Update on Precursor and Early Lesions of
Hepatocellular Carcinomas
Young Nyun Park, MD, PhD
Nmultistep
Context.—There is increasing evidence to support a
model of the process of human hepatocarcino-
genesis. Precursor lesions are characterized by the
appearance of dysplastic lesions in the form of microscopic
dysplastic foci and macroscopic dysplastic nodules. There
are 2 types of small hepatocellular carcinoma (HCC)
(#2 cm in diameter): (1) early HCC with an indistinct
margin and (2) progressed HCC with a distinct margin.
Pathologic diagnostic criteria for early HCC have recently
been set up based on a consensus between Eastern and
Western pathologists.
Objective.—To review the nomenclature, pathology,
and biomarkers of precursor and early lesions of HCC.
Data Sources.—Literature review and illustrations from
case materials were used.
Conclusions.—Dysplastic foci are composed of large and
small cell changes. Small cell change is considered to be a
more advanced precursor lesion than large cell change,
IHepatocellular
n humans, most hepatocellular carcinomas (HCCs) arise
in the background of chronic hepatitis/cirrhosis.
carcinoma usually follows a multistep
sequence, and de novo development of HCC may occur,
although this appears to be rare. Morphologically recog-
nizable lesions during hepatocarcinogenesis include dys-
plastic lesions (dysplastic foci and dysplastic nodules
[DNs]) and small cancerous lesions (#2 cm in diameter)
(early HCC and small progressed HCC) (Figure 1;
Table 1). Their pathologic features are discussed with
emerging biomarkers.
DYSPLASTIC FOCI
Dysplastic foci are microscopic lesions composed of
dysplastic hepatocytes that measure less than 1 mm in size
and occur in chronic liver disease, particularly in cirrhosis.
Accepted for publication January 11, 2011.
From the Department of Pathology, Brain Korea 21 Project for
Medical Science, Center for Chronic Metabolic Disease, and the
Severance Biomedical Science Institute, Yonsei University Health
System, Seoul, South Korea.
The author has no relevant financial interest in the products or
companies described in this article.
Presented at the 9th Spring Seminar of the Korean Pathologists
Association of North America; March 18–20, 2010; Washington, DC; in
conjunction with the 99th Annual Meeting of the United States and
Canadian Academy of Pathology.
Reprints: Young Nyun Park, MD, PhD, Department of Pathology,
Yonsei University Health System, 250 Seongsanno, Seodaemun-gu,
Seoul 120-752, South Korea (e-mail: young0608@yuhs.ac).
704 Arch Pathol Lab Med—Vol 135, June 2011
and large cell change is a rather heterogeneous lesion that
may represent both reactive change and true dysplasia.
Dysplastic nodules can be categorized as low or high grade
according to the degree of atypia. High-grade dysplastic
nodules have been reported to show molecular changes
similar to HCC and have a high risk of malignant
transformation. Early HCC, which may correspond to
microinvasive carcinomas of other organs, is a well-
differentiated HCC, and differential diagnosis between
early HCC and high-grade dysplastic nodule is difficult.
Identification of stromal invasion and application of a
panel of markers (glypican-3, heat shock protein 70, and
glutamine synthetase) is helpful for diagnosis of early HCC.
Detection of precursor lesions of HCC is important in
recognizing patients with higher risk of developing HCC,
and diagnosis of early HCC can improve patient survival by
allowing for early and adequate treatment.
(Arch Pathol Lab Med. 2011;135:704–715)
This term was introduced by an international consensus
article published in 1995,1 and its arbitrary size criterion is
related to the fact that these microscopic lesions are
usually contained within a single hepatic lobule or
cirrhotic nodule.2,3 In most cases, dysplastic foci are
recognized incidentally in liver biopsies or resected liver
specimens, as they are not macroscopically detectable.
Dysplastic foci are categorized according to the main cell
type as small cell foci, large cell foci, or iron-free foci, and
dysplastic hepatocytes showing small cell changes (SCCs)4
or large cell changes (LCCs)5 are also part of the spectrum
of cytologic abnormalities occurring in DNs.
Small cell change, originally described as small cell
dysplasia,4 is defined as hepatocytes showing decreased
cell volume, increased nuclear to cytoplasmic ratio, mild
nuclear pleomorphism and hyperchromasia, and cyto-
plasmic basophilia, giving the impression of nuclear
crowding (Figure 2, A).3 Small cell change is characterized
by higher proliferative activity than the surrounding
normal-looking hepatocytes, telomere shortening with
p21 checkpoint inactivation, increased formation of
micronuclei suggesting chromosomal instability, chromo-
somal gains and losses, a morphologic resemblance to
well-differentiated HCC, and a histologic continuum to
HCC.2,3,6,7 These data support the precancerous nature of
SCC. Small cell change occurring in small foci, with
expansile rather than widespread growth, was reported to
be associated with HCC development.2 Thus, expansile
foci of SCC are considered to correspond to dysplastic foci
Precursor and Early Lesions of Hepatocellular Carcinoma—Park
Figure 1. Scheme of preneoplastic and neoplastic nodules during hepatocarcinogenesis. Abbreviations: DN, dysplastic nodule; HCC,
hepatocellular carcinoma; LCC, large liver cell change; SCC, small liver cell change.

in the International Working Party classification.1 In
contrast, a diffuse pattern of SCC may represent regener-
ating, rather than dysplastic, hepatocytes.8,9 The difficulty
in distinguishing precancerous SCC from regenerative
changes may be one reason for the limited predictive
value of SCC for HCC development.2 Some reports have
shown a significant correlation between the presence of
SCC and HCC,10,11 whereas others have not.12–14
Large cell change, originally termed liver cell dysplasia,5
is defined as hepatocytes with both nuclear and cytoplas-
mic enlargement (therefore, a preserved nuclear to
cytoplasmic ratio), nuclear pleomorphism and hyperchro-
masia, and frequent multinucleation (Figure 2, B).3 A
definitive consensus has not been reached regarding the
biologic nature of LCC.2 The data supporting LCC as a
reactive process related to chronic injury, or senescence,
include low proliferative activity and increased apopto-
sis,15 absence of a histologic continuum with HCC,15
association with cholestasis,16 and absence of genetic
alterations present in adjacent HCCs.6 Data showing that
LCC has higher argyrophilic nucleolar organizer region
values than other normal-looking hepatocytes (with the
highest argyrophilic nucleolar organizer region values
being strongly associated with HCC development during
follow-up),17 abnormal DNA content,18–20 chromosomal
numerical aberrations, and chromosomal gains and
losses21,22 all demonstrate that LCC is a precancerous
lesion. In addition, the cirrhotic macronodules with LCC
were reported to be monoclonal, a prerequisite step of
hepatocarcinogenesis.23 A recent study reported that
telomere shortening, DNA damage, increased prolifera-
tion, increased DNA damage, and inactivation of the cell
cycle check point (p16 and p21) were found in LCC of B
viral cirrhosis, while these features are not found in LCC
of chronic cholestasis.24 These conflicting data suggest that
LCC is a heterogeneous entity with 2 types: one that is not
totally benign and tumor-related (true dysplasia), and
another one that is benign and non–tumor-related

Table 1. Hepatic Precancerous Lesions and Small Hepatocellular Carcinoma (HCC)

Dysplastic focus
N Cluster of hepatocytes, ,1 mm in size, characterized by presence of either small cell change or large cell change
Dysplastic nodule
N A distinctly nodular lesion (usually 1 cm in size) differing from the surrounding liver parenchyma regarding size, color, and texture and that
bulges from the surrounding liver on the cut surface
N Dysplastic nodule, low grade: mild atypia
N Dysplastic nodule, high grade: at least moderate atypia, but insufficient for a diagnosis of HCC
Small HCC (#2 cm in diameter)
N Early HCC (small HCC with indistinct margins, small HCC with vaguely nodular type)
N Small and progressed HCC (small HCC with distinct margins)

Arch Pathol Lab Med—Vol 135, June 2011 Precursor and Early Lesions of Hepatocellular Carcinoma—Park 705

Figure 2. Dysplastic foci. A, Dysplastic foci showing small liver cell
change (arrows). B, Dysplastic foci showing large liver cell change
(arrows) (hematoxylin-eosin, original magnifications 3200 [A and B]).
(reactive change).25 Actually, the presence of LCC in B
viral or C viral cirrhosis has been reported to be an
important independent risk factor for subsequent devel-
opment of HCC.12–14 Interestingly, in chronic liver disease,
telomere shortening, chromosomal instability, cell cycle
check point inactivation, and DNA damage were progres-
sively increased from LCC to SCC with peak levels at
HCC.7,24 These data suggest that SCC may be a more
advanced precancerous lesion and that LCC might be a
very early precursor of HCC in chronic viral hepatitis B
or C.
Iron-free foci in genetic hemochromatosis were report-
ed to be proliferative lesions associated with a high
incidence of HCC during follow-up.26 From a practical
point of view, identification of SCC, LCC, or iron-free foci
in liver biopsies may signify an increased risk of HCC over
time. The presence of such lesions should be noted on
pathology reports.
DYSPLASTIC NODULE
Dysplastic nodules are usually detected in cirrhotic
livers but are occasionally found along with chronic liver
disease without cirrhosis.1–3,27,28 A DN is a distinctly
nodular lesion that differs from the surrounding liver
parenchyma regarding size, color, and texture and that
706 Arch Pathol Lab Med—Vol 135, June 2011
bulges from the surrounding liver on a cut surface
(Figure 3, A). Dysplastic nodules mostly measure about
1 cm in diameter. They may be single or multiple (less
than 10 in number). According to international consen-
sus,1 DNs are classified as low grade or high grade,
depending on the degree of atypia.
Histologically, low-grade DNs show mild increases in
cell density with a monotonous pattern compared with
that of cirrhotic nodules (Figure 3, B through D). They
have features suggestive of a clonal cell population, such
as diffuse iron or copper accumulation, or uniform
steatosis in livers without fatty change. Cytologic atypia
is mild. Large cell change may be found; however SCC is
not present. Cell density is slightly higher than in the
surrounding liver but less than 1.3-fold. Architectural
changes beyond clearly regenerative features are not
present; these lesions do not contain pseudoglands.
High-grade DNs show at least moderate cytologic or
architectural atypia that approaches but does not quite
reach the levels of HCC (Figure 3, E). These lesions most
often show increased cell density, 1.3 to 2 times greater
than that of the adjacent liver tissue, and SCC is the most
frequently seen form of cytologic atypia in high-grade
DNs.
Dysplastic nodules may derive their blood supply both
from portal vessels and from newly formed arteries
(termed unpaired or nontriadal arteries) (Figure 3, F).2,3,29–31
Portal tracts are commonly seen in DNs but may be few
and scarred. Unpaired arteries, which have no accompa-
nying bile ducts, are not present in cirrhosis. They are least
prominent in low-grade DNs, both in number and in size,
increasing in numbers through high-grade DNs and are
most abundant in HCC. Similarly, sinusoidal capillariza-
tion is minimal in cirrhosis, and it increases from low- to
high-grade DN, with the highest levels in HCC. Neoan-
giogenesis is caused by growth factor production includ-
ing vascular endothelial growth factor by lesional cells.32 It
is also correlated with radiologic features; DN usually
appears isovascular or hypovascular compared with the
surrounding parenchyma, whereas HCC usually shows a
hypervascular appearance in the arterial phase of con-
trast-enhanced hepatic imaging.2,3,27
The following evidence supports the theory of a
premalignant nature of DN:
1. An epidemiologic association of DNs with HCC in
resected and explanted livers, particularly in end-stage
cirrhotic patients.33–37 Their association with HCC takes
2 forms. First, both low- and high-grade DNs are
markers of an increased risk of cancer development in
the liver. In fact, HCCs do not always develop within
DNs but may be found elsewhere in the liver,
independent of the latter. Second, subnodules of
HCC are often seen within DNs (nodule-within-
nodule pattern) (Figure 4).
2. The natural history of DNs shows an increased risk
of malignant transformation compared with control
patients with cirrhosis. There are several reports
that have evaluated the natural history of large
hepatic nodules. Borzio and colleagues38 followed 90
cirrhotic patients with histologically proven large
regenerative nodules (n 5 56) or low-grade (n 5 16)
or high-grade (n 5 19) DNs and found that the
presence of high-grade DNs was associated with a
higher risk for HCC development (hazard ratio, 2.4
Precursor and Early Lesions of Hepatocellular Carcinoma—Park
Figure 3. Dysplastic nodule (DN). A, Macroscopic feature of DN (arrows) in B viral cirrhosis. B, Microscopic feature of low-grade DN (above
dotted line). Portal tracts are present inside DN. Comparison of cell density among cirrhotic nodule (C), low-grade DN (D), and high-grade DN (E) at
the same magnification. Low-grade DN (D) shows a slightly increased cell density compared with extranodular cirrhotic liver and mild cellular
atypia. The intranodular portal tract is marked by arrows. High-grade DN (E) shows high cell density, a thin trabecular pattern, and small cell change
with an increased nuclear to cytoplasmic ratio. F, Immunohistochemical stain for CD34 shows increased sinusoidal capillarization and unpaired
arteries (arrow) in high-grade DN (hematoxylin-eosin, original magnifications 3100 [B] and 3200 [C through E]; original magnification 3200 [F]).

during a mean follow-up period of 33 months).
Large regenerative nodules and low-grade DNs
were associated with a low risk for malignant
transformation. In another study, Kobayashi and
Arch Pathol Lab Med—Vol 135, June 2011
colleagues39 followed 154 patients who had histo-
logically proven large regenerative nodules (n 5 99)
or low-grade (n 5 42) or high-grade (n 5 13) DNs
for a median period of 2.8 years. The hazard ratios
Precursor and Early Lesions of Hepatocellular Carcinoma—Park 707
Figure 4. Hepatocellular carcinoma (HCC) arising in dysplastic nodule. A, A well-defined and dark brown nodule in cirrhosis shows a nodule-in-
nodule pattern. The inner nodule shows a yellowish tan color. B, The outer nodule shows the features of high-grade dysplastic nodule. The
intranodular portal tract is marked by arrows. C, Nodule-in-nodule pattern. The inner nodule (below dotted line) shows a well-differentiated HCC
with fatty change and Mallory bodies. D, Immunohistochemical stain for CD34 shows increased sinusoidal capillarization and unpaired arteries in
the inner nodule of HCC (below dotted line) than in the outer nodules of the dysplastic nodule (hematoxylin-eosin, original magnifications 3200 [B
and C]; original magnification 3200 [D]).

of high-grade DN, low-grade DN, and large regenera-
tive nodules for malignant transformation were 16.8,
2.96, and 1.0, respectively. In this study, however, SCC
was considered to be a feature of low-grade as well as
high-grade DNs. Finally, Terasaki and colleagues40
found that histologic features predictive of malignant
transformation of DNs included increased cellularity,
clear cell change, SCC, and fatty change.
3. Similarities in both genetic and epigenetic changes
between DNs and HCC have been detected. The
incidence and extent of these changes is between those
observed in cirrhotic nodules and those in HCC. In
some cases, the very same molecular alteration has
been reported in DNs and the adjacent HCC.41–45
4. Dysplastic nodules, especially high-grade DNs, have
shortened telomeres with increased chromosomal insta-
bility, and most high-grade DNs strongly express
hTERT mRNA at levels similar to those of HCCs, and
33% of them showed high telomerase activity.46–48 Fur-
thermore, the p21 check point is inactivated in DNs in
contrast to cirrhotic nodules where they are activated.49
Thus, DNs, especially high grade, are considered to be
708 Arch Pathol Lab Med—Vol 135, June 2011
vulnerable to further genetic change for malignant
transformation.
Important pathologic features that may be helpful for
the differential diagnosis of hepatic nodules are summa-
rized in Table 2. The differentiation between high-grade
DNs and well-differentiated HCC is often difficult and
recognition of stromal invasion of tumor cells supports the
diagnosis of HCC. This is further discussed in the section
on early HCC and biomarkers.50 Another diagnostic
difficulty is making the distinction between low-grade
DN and large regenerative nodules, as these lesions share
a number of histologic features. The presence of unpaired
arteries or evidence of a clonelike cell population in a large
nodule suggest that it is dysplastic rather than regenera-
tive. Interestingly, about 15% of low-grade DNs showed
shortened telomere length and 7% showed telomerase
activity equal to the levels found in high-grade DNs,
although there was no histologic difference between the
lesions with and without these changes.46–48 Chromosomal
instability, indicated by micronuclei, is higher in low-
grade DN than in cirrhotic nodules, and the p21
checkpoint is deactivated in low-grade DNs unlike in
Precursor and Early Lesions of Hepatocellular Carcinoma—Park
 Table 2. Important Pathologic Features of Hepatocellular Nodules
LRN LGDN HGDN WD HCC
Cytologic features
Small cell change 2 2 + +
Large cell change 6 6 6 2
Clonelike foci (clear, fatty) 2 6 + +
Architectural features
Plate thickening $3 cells 2 2 2 +
Increased cell density compared with surroundings 2 2 1.3 to 2 times .2 times
Pseudoglands 2 2 6 +
Nodule-in-nodule 2 2 2 6
Portal tract + + + 6
Unpaired arteries and capillarized sinusoidsa 2 6 6 +
Stromal invasionb 2 2 2 +
Reticulin framework + + + 6
Tumor markers
Glypican-3 2 2 6 (9%) + (69%)
Heat shock protein 70 2 2 6 (5%) + (78%)
Glutamine synthetase 2 2 6 (13%) + (59%)
Positive in at least 2 of above 3 markers 2 2 2 + (72%)
Abbreviations: 2, absent; 6, may be present; +, usually present; ( ), % of positivity in resected specimen; HGDN, high-grade dysplastic nodule;
LGDN, low-grade dysplastic nodule; LRN, large regenerative nodule; WD HCC, well-differentiated hepatocellular carcinoma.
a
Immunohistochemical stain for CD34 is helpful.
b
Immunohistochemical stain for keratin 7/19 is helpful.

cirrhotic nodules, where the p21 is activated.49 Thus, some
low-grade DNs may have more potential to progress
along the multistep hepatocarcinogenesis course, and this
diagnosis may indicate that the patient is at increased risk
of developing HCC. In a report from the International
Consensus Group for Hepatocellular Neoplasia, diagnos-
tic agreement for low-grade DN is low, and from a
practical standpoint, the distinction between low-grade
DN and large regenerative nodules of cirrhotic livers is
difficult to make by morphology alone.27 Fortunately, this
distinction does not have any significant clinical impact at
present, as low-grade DNs are followed up and urgent
treatment is not required.
EARLY HCC
Small HCC is defined arbitrarily as carcinoma that
measures less than 2.0 cm in diameter. Studies from
Japan36,51,52 have shown that there are 2 types of small
HCCs: early HCC and (small) progressed HCC. Early
HCC is a low-grade, early-stage tumor whose definition
was agreed upon after a prolonged discussion with
circulation of slides between a group of Eastern and
Western pathologists.27 Early HCC is a vaguely nodular
and small-sized nodule (Figure 5, A). In a series of 116
small HCCs, the mean size of the early HCCs was 11.9 mm,
but that of small progressed HCCs (small HCCs with a
distinct margin) was 16.0 mm.28 The margin of early HCCs
is usually indistinct as tumor cells grow by replacing the
nonneoplastic hepatocyte cords without forming a tumor
capsule (Figure 5, B). Therefore, it may be difficult to
recognize at a macroscopic level. On the other hand, in the
setting of advanced cirrhosis, early HCC may show a
more distinctly nodular feature as it is surrounded by
cirrhotic septa (not tumor capsule).33,53
Histologically, early HCCs are usually well differenti-
ated and consist of small neoplastic cells (cytologically
reminiscent of SCC) with increased nuclear to cytoplasmic
ratio arranged in irregular, thin trabeculae and pseudo-
glandular structures (Figure 5, C and D). Thus, tumor cells
Arch Pathol Lab Med—Vol 135, June 2011
of well-differentiated HCC mimic nonneoplastic hepato-
cytes, and identification of these lesions as cancer may be
difficult microscopically. The cell density of early HCC is
more than 2 times that of the surrounding hepatic
parenchyma. Careful examination of areas with increased
cell density on low power can be helpful to not miss the
region of a well-differentiated HCC. Fatty change is
common, reported in about 40% of cases. In areas of fatty
change, the nuclear to cytoplasmic ratio is relatively low
and cytologic atypia may be difficult to detect. Tumor cells
often invade the fibrous tissue of portal tracts within or
outside the nodule, and detection of stromal invasion can
be aided by the use of Victoria blue staining outlining
residual portal tracts or by a lack of ductular reaction,
which usually takes place around nonmalignant nodules,
visualized by keratin 7/19 immunostaining (Figure 5, E
and F).50,54 However, early HCC does not show vascular
invasion, and it usually does not metastasize. Therefore,
early HCC can correspond to an entity in between in situ
carcinoma and invasive carcinoma, similar to microinva-
sive carcinoma of other organs. Varying numbers of portal
tracts are found within the nodule and arterial neovascu-
larization, which can be easily detected by immunohisto-
chemistry for CD34, is more developed than in high-grade
DNs but incomplete compared with progressed HCC2,3
(Figure 5, G and H). Therefore, early HCCs usually show
isovascular or hypovascular and rarely hypervascular
appearance in the arterial phase of contrast-enhanced
hepatic imaging. The reticulin framework is usually
reduced but not totally lost as in progressed HCCs. Early
HCC is considered to be a precursor of distinctly nodular
(progressed) HCC, and actually in some cases of pro-
gressed HCCs, a component of early, well-differentiated
HCC is detected at the periphery of tumor, indicating a
multistep progression of hepatocarcinogenesis. It should
also be noted that the characteristic histologic features of
early HCC may sometimes be seen in tumors measuring
more than 2 cm in diameter, suggesting that some HCCs
have a slow biologic evolution.
Precursor and Early Lesions of Hepatocellular Carcinoma—Park 709
Figure 5. Early hepatocellular carcinoma (HCC). A, Macroscopic features of early HCC showing a vaguely nodular appearance with an ill-defined
margin. B, At low power, early HCC (left side) shows a replacing growth pattern without a tumor capsule at the tumor border. The cell density of the
tumor is more than 2 times higher than the surrounding cirrhotic nodules (right side). Fatty change and some portal tracts are present in the tumor. C,
At medium power, an increased cell density is more obvious in the areas without fatty change. D, At high power, early HCC shows a well-
differentiated histology and small tumor cells with high nuclear to cytoplasmic ratios, thin trabecular pattern with 2- to 3-cell thickness, and acinar
pattern. E, Stromal invasion of tumor cells (arrows) into fibrous stroma of the portal tract. F, Immunohistochemical stain for keratin 19 showing no
ductular reaction around the stromal invasion of tumor cells (arrows). Bile ducts show a positive expression of keratin 19. G, Development of
unpaired arteries (arrows) without accompanying bile ducts in early HCC. H, Immunohistochemical stain for CD34 showing increased sinusoidal
capillarization and unpaired arteries (arrows) in early HCC (hematoxylin-eosin, original magnifications 340 [B], 3100 [C], and 3200 [D, E, and G];
original magnifications 3200 [F and H]).

710 Arch Pathol Lab Med—Vol 135, June 2011 Precursor and Early Lesions of Hepatocellular Carcinoma—Park

Figure 6. Small and progressed hepatocellular carcinoma (HCC). A,
Macroscopic features of small progressed HCC showing a distinctively
nodular appearance with tumor capsule in cirrhosis. B, Microscopic
features of small progressed HCC showing moderately differentiated
histology. Invasion of the tumor capsule is noted (arrows) (hematoxylin-
eosin, original magnification 3200 [B]).
On the other hand, small and progressed HCCs (small
HCCs of the distinctly nodular type) are usually moder-
ately differentiated and often form subnodules with less
differentiation (Figure 6). A tumor capsule is found in
about 50% of cirrhotic livers. Invasion of portal vein
branches by tumor cells and minute intrahepatic metas-
tases have been described in 27% and 10% of cases,
respectively.52 Unpaired (nontriadal) arteries are more
developed in distinctly nodular HCCs than in early HCCs,
and portal tracts are absent in the nodule55 (Figure 7, A, C,
and D). Therefore, progressed HCC shows a hypervas-
cular appearance in the arterial phase of contrast-
enhanced hepatic imaging.
BIOMARKERS: APPLICATION OF IMMUNOCHEMICAL
STAIN FOR DIFFERENTIAL DIAGNOSIS OF
HEPATIC NODULES
Keratins 7 and 19
Stromal invasion is defined as the presence of tumor
cells in portal tracts or fibrous septa within or outside the
lesion under examination (Figure 5, E). The presence of
stromal invasion is a very helpful feature in the dis-
crimination of well-differentiated HCC from high-grade
Arch Pathol Lab Med—Vol 135, June 2011
DN. In well-differentiated HCC, tumor cells mimic
nontumor hepatocytes; therefore, stromal invasion is
sometimes difficult to distinguish from clusters of
nonneoplastic hepatocytes that are localized around the
portal tracts or fibrous septa of chronic hepatitis/cirrhosis
(pseudoinvasion), close to the infiltrating edge of the
tumor. These can be distinguished by immunostaining for
keratin 7 and keratin 19, which highlight the presence of a
ductular reaction around reactive and regenerating
clusters (pseudoinvasion) as a ductular reaction is absent
around tumor cells of stromal invasion (Figure 5, F).50
Glypican-3
Glypican-3 (GPC3), a cell-surface heparin sulfate pro-
teoglycan, has recently become established as a serum and
tissue marker for HCC.27,56–59 Immunohistochemistry for
GPC3 demonstrates a cytoplasmic and sometimes mem-
branous or canalicular staining pattern (Figure 7, E).
GPC3 immunoreactivity of resected liver specimens was
reported in 69% of well-differentiated HCCs and in 81% of
moderately to poorly differentiated HCCs, while 9% of the
high-grade DNs and none of the low-grade DNs were
positive.60 GPC3 staining must be interpreted in the
context of histologic features because it is also reported
in regenerating hepatocytes of chronic hepatitis61 and in
melanocytic lesions.62
Heat Shock Protein 70
Heat shock protein 70 (HSP70) is a chaperone stress
protein and a potent antiapoptotic survival factor.63,64
Significantly more upregulation of HSP70 was reported
in early HCC than in DNs among a set of 12 600 genes
studied, and it was furthermore significantly overex-
pressed in progressed HCC compared with early HCC.65
HSP70 immunoreactivity is found in the nucleus and
cytoplasm (Figure 7, F). HSP70 immunoreactivity in a
resected specimen was recently reported in 78% of well-
differentiated HCCs and in 67% of moderately to poorly
differentiated HCCs, while it was detected in 5% of high-
grade DNs and in no low-grade DNs.60 The hepatobiliary
cells of ductular reactions also showed positive reactions,
which can be used as an internal positive control.
Glutamine Synthetase
Glutamine synthetase (GS) is a target gene of b-catenin
and its overexpression is associated with mutations of b-
catenin or with activation of this pathway.27,66,67 Upregula-
tion of GS messenger RNA, protein, and activity was
shown in human HCC,66,67 and the stepwise increase in GS
immunoreactivity was reported from precancerous le-
sions to early HCC to progressed HCC.68 Glutamine
synthetase is expressed in hepatocytes surrounding the
terminal hepatic venules in normal livers,69 so to increase
its specificity as a marker of malignancy, GS immuno-
staining should be diffuse and of strong intensity
(Figure 7, B). This pattern was reported in 14% of high-
grade DNs, 59% of well-differentiated HCCs, and 86% of
moderately to poorly differentiated HCCs of resected
specimens.60
Diffuse immunoreactivity of GS is also reported in the
b-catenin–activated subtype of hepatocellular adenoma.
Although hepatocellular adenomas rarely transform to
HCC, a subtype of hepatocellular adenoma has been
recently identified that has an increased risk of malignant
Precursor and Early Lesions of Hepatocellular Carcinoma—Park 711
Figure 7. A panel of immunohistochemical markers for hepatocellular carcinoma (HCC). A well- to moderately differentiated HCC showing a
nodule-in-nodule pattern (A, C). The margin of the tumor is marked by the dotted line. Immunohistochemical stain for glutamine synthetase (B)
shows a positive reaction in the tumor, with the nontumor hepatocytes in zone 3 also showing a positive reaction. Sinusoidal capillarization (CD34
immunostaining, D) is more marked in the moderately differentiated inner HCC nodule than in the well-differentiated outer HCC nodule. Glypican-3
(E) and heat shock protein 70 (F) are positive in HCC, with weak staining in well-differentiated HCC (outer nodule) and strong staining in moderately
differentiated HCC (inner nodule). Bile ducts and ductules are also positive for heat shock protein 70 (F) (hematoxylin-eosin, original magnifications
3100 [A] and 3200 [C]; original magnifications 340 [B] and 3200 [D through F]).

712 Arch Pathol Lab Med—Vol 135, June 2011 Precursor and Early Lesions of Hepatocellular Carcinoma—Park
transformation and is characterized by activating muta-
tions in the gene encoding b-catenin.70
The Combination of GPC3, HSP70, and GS
The sensitivity and specificity of individual markers for
the detection of well-differentiated HCC, including early
HCC, were reported to be 59% and 86% for GS, 69% and
91% for GPC3, and 78% and 95% for HSP70, respectively,
and the immunoreactivity of these markers may be weak
or only focal in well-differentiated HCC, including early
HCC. Thus, application of a single marker does not seem
to be very helpful in diagnosing well-differentiated HCC.
Application of more than 1 marker raises the overall
accuracy. When applying a panel of these 3 markers
(GPC3, HSP70, and GS) to resected small lesions, the
positivity for any 2 markers had a sensitivity of 72% and a
specificity of 100% for detecting well-differentiated HCC.
When applying 2 markers, the combination of HSP70 and
GPC3 seems to be best with 59% sensitivity and 100%
specificity for well-differentiated HCC in resected cases.60
CD34
Newly formed arteries have no accompanying bile
ducts, unlike normal hepatic arteries; thus, they are termed
unpaired or nontriadal arteries. Unpaired (nontriadal)
arteries and capillarized sinusoids can be easily detected
via immunohistochemical stain for CD34 in contrast to
normal sinusoidal endothelial cells that do not express
CD34 (Figure 7, D). Sinusoidal capillarization may occur in
relation to increased blood flow and pressure. These
features increase from low-grade DN, high-grade DN,
and early HCC to progressed HCCs29,30; it can therefore be
concluded that the semiquantitative evaluation of CD34
expression can be helpful in supporting diagnosis based on
histology. However, it is not very helpful to differentiate
high-grade DN from well-differentiated HCC because this
is a gradual rather than stepwise change, and no definite
cutoff values have been validated for each lesion during
multistep hepatocarcinogenesis.
PCNA or Ki-67
Proliferative activity gradually increases from low-grade
DNs, high-grade DNs, and early HCCs to HCCs, and
although activity is low in low-grade DNs, it is slightly
higher than in cirrhosis.71 Application of PCNA or Ki-67 is
helpful in detecting the proliferation rate of the lesions;
however, semiquantitative evaluation of proliferative activ-
ity is not very helpful in differentiating high-grade DN from
well-differentiated HCC, as no definite cutoff values have
been established for the various histologic parameters.
a-Fetoprotein
a-Fetoprotein has long been a well-established marker
for HCC; however, serum a-fetoprotein is rarely elevated
in early HCCs and is not detected in DNs.27,72 Likewise, it
is not useful as a tissue marker for HCC because of its low
sensitivity (about 30%), even in progressed and less-
differentiated HCC.27
p53
Mutations of TP53, which seem to play a pivotal role in
hepatocarcinogenesis, occur late in the process, being
detectable in progressed and less-differentiated HCC.
Mutated TP53 can be detected by nuclear positivity in
Arch Pathol Lab Med—Vol 135, June 2011
immunohistochemistry findings, which provides confir-
matory evidence of malignancy in doubtful cases.
LIVER BIOPSY INTERPRETATION FOR PRECURSOR
AND EARLY LESIONS OF HCC
International guidelines recommend that a biopsy
should be performed for nodules less than 2 cm in size if
their radiologic findings are not typical of HCC, and a
biopsy is not necessary for lesions showing characteristic
radiologic findings.73 Moderately or poorly differentiated
HCC can be easily diagnosed based on histology, while
there is diagnostic difficulty in the distinction of high-
grade DN from well-differentiated HCC. In addition, it is
even more difficult when the diagnosis is made on a small
biopsied sample, as only a limited portion of the lesion is
available. The distinction between low-grade DNs and
large regenerative nodules is also very difficult to make,
and it is not recommended to attempt such a distinction
on a biopsy, as it cannot be made confidently based on
morphology alone.27
It is recommended that sampling includes both
intralesional and extralesional tissues because the archi-
tectural and cytologic abnormalities are better appreci-
ated by comparing these 2 regions with each other.
Microscopically, the identification of stromal invasion is
important for the diagnosis of HCC, but evaluating
stromal invasion is difficult in a biopsy because only a
small portion of the tumor-nontumor interface and
intralesional portal tracts is sampled, and stromal
invasion may not be included in the biopsied tissue. In
a recent study based on liver biopsies, a negative or focal
(,10% of stromal-parenchymal interface) ductular reac-
tion in a desmoplastic area adjacent to abnormal-looking
hepatocytes suggests stromal invasion of tumor cells,
indicating HCC. In contrast, the presence of a keratin 7/
19–positive ductular reaction around abnormal-looking
hepatocytes located in portal/periportal areas represents
pseudoinvasion and is evidence against HCC.50 Appli-
cation of a panel of GPC3, HSP70, and GS is reported to
be helpful in detecting well-differentiated HCCs, and the
sensitivity and specificity in liver biopsies were 73% and
100%, respectively, when any 2 of the 3 markers were
positive, although sensitivity was lower than in resected
specimens.74 These tumor markers are also helpful in
detecting less-differentiated HCC, when the tumor
portion is minimally sampled and the tissue artifact is
severe. Before making the final diagnosis based on
biopsied liver tissue, clinicopathologic or radiopatholo-
gic correlation is recommended as gross morphology is
not available, and only a limited portion of the nodular
lesion is present in the biopsied material.
Cytology alone is not recommended for the distinction
between well-differentiated HCC and high-grade DN, as
it cannot provide architectural information. It is rather
suggested to be used as a confirmatory procedure for
progressed and less-differentiated HCC or as a method of
cell sampling for molecular studies.
In conclusion, morphologically recognizable lesions
during hepatocarcinogenesis include dysplastic foci,
DNs, early HCCs, and progressed HCCs. The pathologic
diagnosis of high-grade DNs or small HCCs, including
both early and progressed HCCs, is important as these
lesions should be treated with local ablation, surgical
resection, or liver transplantation.
Precursor and Early Lesions of Hepatocellular Carcinoma—Park 713
 This work was supported by a National Research Foundation
grant funded by the Korean government (MEST) (R13-2002-054-
03004-0).
References
1. International Working Party. Terminology of nodular hepatocellular lesions.
Hepatology. 1995;22(3):983–993.
2. Hytiroglou P, Park YN, Krinsky G, Theise ND. Hepatic precancerous lesions
and small hepatocellular carcinoma. Gastroenterol Clin North Am. 2007;36(4):
867–887, vii.
3. Theise ND, Curado MP, Franceschi S, et al. Hepatocellular carcinoma. In:
Bosman FT, Carneiro F, Hruban RH, Heise ND, eds. WHO Classification of
Tumours of the Digestive System. 4th ed. Lyon, France: IARC Press; 2010:205–
216.
4. Watanabe S, Okita K, Harada T, et al. Morphologic studies of the liver cell
dysplasia. Cancer. 1983;51(12):2197–2205.
5. Anthony PP, Vogel CL, Barker LF. Liver cell dysplasia: a premalignant
condition. J Clin Pathol. 1973;26(3):217–223.
6. Marchio A, Terris B, Meddeb M, et al. Chromosomal abnormalities in liver
cell dysplasia detected by comparative genomic hybridisation. Mol Pathol. 2001;
54(4):270–274.
7. Plentz RR, Park YN, Lechel A, et al. Telomere shortening and inactivation of
cell cycle checkpoints characterize human hepatocarcinogenesis. Hepatology.
2007;45(4):968–976.
8. Nakanuma Y, Hirata K. Unusual hepatocellular lesions in primary biliary
cirrhosis resembling but unrelated to hepatocellular neoplasms. Virchows Arch A
Pathol Anat Histopathol. 1993;422(1):17–23.
9. Zhao M, Zhang NX, Du ZY, Laissue JA, Zimmermann A. Three types of liver
cell dysplasia (LCD) in small cirrhotic nodules are distinguishable by karyometry
and PCNA labelling, and their features resemble distinct grades of hepatocellular
carcinoma. Histol Histopathol. 1994;9(1):73–83.
10. Makino Y, Shiraki K, Sugimoto K, et al. Histological features of cirrhosis
with hepatitis C virus for prediction of hepatocellular carcinoma development; a
prospective study. Anticancer Res. 2000;20(5C):3709–3715.
11. Libbrecht L, Craninx M, Nevens F, Desmet V, Roskams T. Predictive value
of liver cell dysplasia for development of hepatocellular carcinoma in patients
with non-cirrhotic and cirrhotic chronic viral hepatitis. Histopathology. 2001;
39(1):66–73.
12. Borzio M, Bruno S, Roncalli M, et al. Liver cell dysplasia is a major risk
factor for hepatocellular carcinoma in cirrhosis: a prospective study. Gastroen-
terology. 1995;108(3):812–817.
13. Ganne-Carrie N, Chastang C, Chapel F, et al. Predictive score for the
development of hepatocellular carcinoma and additional value of liver large cell
dysplasia in western patients with cirrhosis. Hepatology. 1996;23(5):1112–1118.
14. Koo JS, Kim H, Park BK, et al. Predictive value of liver cell dysplasia for
development of hepatocellular carcinoma in patients with chronic hepatitis B. J
Clin Gastroenterol. 2008;42(6):738–743.
15. Lee RG, Tsamandas AC, Demetris AJ. Large cell change (liver cell
dysplasia) and hepatocellular carcinoma in cirrhosis: matched case-control
study, pathological analysis, and pathogenetic hypothesis. Hepatology. 1997;
26(6):1415–1422.
16. Natarajan S, Theise ND, Thung SN, Antonio L, Paronetto F, Hytiroglou P.
Large-cell change of hepatocytes in cirrhosis may represent a reaction to
prolonged cholestasis. Am J Surg Pathol. 1997;21(3):312–318.
17. Borzio M, Trere D, Borzio F, et al. Hepatocyte proliferation rate is a
powerful parameter for predicting hepatocellular carcinoma development in liver
cirrhosis. Mol Pathol. 1998;51(2):96–101.
18. Roncalli M, Borzio M, Brando B, Colloredo G, Servida E. Abnormal DNA
content in liver-cell dysplasia: a flow cytometric study. Int J Cancer. 1989;44(2):
204–207.
19. Thomas RM, Berman JJ, Yetter RA, Moore GW, Hutchins GM. Liver cell
dysplasia: a DNA aneuploid lesion with distinct morphologic features. Hum
Pathol. 1992;23(5):496–503.
20. El-Sayed SS, El-Sadany M, Tabll AA, Soltan A, El-Dosoky I, Attallah AM.
DNA ploidy and liver cell dysplasia in liver biopsies from patients with liver
cirrhosis. Can J Gastroenterol. 2004;18(2):87–91.
21. Terris B, Ingster O, Rubbia L, et al. Interphase cytogenetic analysis reveals
numerical chromosome aberrations in large liver cell dysplasia. J Hepatol. 1997;
27(2):313–319.
22. Zondervan PE, Wink J, Alers JC, et al. Molecular cytogenetic evaluation of
virus-associated and non-viral hepatocellular carcinoma: analysis of 26
carcinomas and 12 concurrent dysplasias. J Pathol. 2000;192(2):207–215.
23. Paradis V, Laurendeau I, Vidaud M, Bedossa P. Clonal analysis of
macronodules in cirrhosis. Hepatology. 1998;28(4):953–958.
24. Kim H, Oh BK, Roncalli M, et al. Large liver cell change in hepatitis B
virus-related liver cirrhosis. Hepatology. 2009;50(3):752–762.
25. Park YN, Roncalli M. Large liver cell dysplasia: a controversial entity. J
Hepatol. 2006;45(5):734–743.
26. Deugnier YM, Charalambous P, Le Quilleuc D, et al. Preneoplastic
significance of hepatic iron-free foci in genetic hemochromatosis: a study of 185
patients. Hepatology. 1993;18(6):1363–1369.
27. International Consensus Group for Hepatocellular Neoplasia. Pathologic
diagnosis of early hepatocellular carcinoma: a report of the international
consensus group for hepatocellular neoplasia. Hepatology. 2009;49(2):658–664.
714 Arch Pathol Lab Med—Vol 135, June 2011
28. Kojiro M. Pathology of Hepatocellular Carcinoma. Malden, MA: Blackwell
Publishing; 2006:31–49.
29. Park YN, Yang CP, Fernandez GJ, Cubukcu O, Thung SN, Theise ND.
Neoangiogenesis and sinusoidal ‘‘capillarization’’ in dysplastic nodules of the
liver. Am J Surg Pathol. 1998;22(6):656–662.
30. Roncalli M, Roz E, Coggi G, et al. The vascular profile of regenerative and
dysplastic nodules of the cirrhotic liver: implications for diagnosis and
classification. Hepatology. 1999;30(5):1174–1178.
31. Ueda K, Terada T, Nakanuma Y, Matsui O. Vascular supply in
adenomatous hyperplasia of the liver and hepatocellular carcinoma: a
morphometric study. Hum Pathol. 1992;23(6):619–626.
32. Park YN, Kim YB, Yang KM, Park C. Increased expression of vascular
endothelial growth factor and angiogenesis in the early stage of multistep
hepatocarcinogenesis. Arch Pathol Lab Med. 2000;124(7):1061–1065.
33. Theise ND, Park YN, Kojiro M. Dysplastic nodules and hepatocarcino-
genesis. Clin Liver Dis. 2002;6(2):497–512.
34. Terada T, Terasaki S, Nakanuma Y. A clinicopathologic study of
adenomatous hyperplasia of the liver in 209 consecutive cirrhotic livers
examined by autopsy. Cancer. 1993;72(5):1551–1556.
35. Furuya K, Nakamura M, Yamamoto Y, Togei K, Otsuka H. Macroregen-
erative nodule of the liver: a clinicopathologic study of 345 autopsy cases of
chronic liver disease. Cancer. 1988;61(1):99–105.
36. Sakamoto M, Hirohashi S, Shimosato Y. Early stages of multistep
hepatocarcinogenesis: adenomatous hyperplasia and early hepatocellular carci-
noma. Hum Pathol. 1991;22(2):172–178.
37. Theise ND, Schwartz M, Miller C, Thung SN. Macroregenerative nodules
and hepatocellular carcinoma in forty-four sequential adult liver explants with
cirrhosis. Hepatology. 1992;16(4):949–955.
38. Borzio M, Fargion S, Borzio F, et al. Impact of large regenerative, low
grade and high grade dysplastic nodules in hepatocellular carcinoma develop-
ment. J Hepatol. 2003;39(2):208–214.
39. Kobayashi M, Ikeda K, Hosaka T, et al. Dysplastic nodules frequently
develop into hepatocellular carcinoma in patients with chronic viral hepatitis and
cirrhosis. Cancer. 2006;106(3):636–647.
40. Terasaki S, Kaneko S, Kobayashi K, Nonomura A, Nakanuma Y.
Histological features predicting malignant transformation of nonmalignant
hepatocellular nodules: a prospective study. Gastroenterology. 1998;115(5):
1216–1222.
41. Maggioni M, Coggi G, Cassani B, et al. Molecular changes in
hepatocellular dysplastic nodules on microdissected liver biopsies. Hepatology.
2000;32(5):942–946.
42. Sun M, Eshleman JR, Ferrell LD, et al. An early lesion in hepatic
carcinogenesis: loss of heterozygosity in human cirrhotic livers and dysplastic
nodules at the 1p36-p34 region. Hepatology. 2001;33(6):1415–1424.
43. Tornillo L, Carafa V, Sauter G, et al. Chromosomal alterations in
hepatocellular nodules by comparative genomic hybridization: high-grade
dysplastic nodules represent early stages of hepatocellular carcinoma. Lab
Invest. 2002;82(5):547–553.
44. Wong CM, Ng IO. Molecular pathogenesis of hepatocellular carcinoma.
Liver Int. 2008;28(2):160–174.
45. Kondo Y, Kanai Y, Sakamoto M, Mizokami M, Ueda R, Hirohashi S.
Genetic instability and aberrant DNA methylation in chronic hepatitis and
cirrhosis—a comprehensive study of loss of heterozygosity and microsatellite
instability at 39 loci and DNA hypermethylation on 8 CpG islands in
microdissected specimens from patients with hepatocellular carcinoma. Hepa-
tology. 2000;32(5):970–979.
46. Oh BK, Chae KJ, Park C, et al. Telomere shortening and telomerase
reactivation in dysplastic nodules of human hepatocarcinogenesis. J Hepatol.
2003;39(5):786–792.
47. Oh BK, Kim YJ, Park YN, Choi KJ, Kim KS, Park C. Quantitative assessment
of hTERT mRNA expression in dysplastic nodules of HBV-related hepatocarcin-
ogenesis. Am J Gastroenterol. 2006;101(4):831–838.
48. Oh BK, Kim YJ, Park C, Park YN. Up-regulation of telomere-binding
proteins, TRF1, TRF2, and TIN2 is related to telomere shortening during human
multistep hepatocarcinogenesis. Am J Pathol. 2005;166(1):73–80.
49. Lee YH, Oh BK, Yoo JE, et al. Chromosomal instability, telomere
shortening, and inactivation of p21(WAF1/CIP1) in dysplastic nodules of hepatitis
B virus-associated multistep hepatocarcinogenesis. Mod Pathol. 2009;22(8):
1121–1131.
50. Park YN, Kojiro M, Di Tommaso L, et al. Ductular reaction is helpful in
defining early stromal invasion, small hepatocellular carcinomas, and dysplastic
nodules. Cancer. 2007;109(5):915–923.
51. Nakashima O, Sugihara S, Kage M, Kojiro M. Pathomorphologic
characteristics of small hepatocellular carcinoma: a special reference to small
hepatocellular carcinoma with indistinct margins. Hepatology. 1995;22(1):101–
105.
52. Kojiro M, Nakashima O. Histopathologic evaluation of hepatocellular
carcinoma with special reference to small early stage tumors. Semin Liver Dis.
1999;19(3):287–296.
53. Roncalli M, Park YN, Di Tommaso L. Histopathological classification of
hepatocellular carcinoma. Dig Liver Dis. 2010;42(suppl 3):S228–S234.
54. Kondo F, Kondo Y, Nagato Y, Tomizawa M, Wada K. Interstitial tumour
cell invasion in small hepatocellular carcinoma: evaluation in microscopic and
low magnification views. J Gastroenterol Hepatol. 1994;9(6):604–612.
Precursor and Early Lesions of Hepatocellular Carcinoma—Park
 55. Nakashima Y, Nakashima O, Hsia CC, Kojiro M, Tabor E. Vascularization
of small hepatocellular carcinomas: correlation with differentiation. Liver. 1999;
19(1):12–18.
56. Capurro M, Wanless IR, Sherman M, et al. Glypican-3: a novel serum and
histochemical marker for hepatocellular carcinoma. Gastroenterology. 2003;
125(1):89–97.
57. Midorikawa Y, Ishikawa S, Iwanari H, et al. Glypican-3, overexpressed in
hepatocellular carcinoma, modulates FGF2 and BMP-7 signaling. Int J Cancer.
2003;103(4):455–465.
58. Moriguchi H, Sato C. The values and limitations of glypican-3 as a novel
tumor marker for hepatocellular carcinoma from clinical and economic view
points. Gastroenterology. 2004;127(2):679–680.
59. Kandil D, Leiman G, Allegretta M, et al. Glypican-3 immunocytochemistry
in liver fine-needle aspirates: a novel stain to assist in the differentiation of benign
and malignant liver lesions. Cancer. 2007;111(5):316–322.
60. Di Tommaso L, Franchi G, Park YN, et al. Diagnostic value of HSP70,
glypican 3, and glutamine synthetase in hepatocellular nodules in cirrhosis.
Hepatology. 2007;45(3):725–734.
61. Abdul-Al HM, Makhlouf HR, Wang G, Goodman ZD. Glypican-3
expression in benign liver tissue with active hepatitis C: implications for the
diagnosis of hepatocellular carcinoma. Hum Pathol. 2008;39(2):209–212.
62. Nakatsura T, Kageshita T, Ito S, et al. Identification of glypican-3 as
a novel tumor marker for melanoma. Clin Cancer Res. 2004;10(19):6612–
6621.
63. Garrido C, Gurbuxani S, Ravagnan L, Kroemer G. Heat shock proteins:
endogenous modulators of apoptotic cell death. Biochem Biophys Res Commun.
2001;286(3):433–442.
64. Jolly C, Morimoto RI. Role of the heat shock response and molecular
chaperones in oncogenesis and cell death. J Natl Cancer Inst. 2000;92(19):1564–
1572.
Arch Pathol Lab Med—Vol 135, June 2011
65. Chuma M, Sakamoto M, Yamazaki K, et al. Expression profiling in
multistage hepatocarcinogenesis: identification of HSP70 as a molecular marker
of early hepatocellular carcinoma. Hepatology. 2003;37(1):198–207.
66. Christa L, Simon MT, Flinois JP, Gebhardt R, Brechot C, Lasserre C.
Overexpression of glutamine synthetase in human primary liver cancer.
Gastroenterology. 1994;106(5):1312–1320.
67. Zucman-Rossi J, Benhamouche S, Godard C, et al. Differential effects of
inactivated Axin1 and activated beta-catenin mutations in human hepatocellular
carcinomas. Oncogene. 2007;26(5):774–780.
68. Osada T, Sakamoto M, Nagawa H, et al. Acquisition of glutamine
synthetase expression in human hepatocarcinogenesis: relation to disease
recurrence and possible regulation by ubiquitin-dependent proteolysis. Cancer.
1999;85(4):819–831.
69. Moorman AF, de Boer PA, Geerts WJ, van den Zande L, Lamers WH,
Charles R. Complementary distribution of carbamoylphosphate synthetase
(ammonia) and glutamine synthetase in rat liver acinus is regulated at a
pretranslational level. J Histochem Cytochem. 1988;36(7):751–755.
70. Bioulac-Sage P, Rebouissou S, Thomas C, et al. Hepatocellular adenoma
subtype classification using molecular markers and immunohistochemistry.
Hepatology. 2007;46(3):740–748.
71. Park YN, Chae KJ, Kim YB, Park C, Theise N. Apoptosis and proliferation
in hepatocarcinogenesis related to cirrhosis. Cancer. 2001;92(11):2733–2738.
72. Theise ND, Fiel IM, Hytiroglou P, et al. Macroregenerative nodules in
cirrhosis are not associated with elevated serum or stainable tissue alpha-
fetoprotein. Liver. 1995;15(1):30–34.
73. Bruix J, Sherman M. Management of hepatocellular carcinoma. Hepatol-
ogy. 2005;42:1208–1236.
74. Di Tommaso L, Destro A, Seok JY, et al. The application of markers
(HSP70 GPC3 and GS) in liver biopsies is useful for detection of hepatocellular
carcinoma. J Hepatol. 2009;50:746–754.
Precursor and Early Lesions of Hepatocellular Carcinoma—Park 715