Multistep hepatocarcinogenesis from a dysplastic nodule to well-differentiated hepatocellular carcinoma in a patient with alcohol-related liver cirrhosis

Hepatocellular Carcinoma and Its Precursors in 103 HBV-Related Cirrhotic Explanted Livers: A Study from South Iran

BACKGROUND

The most common cause of liver transplantation in Iran is hepatitis B positive cirrhosis, and it also one of the major and important causes of hepatocellular carcinoma (HCC). Most cases with HCC follow a multistep sequence. Morphologic lesions during hepatocarcinogenesis include dysplastic lesions and small cancerous lesions (2 cm in diameter; early HCC). However, insufficient information is available on the incidence of HCC and its precursors in hepatitis B-related cirrhosis.

OBJECTIVES

In this study, we determined the incidence of HCC and its precursors in hepatitis B-related cirrhosis in the largest liver transplant center in Iran.

METHODS

In a two-year study, all explanted livers of patients with hepatitis B virus (HBV)-positive cirrhosis were completely sectioned and examined. Each specimen was investigated grossly and microscopically to determine any abnormal nodule or cellular changes (at least 15 sections from each liver).

RESULTS

Among all explanted cirrhotic livers (103 livers) during the study period (2014 - 2015), 92 (89.3%) had dysplastic foci with large cell changes (LCC), 57 (55.3%) of which showed small cell changes (SCC) as well. Thirty-nine cases (37.9%) had low-grade dysplastic nodules (LGDN), 38 (36.9%) high-grade dysplastic nodules (HGDN), 19 (18.4%) were early hepatocellular carcinoma (eHCC), and 21 (20.4%) were hepatocellular carcinoma more than 2 cm. All the cases with eHCC and HCC of more than 2 cm also had SCC, LCC, HGDN, and LGDN. Thirteen cases of eHCC were accompanied with HCCs more than 2 cm, and 6 cases of eHCC did not show any HCC (larger than 2 cm).

CONCLUSIONS

SCC, LGDN, and HGDN are common associated findings and precursors of HCC in livers infected with hepatitis B. A strict follow-up and a precise and thorough sampling of livers with SCC and any abnormal dysplastic nodules (DNs), especially those larger than 1 cm, are highly recommended because these DNs are highly associated with malignancy.

Discrimination of cirrhotic nodules, dysplastic lesions and hepatocellular carcinoma by their vibrational signature

Background

Hepatocarcinogenesis is a multistep process characterized in patients with chronic liver diseases by a spectrum of hepatic nodules that mark the progression from regenerative nodules to dysplastic lesions followed by hepatocellular carcinoma (HCC). The differential diagnosis between precancerous dysplastic nodules and early HCC still represents a challenge for both radiologists and pathologists. We addressed the potential of Fourier transform-infrared (FTIR) microspectroscopy for grading cirrhotic nodules on frozen tissue sections.

Methods

The study was focused on 39 surgical specimens including normal livers (n = 11), dysplastic nodules (n = 6), early HCC (n = 1), progressed HCC on alcoholic cirrhosis (n = 10) or hepatitis C virus cirrhosis (n = 11). The use of the bright infrared source emitted by the synchrotron radiation allowed investigating the biochemical composition at the cellular level. Chemical mapping on whole tissue sections was further performed using a FTIR microscope equipped with a laboratory-based infrared source. The variance was addressed by principal component analysis.

Results

Profound alterations of the biochemical composition of the pathological liver were demonstrated by FTIR microspectroscopy. Indeed, dramatic changes were observed in lipids, proteins and sugars highlighting the metabolic reprogramming in carcinogenesis. Quantifiable spectral markers were characterized by calculating ratios of areas under specific bands along the infrared spectrum. These markers allowed the discrimination of cirrhotic nodules, dysplastic lesions and HCC. Finally, the spectral markers can be measured using a laboratory FTIR microscope that may be easily implemented at the hospital.

Conclusion

Metabolic reprogramming in liver carcinogenesis can constitute a signature easily detectable using FTIR microspectroscopy for the diagnosis of precancerous and cancerous lesions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12967-016-0763-6) contains supplementary material, which is available to authorized users.

Contrast-enhanced magnetic resonance imaging of 102 nodules in cirrhosis: correlation with histological findings on explanted livers

PURPOSE

To analyze Gd-EOB-DTPA-enhanced magnetic resonance (MR) findings of nodules (low-grade dysplastic nodules-LGDNs; high-grade dysplastic nodules-HGDN, and hepatocellular carcinoma-HCC), histologically identified on cirrhotic, explanted livers.

METHODS

IRB approval was obtained for this study. Thirty-four patients underwent Gd-EOB-DTPA-enhanced MR examinations (1.5T system), that included 20-min delayed hepatobiliary (HB) phase imaging, before undergoing orthotopic liver transplantation (OLT; mean time MR-OLT: 2.7 months). A total of 102 hepatic nodules were identified and analyzed at histopathological examination, and classified as LGDN, HGDN, and HCC. Two radiologists by consensus performed a quantitative (enhancement ratios, ERs) and a qualitative analyses of signal intensities of identified nodules on vascular dynamic phases (30-35 s after injection-arterial phase; 180-190 s after injection late phase) and on HB phases. Correlation between nodules MR patterns and histological classification was analyzed by means of dedicated statistical software.

RESULTS

No differences were appreciable among ERs of HGDN and HCCs on HB phase (P > 0.001). Lesions' enhancement on vascular dynamic and on HB phases significantly correlated to histological classification of nodules (P < 0.0001). Nodular hyperintensity on arterial phase and hypointensity on late phase were highly predictive for HCC (PPV 100%), with a moderate sensitivity (72.5%). Nodular hypointensity on HB phase was detected on 39/40 HCCs (sensitivity 97.5%) and in 21/30 HGDNs, whereas no LGDN showed it.

CONCLUSIONS

Hyperenhancement on arterial phase and hypointensity on late phase are the most specific clues for the diagnosis of HCC. Hypointensity on HB phase shows a PPV of 100% in suggesting nodular premalignancy/malignancy, independently from nodular dynamic vascular enhancement.

Radiofrequency ablation of high-grade dysplastic nodules

High-grade dysplastic nodules (HGDNs) are known to be premalignant lesions of hepatocellular carcinoma (HCC). We devised a model to estimate the long-term survival benefit of treating HGDNs by radiofrequency ablation (RFA) (Group I), as compared with regular follow-up and timely treatment by resection (Group II). A hypothetical 60-year-old compensated patient with cirrhosis was assumed. The system being modeled was assumed to be a simple Markov process, and state transition probabilities were given as parameters. Data used for simulation were obtained by a systematic review of the literature. The reported overall malignant transformation rates of HGDNs ranged from 12.5% to 80.8%, and were assumed to be 20%, 50%, and 80% using the best, moderate, and worst scenarios for Group II, respectively. The 5-year overall survival benefit of Group I compared with Group II was calculated by summing the detrimental effect of overtreatment and the beneficial effects of avoiding operative mortality. When the overall malignant transformation rate was set at 20%, 50%, or 80% the expected additional 5-year overall survival benefits of Group I compared with Group II were -0.05%, 0.20%, and 0.47%, respectively, and the corresponding additional 10-year overall survival benefits were 0.03%, 0.33%, and 0.55%, respectively. One-way sensitivity analysis showed that Group I was preferable to Group II in terms of 5-year overall survival when the 5-year overall malignant transformation rate was greater than 25.9%.

CONCLUSION

No definite evidence indicates that the treatment of HGDNs by RFA provides additional long-term overall survival benefit as compared with regular follow-up and timely treatment. The findings of the present study concur with the present American Association for the Study of Liver Diseases guidelines.

Large (>or=2 cm) non-hypervascular nodules depicted on MRI in the cirrhotic liver: fate and implications

AIM

To determine the fate and clinical implication of large (>or=2 cm), non-hypervascular nodules depicted on magnetic resonance imaging (MRI) in the cirrhotic liver.

MATERIALS AND METHODS

In 21 patients with cirrhosis (14 hepatitis B, two ethanol abuse, four cryptogenic, one Wilson's disease), 25 large (>or=2 cm in the longest dimension) non-hypervascular nodules were identified on dynamic MRI. The implications for diagnosis of the initial size, contour, and signal characteristics on MRI in addition to patients' age and cause of cirrhosis were assessed in our analysis.

RESULTS

Twelve (75%) out of 16 lesions were malignant or potentially-malignant from 14 hepatitis B patients, while seven (78%) of the nine lesions from other patients were benign (p=0.016). The mean age of the patients who had malignant or potentially malignant lesions (57 years) was older than that for the other patients (47 years; p=0.039). The ratio of the short-to-long diameter was higher in malignant or potentially malignant lesions (mean 0.86) than in benign lesions (mean 0.69; p=0.008). There was no discriminative signal intensity characteristic (p>0.2 for all factors) that indicated the malignant potential for each non-hypervascular nodule. For all 10 lesions in the hepatitis B patients who were older than 52 years with a short-to-long diameter ratio of more than 0.75, the positive predictive value for malignant potential based on these three combined factors was 100%.

CONCLUSION

In older patients with cirrhosis from hepatitis B, large (>or=2 cm), non-hypervascular nodules with a spherical contour have a high malignant potential.