). The TCGA database analysis showed upregulation of EWSR1 was associated with histological grade, pathologic T stage and death, in addition to that, the T staging, N staging, TNM staging, Ki67, AFP expression were extremely higher in the EWSR1 over-expression group in our cohort. Univariate and multivariate Cox hazard regression analysis results revealed that EWSR1 was an independent prognostic factor for OS in HCC, and bioinformatics analysis showed RNA splicing process represented the major function and pathway. In conclusion, our data showed EWSR1 could serve as a novel promising prognostic biomarker for HCC patients.Abbreviations: AFP, Alpha-fetoprotein; CCL14, C-C motif chemokine ligand 14; CK19, Cytokeratin 19; CI, coefficient interval; COL1A1, Collagen 1A1; DFS, Disease-free Survival; EWSR1, Ewing Sarcoma breakpoint region 1/EWS RNA binding protein 1; FLI1, Friend leukemia virus integration 1; GEO, Gene Expression Omnibus; GO, Gene Ontology; HCC, Hepatocellular carcinoma; HR, Hazard ratio; KEGG, Kyoto Encyclopedia of Genes and Genomes; mRNA, messenger Ribonucleic Acid; N, nodule; OS, Overall survival; PPI, Protein-Protein Interaction analysis; RNA, Ribonucleic Acid; SD, Standard Deviation; TCGA, The Cancer Genome Atlas; T, tumor; TNM, tumor-nodule-metastasis.
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Affiliation(s)
- Weijie Jiang
- Department of Pathology, The People's Hospital of Jianyang City, Jianyang, Sichuan, 641499, China
| | - Tao Wu
- Department of Pathology, The People's Hospital of Jianyang City, Jianyang, Sichuan, 641499, China
| | - Xuan Shi
- Department of Pathology, The People's Hospital of Jianyang City, Jianyang, Sichuan, 641499, China
| | - Jiawen Xu
- Department of Pathology, Shandong Provincial Hospital affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China.,Department of Pathology, Shandong Provincial Hospital affiliated to Shandong University, Jinan, Shandong, 250021, China
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