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Criteria: HEPAT Found: 15 cases
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Case 1 - ecp23, Hepatobiliary and Pancreatic Pathology
Presented by: Irene Esposito, Munich, Germany

65 years-old female patient affected by breast cancer (diagnosed in 2005); two family members (father and cousin) died of pancreatic cancer. The patient underwent a magnetic resonance cholangiopancreatography (MRCP) to exclude the presence of a pancreatic tumor. In MRCP multiple small cysts communicating with the main pancreatic duct were seen. The patient decided to undergo a prophylactic total pancreatectomy. The specimen was sectioned in 0.5 cm thick slices. At gross inspection multiple 0.1-1.3 cm cysts were seen throughout the pancreas, some of them filled with mucinous material. No suspicion of cancer. The histological images shown here are taken from the largest cyst, which was found in the pancreatic head above the ampulla.
Slide 1Multiple cysts communicating with main ductOverview of largest cystDetail of papillary projections (1)Detail of papillary projections (2)Muc1Muc5
Ki-67
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Case 2 - ecp23, Hepatobiliary and Pancreatic Pathology
Presented by: Günter Klöppel, München, Germany

An abdominal mass was detected in a 65 year-old woman, who presented with upper abdominal dsicomfort. Imaging studies showed a multi- and microcystic tumor mass in the tail of the pancreas. The tumor was resected and presented as a nodular and well-demarcated mass, 11 cm in greatest dimension. The cut surface of the tumor was reddish and soft with multiple microcysts between solid areas. The cysts were filled with serous fluid.
Slide 1PET cystic MIB1PET cystic K135PET cystic K135
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Case 3 - ecp23, Hepatobiliary and Pancreatic Pathology
Presented by: Ari Ristimäki, Helsinki, Finland

A 26 years-old female patient, who presented sudden lower abdominal pain. Gynecological status normal except lower left-sided abdominal tenderness upon palpation (normal delivery six months ago). Abdominal ultrasound showed a 15 cm cystic expansion that is attached to the pancreas and extends to left abdominal cavity. CA19-9 and CEA were within normal range. Computer tomography scan showed a 13x9x9 cm multicystic fluid containing retroperitoneal mass that is attached to the tail of the pancreas, which was interpreted as an unusual pseudocyst or lymfangioma/lymfangiomyoma. A cystic 20x13x10 cm retroperitoneal mass was removed three months later, which macroscopically showed sponge-like appearance (Snapshot 1). The specimen contained tail of the pancreas and spleen (280 g) that were attached to the tumor.
Slide 1Snapshot 1 (Macro)Snapshot 2 (HE; 40x and 400x)Snapshot 3
(HE; 200x)
Snapshot 4
(HE; 100x)
Snapshot 5
(CD31; 200x)
Snapshot 6
(D2-40; 200x)
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Case 4 - ecp23, Hepatobiliary and Pancreatic Pathology
Presented by: Luigi Terracciano, Basel, Switzerland

A 61 year-old man with mild hepatomegaly and slight abdominal pain in the right hypochondrium. Computed tomography scans showed a large cystic mass (20 cm Ø) in the right hepatic lobe with.a mural nodule of 6,5 cm in diameter and thick irregular walls.

2 months later the cystic lesion was resected (bisegmentectomy: segment V and VI). No others tumor was found outside the liver.

Macroscopically, the excised mass consisted of an unilocular cystic lesion, 20 cm Ø, with haemorrhagic, thick irregular walls. A mural nodule, 6,5 cm Ø, with spongy-like appearance was present. Circulating slides from the mural nodule.
Slide 1
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Case 5 - ecp23, Hepatobiliary and Pancreatic Pathology
Presented by: Benoit Terris, PARIS, France

A 49 year-old man was followed for a sclerosing cholangitis revealed by an episode of obstructive jaundice 16 months ago. Imaging results were in favor of such diagnosis with a predominant involvement of intrahepatic biliary tree. No chronic inflammatory bowel diseases were noted. A cholangitis occurred after an endoscopic retrograde cholangiopancreatography and an attempt of stent insertion. Due to the increase of jaundice, an orthotopic liver transplantation was performed.

Liver sections from the right and left lobe showed white, friable and papillary granular intraductal masses. The liver parenchyma exhibited a severe cholestatic pattern and 3 centimetric white nodules were present at distance of the hilum.

The selected slide corresponds to the polypoid endobiliary tumor of the hilum.
Slide 1
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Case 6 - ecp23, Hepatobiliary and Pancreatic Pathology
Presented by: Giuseppe Zamboni, Verona, Italy

A 54 year-old female developed abdominal tenderness with dyspepsia. Physical examination was unremarkable. There was no history of alcohol intake or pancreatic disease. Ultrasound and CT scan examination demonstrated a unilocular cystic lesion in the tail of the pancreas consistent with cyst neoplasia. The patient underwent distal pancreatectomy.

Macroscopically, the tail of the pancreas presented with a well circumscribed unilocular cystic lesion measuring 9 cm in greater dimension, separated from a normal pancreatic parenchyma by a fibrous pseudocapsule. The wall of the cysts was focally thick for the presence of white-yellow areas; the intracystic fluid was hemorrhagic. The internal surface of the cyst was smooth. The cystic lesion did not communicated with the main pancreatic duct, which presented a regular size.
Fig. 1-MacroscopyFig. 2-HE-whole mount sectionFig. 3-HE-20XFig. 4-HE-40XFig. 5-HE-100XFig. 6-HE-40XFig. 7-Progesteron Receptor-100x
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Case 7 - ecp23, Hepatobiliary and Pancreatic Pathology
Presented by: Yoh Zen, London, United Kingdom

A 60-year-old woman symptomatically presented with abdominal discomfort. Abdominal US revealed a large cystic mass, measuring 120 mm in diameter, in the liver. Radiologically, the tumour showed a multiloculated cystic appearance with septation. Solid mural nodules were also identified. CA19-9 and CEA were within normal range. The tumour was surgically resected.
Slide 1GrossHE1HE2HE3HE4HE5
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Case 1 [111/1] - esp2010, Liver and Pancreatobiliary Pathology
Presented by: Irene Esposito, Munich, Germany

64 year old male patient with abnormal liver function tests (alkaline phosphatase 378, gamma-glutamyltransferase 432, alanine aminotransferase 60, total bilirubin 0.6). In magnetic resonance imaging (MRI) suspicion of pancreatic cancer with infiltration and obstruction of the portal vein and liver metastases. Explorative laparotomy, three frozen sections submitted to histopathological analysis for diagnosis confirmation.

Slide 1: Tissue sample of the left lobe of the liver with the typical diagnostic features of the presented case (hematoxylin eosin staining).
Slide 1
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Case 2 [111/2] - esp2010, Liver and Pancreatobiliary Pathology
Presented by: Johanna Delladetsima, Athens , Greece

A 37-year-old man presented with gradually progressive jaundice and pruritus over the last 5 days. His medical and family history was non significant and he had not received any medications or herbals. He has been consuming ~ 320 g of alcohol twice/week. Moreover, he had been an occasional cannabis user and cocaine inhaler for a 5-month period until 2 months before the icteric episode.

At presentation, there was no evidence of splenomegaly or ascites. Laboratory findings showed normal white and red blood cell counts. Liver function tests displayed a predominant cholestatic pattern (t.bilirubin 9.87mg/dL,  ALP 315 IU/L, GGT 1082 IU/L) and elevated aminotransferase levels (AST 122 IU/L, ALT 245 IU/L). Prothrombin time and serum albumin were within normal limits. Acute phase proteins were elevated. Serological markers of hepatitis A, B and C, anti-HIV1,2 and IgM for CMV were undetectable. Tests for autoantibodies (ANA, anti-ds-DNA, AMA, ASMA, p- & c-ANCA) were negative. IgG, IgA, IgM values and protein electrophoresis were normal. 

Magnetic resonance cholangiography (MRCP) did not show any extra-hepatic or intra-hepatic lesions, bile duct dilatation or stenosis. Esophago-gastroduodenoscopy and colonoscopy did not reveal any signs of inflammatory bowel disease.

After histological diagnosis, therapy was initiated with methyl-prednisone and ursodeoxycholic acid. One week later, clinical and laboratory improvement was observed. The patient remains asymptomatic, without any rise of aminotransferases or markers of cholestasis, 6 months after completion of therapy.

Slide 1: Liver biopsy - HE

Snapshots:
1. Interlobular bile ducts showing prominent degenerative changes of the epithelium (HE x 200) 
2. Small interlobular bile duct infiltrated by neutrophils showing nuclear crowding and polymorphism (HE x 400) 
3. Interlobular bile duct (arrow) with nuclear crowding and infiltration of the epithelium by neutrophils and eosinophils Interlobular bile duct (arrowhead) exhibiting mild leucocytic infiltration, degenerative changes and flattening of the epithelium  (HE x 200) 
4-5 Interlobular bile duct showing pericholangitis with concentric fibrosis as well as prominent degenerative changes and damage of the epithelium ( HE x 200) /(HE x 400)
Slide 1 Snapshot 1Snapshot 2Snapshot 3Snapshot 4Snapshot 5
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Case 3 [111/3] - esp2010, Liver and Pancreatobiliary Pathology
Presented by: Alberto Quaglia, London, United Kingdom

Fifty-seven year old gentleman with previous cholectomy for rectal adenocarcinoma. Abnormal liver function tests (alkaline phosphatase 570 (30-130 IU/L), aspartate transaminase 164 (10-50 IU/L), gamma glutamyl transferase 193 (1-55 IU/L), bilirubin total 62 (3-20 umol/L, conjugated 49). Explant liver.

Slide 1: Peripheral sample of liver parenchyma showing biliary cirrhosis with ductopenia
Slide 2: Parahilar sample of liver showing active destructive suppurative cholangitis

Snapshots:
1. Explant liver showing marked segmental/lobar remodelling 
2. Bridging fibrosis with irregular nodules with a peripheral halo 
3. A ductular reaction at the periphery of a nodule with associated neutrophils 
4. Active cholangitis of a parahilar duct; 
5. Close up of figure 4 
6. Hyperplastic peribiliary glands around a parahilar duct; 
7. Severely damaged peripheral bile duct with marked peribiliary fibrosis 
8-9 Fibrous scars replacing peripheral bile ducts
Slide 1Slide 2Snapshot 1Snapshot 2Snapshot 3Snapshot 4Snapshot 5
Snapshot 6Snapshot 7Snapshot 8Snapshot 9
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