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Pathology of Liver Metastases: Barbara A. Centeno, MD
Pathology of Liver Metastases: Barbara A. Centeno, MD
Background: The liver is the most frequent site of metastatic disease, and metastatic disease to the liver is far
more common than primary liver carcinoma in the United States. Pathologic evaluation of biopsy samples is
key to establishing a correct diagnosis for patient management. Morphologic and immunoperoxidase studies,
which are the standard for pathologic practice, accurately classify most tumors. Subclassification of carcinoma
of unknown primary remains problematic.
Methods: The author reviewed the literature for articles pertaining to liver biopsy, diagnosis of specific tumor
types, utility of immunohistochemical markers, and microarray and proteomic analysis.
Results: Sampling of liver lesions is best accomplished by combining fine-needle aspiration and needle core
biopsy. Many malignancies have distinct morphologic and immunohistochemical patterns and can be correctly
subclassified. Adenocarcinoma of unknown primary remains enigmatic since current immunohistochemical
markers for this differential diagnosis lack specificity. Microarray analysis and proteomic analysis of tumors
can provide distinct gene or protein expression profiles, respectively, for tumor classification. These technologies
can be used with fine-needle aspiration and needle core biopsy samples.
Conclusions: Most metastatic malignancies in the liver may be correctly diagnosed using standard morphology
and immunohistochemical techniques. However, subtyping of some carcinomas and identification of site of
unknown primary remains problematic. New technologies may help to further refine our diagnostic capabilities.
Introduction
From Pathology Services at the H. Lee Moffitt Cancer Center &
Research Institute, Tampa, Florida.
Submitted June 29, 2005; accepted November 30, 2005.
The liver is one of the most common sites for metasta-
Address correspondence to Barbara A. Centeno, MD, Pathology Ser- tic disease, accounting for 25% of all metastases to solid
vices, 12902 Magnolia Drive, MCC Room 2071 H, Tampa FL 33612. organs.1 In the United States and Europe, secondary
E-mail: centenba@moffitt.usf.edu liver neoplasms are far more common than primary
No significant relationship exists between the author and the com- hepatic neoplasms. In the adult oncology patient, most
panies/organizations who products or services may be referenced
in this article. are metastatic carcinomas, of which adenocarcinomas
Abbreviations used in this paper: FNA = fine-needle aspiration, are the predominant subtype, followed by squamous
NCB = needle core biopsy. cell carcinomas and neuroendocrine carcinomas.
In order to establish a treatment regimen, tissue diag- Correct clinical history is crucial to the pathologic
nosis of liver masses is required. FNA and NCB using interpretation of a biopsy from a liver mass suspected
either transabdominal ultrasound or computed tomog- of being a metastasis. The most accurate interpretation
raphy scanning guidance are the most frequently used is rendered when the history of previous cancer and
modalities and provide diagnostic specimens in over other pertinent findings, such as radiological findings
90% of cases.2 Endoscopic ultrasound-guided FNA and serum tumor marker levels, are provided for corre-
(EUS-FNA) is being used more frequently to aspirate lation with the pathologic findings.
lesions in the left lobe of the liver. The decision to use The first step when evaluating a liver biopsy is to
FNA or NCB depends on the size and location of the establish the general tumor type, ie, whether the neo-
lesion, the suspected diagnosis, and the risk of compli- plasm is a carcinoma, sarcoma, lymphoma, or melanoma.
cations. The experience of a radiologist performing the Morphology alone is often diagnostic, but frequently
biopsy is also an important factor. The availability of ancillary studies are needed for definitive diagnosis when
cytologists to evaluate the FNA for adequacy may also the tumor is poorly differentiated. A panel incorporating
play a role in selection of sampling technique. at least cytokeratins, S100, and leukocyte-common anti-
A misconception among some clinicians is that gen (LCA) will assist in subcategorizing the neoplasms.
NCB is better than FNA because it procures more tissue. Carcinomas express cytokeratins, most lymphomas
However, studies in the literature and personal experi- (except anaplastic large-cell lymphoma) express LCA,
ence indicate that both are complementary, and an ade- and S100 is the most sensitive marker for the diagnosis of
quate FNA with a well-prepared cellblock can provide melanoma. Additional antibodies can be added once the
sufficient tissue for immunohistochemical studies. differential diagnosis has been narrowed down.
In one recent study of 141 patients with abdominal
lesions sampled with both FNA and NCB, FNA proved Carcinomas
more sensitive than NCB at diagnosing malignancy Carcinomas are the most frequent source of metastases
(86.1% vs 80.6%, respectively).3 In other studies evalu- to the liver. Lung, colon, pancreas, breast, and stomach
Fig 1. — Squamous cell carcinoma, FNA. This sheet of cells has dense
polygonal cytoplasm with junctions. The nuclei show an increased nuclear
to cytoplasmic ratio and atypia (Papanicolaou, × 63). Fig 3. — Urothelial carcinoma, FNA. The cells are dispersed as single cells.
Many of the cells have a bulbous head and a tail, characteristic of cercari-
form cells (Papanicolaou, × 60).
Fig 2. — Squamous cell carcinoma, core biopsy. The cells have abundant, Fig 4. — Urothelial carcinoma, core biopsy. The cells are arranged in cohe-
dense, polygonal eosinophilic cytoplasm. Intercellular junctions between sive nests and have abundant eosinophilic cytoplasm. The nuclei show
the cells are evident (hematoxylin-eosin, × 40). nuclear grooves, a feature or urothelial carcinoma (hematoxylin-eosin, × 40).
Fig 5. — Carcinoid tumor, FNA. The cells have abundant amphophilic cyto- Fig 7. — Small cell carcinoma, FNA. In contrast to the carcinoid tumor,
plasm and the nuclei are eccentrically placed, imparting a plasmacytoid these cells —exhibit greater variation in nuclear contour. The cells have
appearance. Some cells are binucleated. The cells exhibit the characteris- scant amphophilic cytoplasm. Nuclear molding, crush artifact and necro-
tic salt and pepper chromatin pattern (Papanicolaou × 40). sis are evident. The salt and pepper chromatin pattern typical of neuroen-
docrine neoplasms is retained (Papanicolaou, × 63).
Fig 6. — Carcinoid tumor, core biopsy. The cells are arranged in solid
nests with focal areas of palisading or acinar structure formation. The Fig 8. — Small cell carcinoma, FNA, cell block. The cells have scant,
nuclei are round and uniform with a salt and pepper chromatin (hema- eosinophilic cytoplasm. The nuclei are elongated and fusiform. Apoptosis
toxylin-eosin, × 40). is noted (hematoxylin-eosin, × 40).
Fig 9. — Adenocarcinoma, NOS, core biopsy. The cells are arranged in an Fig 11. — Colonic adenocarcinoma, core biopsy. The glands show abun-
acinar pattern, characteristic of adenocarcinoma from any site. Pale, dant central necrosis, a characteristic feature of colonic adenocarcinoma
bluish mucin is evident the cytoplasm of some cells and lumen (hema- (hematoxylin-eosin, × 40).
toxylin-eosin, × 40).
Fig 10. — Colonic adenocarcinoma, FNA. The smear shows columnar cells Fig 12. — Mammary carcinoma, FNA. The cells are dispersed and show
arranged in a palisaded pattern. The background shows abundant necro- eccentric nuclei. A number of cells have intracytoplasmic mucin vacuoles
sis (Papanicolaou, × 40). (Diff-Quik, × 60).
Fig 17. — Signet ring cell carcinoma, core biopsy. Signet ring cells with
Fig 15. — Mucinous carcinoma, FNA. The cluster of malignant cells floats eccentric, elongated nuclei displaced by intracytoplasmic mucin vacuoles
in a background of viscous mucin (Papanicolaou, × 40). (hematoxylin-eosin, × 40).
Fig 20. — Adrenal cortical carcinoma, biopsy. The cells clusters show
Fig 18. — Renal cell carcinoma, biopsy. Clear cells surround by vascular endothelial wrapping, similar to that shown by hepatocellular carcinoma
stroma (hematoxylin-eosin, × 40). (hematoxylin-eosin, × 20).
Fig 19. — Renal cell carcinoma, FNA. This fragment has a central, trans- Fig 21. — Hepatocellular carcinoma, biopsy. Classic pattern of hepatocel-
gressing vasculature, which mimics the pattern seen in hepatocellular car- lular carcinoma showing widened trabeculae and intracytoplasmic inclu-
cinoma. Stripped nuclei are seen in the background (Diff-Quik, × 20). sions (hematoxylin-eosin, × 20).
Fig 24. — Large cell lymphoma, FNA. The malignant cells are dispersed.
Fig 22. — Melanoma, FNA. The smear shows a dispersed cell population. The nuclei are three times the size of normal lymphocytes. The back-
The nuclei vary in size and shape. Some of the cells show black melanin ground shows lymphoglandular bodies, which are characteristic for lym-
pigment in the cytoplasm (Diff-Quik, × 40). phoid processes (Diff-Quik, × 63).
Fig 23. — Melanoma, core biopsy. The malignant cells have atypical nuclei Fig 25. — Large cell lymphoma, biopsy. The specimen shows a popula-
with prominent nucleoli, a feature considered typical of melanoma. tion of cells with scant cytoplasm, irregular nuclear membranes and promi-
Melanin pigment is visible (hematoxylin-eosin, × 40). nent nucleoli (hematoxylin-eosin, × 40).
Fig 28. — Gastrointestinal stromal tumor, core biopsy. The cells are spin-
Fig 26. — Gastrointestinal stromal tumor, FNA. This field demonstrates dle in shape with minimal nuclear atypia. Perinuclear halos are evident
spindle cells embedded in myxoid stroma (Diff-Quik, × 20). (hematoxylin-eosin, × 40).
Fig 27. — Gastrointestinal stromal tumor, core biopsy. The plump spindle Fig 29. — Leiomyosarcoma, core biopsy. The cells show a greater degree
cells tumor vascularity is prominent. Skenoid fibers are noticeable at this of nuclear pleomorphism and are surrounded by a myxoid stroma. The
power (hematoxylin-eosin, × 20). tumor is less vascular than the GIST (hematoxylin-eosin, × 40).
HMW CK – + – –
LMW CK + + –/few cells + –
Vimentin +/– + + +
EMA + + – –
CD 10 Canalicular + – –
AFP + – – –
HepPar + – – –
MART-1 – – + +
S100 – – – +
HMB45 – – – +
Synaptophysin – – + –
Calretinin – – + –
HMW CK = high-molecular-weight cytokeratin
LMW CK = low-molecular-weight cytokeratin
and adrenal cortical carcinoma) and distinguishing cinoma in a canalicular pattern but not in the cyto-
hepatocellular carcinoma from adenocarcinoma. A spe- plasm, as it does for renal cell carcinoma.49
cial problem in the oncology patient is the workup of Other unusual metastases that may mimic hepato-
carcinoma of unknown primary. cellular carcinoma include hepatoid yolk sac tumor,
and oxyphilic follicular carcinoma of the thyroid. Hepa-
Primary Hepatocellular Carcinoma vs toid yolk sac tumors are rare, and follicular carcinoma
Metastases of the thyroid rarely gives rise to liver metastases. The
The morphologic features of renal cell carcinoma and immunohistochemical approach to this differential diag-
adrenal cortical carcinoma overlap with those of hepa- nosis is summarized in Table 1.
tocellular carcinoma, on both cytology smears and
histopathology samples. Immunohistochemical analy- Adenocarcinoma vs Hepatocellular Carcinoma
sis differentiates among these three carcinomas. Adren- Typically, the distinction of adenocarcinoma from hepa-
al cortical carcinomas are weakly positive for cytoker- tocellular carcinoma is clear-cut on morphologic
atin and express vimentin and synaptophysin. MART-1, grounds. Adenocarcinoma is characterized by the for-
also known as melanA, and usually expressed by mation of gland-like or tubular structures. The lumens
melanoma, is useful for diagnosing adrenal cortical car- or the individual cells contain mucin. Hepatocellular
cinoma.39,40 Adrenal cortical carcinoma also expresses carcinoma occasionally forms acinar structures resem-
inhibin, which is slightly more sensitive but less specif- bling adenocarcinoma (Fig 30) or is poorly differentiat-
ic.41 Calretinin has also been shown to be expressed by ed, in which case it cannot be distinguished from ade-
adrenal cortical cells and neoplasms.42-44 Clear cell car- nocarcinoma. In these situations, adjunctive studies are
cinoma of the kidney, the most typical type of renal needed. The presence of bile pigment is pathogno-
neoplasm, expresses cytokeratin, vimentin, epithelial monic for hepatocellular differentiation; therefore, if
membrane antigen (EMA), renal cell carcinoma anti-
body, and CD10.45-47 Exceptions are the papillary vari-
ants and chromophobe cell variants, which do not
express vimentin. Alpha-methyl CoA racemace
(AMACR) is usually expressed by papillary renal cell
carcinomas,48 and chromophobe renal cell carcinomas
demonstrate colloidal iron not demonstrated by hepa-
tocellular carcinoma or adrenal cortical carcinoma.
Hepatocellular carcinoma can usually be identified by
expression of low-molecular-weight cytokeratin, Hep-
Par, and a canalicular pattern rather than a cytoplasmic
pattern of carcinoembryonic antigen (CEA). The
canalicular pattern occurs because the CEA will stain
the bile duct canaliculi in hepatocellular carcinoma but Fig 30. — Hepatocellular carcinoma, biopsy. Acinar pattern demonstrated
not the cytoplasm. CD10 will stain hepatocellular car- in hepatocellular carcinoma (hematoxylin-eosin, × 40).
Cholangiocarcinomas are usually CK7+ and variably from pancreatobiliary, biliary, ovarian, or pulmonary
express CK20.59 Their morphologic expression pattern adenocarcinomas.65,85-87
overlaps with the pattern of many other primary sites. An older antibody panels consisting of MOC31, ker-
The most relevant phenotype to the discussion atins, vimentin, B72.3, CA125, Ca19-9, placental alkaline
of metastatic adenocarcinoma to the liver is the CK7–/ phosphatase, S100 protein, estrogen receptor protein,
CK20 + phenotype because it is highly characteristic of PSA, thyroglobulin, GCDFP15, and CEA obtained a
colorectal primary.61 The predictive probability of this sensitivity of 67%88 for the diagnosis of carcinoma of
immunophenotype is 78%.62 unknown primary. Another study evaluating GCDFP15,
Carcinomas coexpressing CK7/CK20 include breast cancer antigen 225 (BCA225), B72.3, CA15-3,
urothelial carcinoma, metastatic pancreatobiliary carci- CEA, CA19-9, CA125, and estrogen receptor showed a
noma, and mucinous ovarian carcinoma.58,63 Recent sensitivity of 67% for the determination of site of ori-
publications have shown that mucinous colon carcino- gin.89 While individual studies have evaluated the sen-
ma and mucinous bronchoalveolar carcinoma also sitivity and specificity of sets of markers for specific dif-
express the CK7+/CK20+ phenotype.64-67 Morphology ferential diagnoses, the sensitivity of a panel including
can sometimes exclude metastatic urothelial carcinoma CK7 and CK20 with some of the above listed antibod-
since this is not a gland-forming neoplasm; however, its ies has not been determined across a broad number of
features may overlap with those of poorly differentiated cancers in the liver.
adenocarcinoma. The CK7–/CK20– phenotype is usual-
ly typical of prostate, with a probability of 76%.62 Other
tumors rarely show this phenotype. The CK7+/CK20– Future Directions
subtype is the least specific.63 Lung and breast are two
tumors that exclusively have this phenotype, with a Cancer therapy is primarily directed by tumor origin,
probability of 84% and 88%, respectively. However, making correct pathologic diagnosis imperative for
other tumors can express this phenotype, particularly if proper patient management. As discussed, the number
CK20 expression is weak or focal. Of note, gastric and of specific markers available and subjectivity of inter-
esophageal adenocarcinoma have the most variable pretation are factors that limit standard pathologic
CK7/CK20 expression pattern.58,61 Therefore, these practice using morphology and immunohistochem-
need to be included in the differential diagnosis of any istry. Tumor classification, using high throughput tech-
phenotype. Table 3 summarizes the most frequent nologies such as microarray and proteomic screening,
CK7/CK20 expression patterns for carcinomas of dif- promise to improve cancer diagnosis and management.
ferent primary sites. A number of publications have demonstrated the
Other studies can help to further refine the differ- feasibility of using gene expression profiles derived
ential diagnosis. Cytokeratin 17 is associated with from microarray analysis as an approach to diagno-
ampullary and pancreatobiliary carcinomas more often sis.90-92 Proteomic analysis has the potential to yield
than gastric or esophageal carcinomas.68,69 Additional similar data sets.93
markers help to further refine the identification such as In order for these technologies to be clinically rel-
TTF1 (nonmucinous pulmonary adenocarcinomas),64,70- evant, they must be applicable with FNA and NCB.
74 estrogen receptor protein staining (breast, ovarian, Recent studies have shown the feasibility of using
endometrial),29,75 GCDFP15 (breast),27,76-78 WT1 (ovari- FNA or NCB specimens for microarray analysis.94-99 In
an serous tumors),79 PSA and PAP (prostate),80 throm- our own experience, FNA of resection specimens
bomodulin,81 and uroplakin (urothelial carcinoma).80,82 obtained over 1 μg of total RNA for microarray analy-
CA125, when used as part of a panel, is useful for sis.100 The samples were successfully classified using
identifying ovarian carcinomas.83,84 CDX2 is used as a a tumor classifier derived from resection specimens.
marker of intestinal differentiation and can help to dif- Studies evaluating the use of cytology or NCB materi-
ferentiate colorectal, intestinal, or gastric neoplasms al for proteomic analysis are limited.101