Giant cell hepatocellular carcinoma

Glypican-3 and Hep Par-1 are Useful Biomarkers in the Cytologic Assessment of Ascites

Till date, the utility of cytologic assessment of ascites for the identification of hepatocellular carcinoma (HCC) cells is still debated and the usefulness of immunocytochemistry for glypican-3 (GPC3) and Hep Par-1 in this setting has not been reported. Liquid-based cytology of ascitic fluid of 28 cirrhotic patients was performed and the spots obtained were stained with hematoxylin and eosin, papanicolau, and with GPC3 and Hep Par-1 antibodies. GPC3 and Hep Par-1 antibodies stained positively the atypical cells in the ascites of 2 patients with HCC showing an exophytic growth pattern. The specimens of the patients with nonexophytic HCC, other non-HCC cancers, or cirrhosis stained negatively. We hypothesize a relationship with the exophytic growth of the tumor. Thus, GPC3 and Hep Par-1 are useful in the cytologic assessment of peritoneal effusions to distinguish mesothelial cells and neoplastic non-HCC cells from HCC cells, presence of which, however, represent a very rare event. This is the first study in which GPC3 and Hep Par-1 immunostaining has been used in the cytologic assessment of HCC ascites.

Hepatocellular carcinoma with osteoclast-like giant cells: report of the seventh case in the literature

Hepatocellular carcinoma with osteoclast-like giant cells is extremely rare, and only six cases have been previously reported. Its histogenesis is at the moment controversial. The authors report a case of hepatocellular carcinoma with osteoclast-like giant cells found in a 74-year-old woman. The patient came with a dull pain in the right upper abdominal quadrants due to a liver neoplasm described at CT scan. A wedge resection of the fifth hepatic segment with appendectomy, omentectomy, and debulking of the major peritoneal implants was performed. Histologically, the diagnosis of hepatocellular carcinoma with high grade differentiation associated with giant osteoclast-like cells was done without any evidence of hepatitis or cirrhosis in the surrounding hepatic parenchyma. Immunohistochemistry was positive for CD10 and CD68 and in situ hybridization revealed the expression of receptor activator of nuclear factor-kappa B (RANK) in the giant cells and receptor activator of nuclear factor-kappa B ligand (RANKL) in the tumor cells.

Routine review of ascites fluid from patients with cirrhosis or hepatocellular carcinoma is a low-yield procedure: an observational study

BACKGROUND

Patients with cirrhosis develop ascites for physiologic reasons that are unrelated to malignant progression. However, physicians performing paracentesis in these patients, often send fluid to the cytology laboratory, sometimes specifically looking for hepatocellular carcinoma (HCC). We have investigated the diagnostic yield of these specimens.

MATERIALS AND METHODS

A computerized pathology database search for all ascites fluid cases submitted to the cytology laboratory at a major liver transplant center between November 2004 and April 2008 was performed. Clinical history was obtained for each case. Patients with cirrhosis, with or without HCC, were included in the study. Cytologic diagnoses were compiled and follow-up information was obtained for cases with non-negative findings.

RESULTS

A total of 167 specimens from 133 patients ranging from 29 to 85 years of age (mean 56 years) were submitted over the said time period. The causes of cirrhosis included: alcohol - 44; Hepatitis C - 30; Hepatitis B - 6; non-alcoholic steatohepatitis - 7; cryptogenic - 18; other single causes - 6; and multifactorial (alcohol and hepatitis viruses) - 22. Hepatocellular carcinoma (HCC) was present or strongly suspected in 17 patients and had been previously resected in two others. The status of fifteen patients was post liver transplant, with recurrent liver failure. Human immunodeficiency virus was present in seven patients and eight patients had a history of non hepatic malignancies. Among the specimens, 162 were negative, two had atypical lymphocytes worked up for lymphoma, and three had atypical epithelioid cells; none was positive for HCC. Immunohistochemistry demonstrated a mesothelial origin for the atypical epithelioid cells in two cases; in the third case, the patient died shortly after the specimen was collected, with no radiological evidence of HCC.

CONCLUSION

Ascites fluid cytology specimens in patients with cirrhosis, even those known or suspected to have HCC, are almost always negative. Atypical cells seen in such specimens should be treated with skepticism since the likelihood that they represent peritoneal spread of HCC is low..

Management of ascites

The evaluation of ascites includes a directed history, focused physical examination, and diagnostic paracentesis with ascitic fluid analysis. Dietary sodium restriction and oral diuretics are the mainstay of therapy for the majority of patients with cirrhotic ascites. Transjugular intrahepatic portocaval shunt has emerged as the treatment of choice for selected patients with refractory ascites, although serial large-volume paracenteses should be attempted first. Early diagnosis, broad-spectrum antibiotics, and albumin infusion contribute to the successful management of spontaneous bacterial peritonitis (SBP). Referral for liver transplant evaluation should be considered at the first sign of decompensation and should not be delayed until development of ominous clinical features, such as refractory ascites and SBP.