Case Report Hepatocellular Carcinoma with...

Case ReportHepatocellular Carcinoma with Prominent IntracytoplasmicInclusions: A Report of Two Cases

Adeline R. Chelliah1 and Jasim M. Radhi2

1Department of Pathology, Cork University Hospital, Cork, Ireland2Laboratory Medicine, Peterborough Regional Health Centre, Peterborough, ON, Canada

Correspondence should be addressed to Jasim M. Radhi; [email protected]

Received 29 July 2016; Revised 22 September 2016; Accepted 27 September 2016

Academic Editor: Zu-Yau Lin

Copyright © 2016 A. R. Chelliah and J. M. Radhi. This is an open access article distributed under the Creative CommonsAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited.

Hepatocellular carcinoma (HCC) is the commonest primary malignant neoplasm of the liver in most countries with a notoriouslypoor prognosis. Variation in global incidence is well-recognized and the occurrence of HCC is linked to several establishedenvironmental, dietary, and lifestyle factors. HCC demonstrates morphological heterogeneity both within the same tumor andfrom patient to patient. Differing architectural patterns and cytological variants may be seen. Inclusion bodies are believed torepresent organized structures of proteins which contribute to their pathogenesis and share several constituents like chaperones,p62, ubiquitin, and Valosin containing protein.The various hepatocyte cytoplasmic inclusions described in HCC include Mallory-Denk bodies (MDBs), hyaline bodies (HBs), glycogen, fat, fibrinogen, alpha 1 antitrypsin (AAT), and ground glass. MDBs arethe most common inclusions seen in hepatocellular carcinomas. The two cases shared intracytoplasmic inclusions which arecharacterized by larger sizes and present in every section examined. These exhibited features of MDBs and HBs present in mosttumor cells, further supporting close relationship.

1. Case Histories

The first patient is an 83-year-old man who presented withvague upper abdominal discomfort, weight loss, and generalweakness. Blood work was normal and upper and lowergastroscopy revealed no specific lesion or malignancy.

A solitary lesion in the left lobe of liver was foundon computed tomography (CT) scan. Tumor markers werenoncontributory and hepatitis serology was negative.

He has a medical history of hypertension controlled withantihypertensive medications. Liver biopsy showed hepato-cellular carcinoma. Surgical resection of segments 2 and 3including the mass was performed.

The second patient is a 56-year-old female who pre-sented to the emergency department with abdominal pain.Medication used included oral contraceptive and hormonalsupplements. CT scan showed 11 cmheterogeneous livermassin the right lobe with evidence of intralesional hemorrhageand associated contrast extravasation requiring urgent surgi-cal intervention. The lesion was resected. Hepatitis serologyresult was negative.

Macroscopic examination of the first lesion showed a par-tial hepatectomy with 4 cm lobulated green/yellowish masswith surrounding nodular and fibrotic liver parenchyma.Thesecond lesion consisted of an ill-defined tumor, 13 cm size,with a yellow/brown cut-surface and a small peripheral rimof grossly normal liver parenchyma (Figure 1).

Microscopically, both cases showed HCC with admixedtrabecular and pseudoacinar patterns. The malignant hep-atocytes were enlarged and contained prominent, denselyeosinophilic intracytoplasmic globules, many of which hadsurrounding clear halos admixedwithMallory hyaline bodies(arrow) (Figures 2 and 3).

The globular structures were negative for Masson’strichrome, amyloid, and Periodic Acid Schiff/Periodic AcidSchiff Diastase (PAS/PASD) special stains.

By immunohistochemistry (Dako, Carpinteria, CA,USA) the intracytoplasmic globules showed expression ofp62 and focal positivity for ubiquitin (Figures 4(a) and 4(b)).

CAM5.2 showed very focal, weak expression. Fibrino-gen, alpha-fetoprotein, AAT, alpha 1-antichymotrypsin, and

Hindawi Publishing CorporationCase Reports in HepatologyVolume 2016, Article ID 2032714, 3 pageshttp://dx.doi.org/10.1155/2016/2032714

2 Case Reports in Hepatology

Figure 1: Resected hepatocellular carcinoma.

Figure 2: Eosinophilic cytoplasmic inclusionswith globular appear-ance and surrounding clear halo.

fibrinogen immunohistochemistry were all negative. Themorphology and predominant CAM5.2 negativity in themajority of the inclusions suggest they are mainly HBs whilethe focal, weak CAM5.2 staining indicates a focal MDBcomponent.

Case one had occasional neoplastic hepatocytes that alsocontained cytoplasmic fat and was associated with changes ofnonalcoholic steatosis in the adjacent liver.

The background hepatic parenchyma in case two demon-strated changes consistent with cirrhosis.

Electron microscopy revealed dense fibrillary materialarranged in parallel with occasional vesicular structurespresent.

2. Discussion

Hepatocellular carcinoma (HCC) is the commonest primaryliver cancer in most countries with a recognized globalvariation in incidence, being most prevalent in China,Southeastern Asia, and Sub-Saharan Africa [1]. There isa higher incidence in men, in whom it is the fifth mostfrequently diagnosed cancer worldwide but the second mostcommon cause of cancer-related death. Prognosis remainspoor withmost studies reporting 5-year survival rates of <5%in symptomatic patients [1].

Chronic viral infection (HBV or HCV), alcohol inducedliver injury, ingestion of high levels of aflatoxin, iron over-load (hereditary hemochromatosis), and alpha 1 antitrypsin

Figure 3:This photograph shows hyaline andMallory-Denk bodieswithin the same inclusion (arrow).

deficiency are amongst the accepted risk factors forHCC.Thetumor commonly arises in cirrhotic livers.

Symptoms may be due to the tumor or the predisposingchronic liver disease and include abdominal pain, generalfatigue, anorexia, weight loss, nausea, or vomiting.

Microscopically, HCCs show loss of the normal reticulinnetwork with widening of the cell plates (>3 cells thick).The tumor cells resemble hepatocytes to a variable extent,depending on the degree of differentiation. The presence ofintercellular bile and identification of canaliculi confirm thehepatic cell lineage.Theymay show small or large cell changeand be associated with cytological atypia, mitotic activity, and“capillarisation” of the sinusoids.

The report described two cases which presented to theemergency with abdominal pain. On CT scanning bothpatients showed single hepatic mass. No past history of liverdiseases was noted and serology testing for viral hepatitis wasnegative. The initial clinical diagnosis for the first case wasmetastatic carcinoma and for the second case it was hepaticadenoma. Following proper clinical assessment both patientsunderwent surgical resection of the masses which revealedHCC with florid intracytoplasmic inclusions.

Intracytoplasmic inclusions are not uncommon or spe-cific to HCC. MDBs, first described by Mallory in 1911 [2],are the most well-recognized and have since been reported ina range of nonneoplastic and neoplastic processes, includingalcoholic and nonalcoholic steatohepatitis, Wilson’s diseaseand other copper accumulation disorders, cholestatic condi-tions such as primary biliary cirrhosis (PBC), Indian child-hood cirrhosis, exposure to drugs such as amiodarone, focalnodular hyperplasia, hepatic adenoma, and HCC. MDBsoccur in approximately 20–30% of HCCs while HBs are seenin about 20% of cases. Apart from MDBs, other hepatocytecytoplasmic accumulations described include HBs, AATglobules, glycogen (clear cells), fibrinogen (pale bodies),ground glass inclusions, fat, and other plasma proteins. P62is prevalent in inclusions and most implicated in aggregateformation and its overexpression enhanced MDB produc-tion. HBs are eosinophilic round or ovoid globules of variablesizes. The exact chemical composition is still unknown butp62 is considered one of the prominent components of thiscytoplasmic inclusion [3].

Case Reports in Hepatology 3

(a) (b)

Figure 4: (a) The inclusions demonstrate focal ubiquitin expression by immunohistochemistry. (b) The cytoplasmic inclusions are positivefor p62 immunomarker.

Denk et al. [4] demonstrated a close relationship betweenMDBs and HBs, both of which are aggregates of misfoldedproteins forming as a result of hepatocellular stress. Keratins8 and 18, ubiquitin, and p62, a stress-inducible ubiquitin-binding protein, are key components of MDBs. While HBsalso contain p62 as a major constituent [5], they are distinctfrom MDBs in that they lack keratin. MDBs appear asirregular, eosinophilic, rope-like aggregates in the cytoplasmwhile HBs are well-circumscribed, eosinophilic globulessurrounded by a clear halo. MDBs express keratins 8 and 18(granular pattern), p62, and ubiquitin by immunohistochem-istry. In contrast, HBs are keratin negative although they doexpress p62. Ubiquitin is seen in some but not all HBs. MDBsand HBs may sometimes be present in the same cell, forminghybrid inclusions [4].

The inclusions vary in sizes and can be few or numerouswith zonal distribution. Special histochemical and immuno-histochemical markers are required to assist in delineatingsome of the other inclusions such as AAT globules andfibrinogen.

Many of the hepatocyte intracytoplasmic inclusions arenot specific for any disease entity but identifying a particulartype of inclusions in the appropriate histological and clinicalsetting can point to a particular diagnosis.

The prognosis of HCC is a controversial [6] issue; how-ever, the presences of single lesions which are amenable tosurgical treatment, and low grade tumors showing no vascu-lar invasion or metastases. In addition the stable underlyingliver diseases in both cases suggest a long survival. The pres-ence or absence of hepatic inclusions or tumor differentiationhas not been established as prognostic indicators.

3. Conclusion

We report two cases of HCC with unusually florid large,prominent intracytoplasmic inclusions with features of HBs

and MDB present. This is in support that both inclusionsshare common molecular constituents and pathogenesis.

Competing Interests

The authors declare that there are no competing interestsregarding the publication of this paper.

References

[1] A. P. Venook, C. Papandreou, J. Furuse, and L. L. de Guevara,“The incidence and epidemiology of hepatocellular carcinoma:a global and regional perspective,” The oncologist, vol. 15,supplement 4, pp. 5–13, 2010.

[2] F. B. Mallory, “Cirrhosis of the liver. Five different types oflesions from which it may arise,” Bulletin of the Johns HopkinsHospital, vol. 22, pp. 69–74, 1911.

[3] K. Zatloukal, C. Stumptner, A. Fuchsbichler et al., “p62 isa common component of cytoplasmic inclusions in proteinaggregation diseases,” The American Journal of Pathology, vol.160, no. 1, pp. 255–263, 2002.

[4] H. Denk, C. Stumptner, A. Fuchsbichler et al., “Are the Mallorybodies and intracellular hyaline bodies in neoplastic and non-neoplastic hepatocytes related?” Journal of Pathology, vol. 208,no. 5, pp. 653–661, 2006.

[5] C. Stumptner, H. Heid, A. Fuchsbichler et al., “Analysis ofintracytoplasmic hyaline bodies in a hepatocellular carcinoma:demonstration of p62 as major constituent,” American Journalof Pathology, vol. 154, no. 6, pp. 1701–1710, 1999.

[6] J. A. Marrero, M. Kudo, and J.-P. Bronowicki, “The challengeof prognosis and staging for hepatocellular carcinoma,” TheOncologist, vol. 15, supplement 4, pp. 23–33, 2010.

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