Permanent Part A: Liver with patchy sinusoidal fibrosis (see note). Note: The biopsy demonstrates hepatic parenchyma with <10% macrovesicular steatosis. Evaluation of microvesicular steatosis is limited by frozen artifact. Diagnostic features of steatohepatitis are not present. Occasional portal tracts demonstrate mild expansion. No necrosis is present. A trichrome stain highlights patchy mild sinusoidal fibrosis throughout the lobules. Iron stain is negative for stainable iron, and a PAS/D stain is negative for PAS-positive globules.
Frozen Part B: Liver with <10% macrovesicular steatosis and <10% microvesicular steatosis, midzonal cholestasis, focal mild lymphocytic inflammation, bile ductular proliferation, and broad portal expansion with foci s/f bridging fibrosis.
Permanent Part B: Liver with cholestatic features, focal hepatocyte degeneration, and variable fibrosis (see note). Note: The biopsy demonstrates hepatic parenchyma with variable amounts of fibrosis, ranging from mild sinusoidal pericellular fibrosis to irregular expansion of portal tracts and areas of at least bridging fibrosis (trichrome stain examined). Cholestatic features are present. The portal tracts demonstrate a bile ductular reaction and accompanying non-specific mononuclear inflammation. A focus of hepatocyte degeneration is noted. Minimal (<5%) macrovesicular steatosis is present, without diagnostic features of steatohepatitis.
Comparison of H&E permanent sections and trichrome stains confirms that this biopsy (part B) demonstrates significantly more fibrosis than the initial biopsy (part A). These findings raise the possibility of global and regional differences in the extent of fibrosis within the liver.
Annotations and notes
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Clinical history
liver tx bx #1 (Part A) (frozen slides 1, permanent slide 2) liver tx bx #2 (Part B) (frozen slide 3, permanent slide 4)
Diagnosis
Frozen Part A: Liver with <10% macrovesicular steatosis and <20% macrovesicular steatosis. Note that tissue was placed in formalin prior to freezing; assessment might not be accurate. Permanent Part A: Liver with patchy sinusoidal fibrosis (see note). Note: The biopsy demonstrates hepatic parenchyma with <10% macrovesicular steatosis. Evaluation of microvesicular steatosis is limited by frozen artifact. Diagnostic features of steatohepatitis are not present. Occasional portal tracts demonstrate mild expansion. No necrosis is present. A trichrome stain highlights patchy mild sinusoidal fibrosis throughout the lobules. Iron stain is negative for stainable iron, and a PAS/D stain is negative for PAS-positive globules. Frozen Part B: Liver with <10% macrovesicular steatosis and <10% microvesicular steatosis, midzonal cholestasis, focal mild lymphocytic inflammation, bile ductular proliferation, and broad portal expansion with foci s/f bridging fibrosis. Permanent Part B: Liver with cholestatic features, focal hepatocyte degeneration, and variable fibrosis (see note). Note: The biopsy demonstrates hepatic parenchyma with variable amounts of fibrosis, ranging from mild sinusoidal pericellular fibrosis to irregular expansion of portal tracts and areas of at least bridging fibrosis (trichrome stain examined). Cholestatic features are present. The portal tracts demonstrate a bile ductular reaction and accompanying non-specific mononuclear inflammation. A focus of hepatocyte degeneration is noted. Minimal (<5%) macrovesicular steatosis is present, without diagnostic features of steatohepatitis. Comparison of H&E permanent sections and trichrome stains confirms that this biopsy (part B) demonstrates significantly more fibrosis than the initial biopsy (part A). These findings raise the possibility of global and regional differences in the extent of fibrosis within the liver.
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| Sequence | Case | Clinical history | Diagnosis |
|---|---|---|---|
| 1 | DZI20-206-Case-1 DZI20-206-Case-1 | live tx bx | Hepatic parenchyma with focal hepatocyte necrosis.
No steatosis, inflammation or fibrosis identified. Hepatic parenchyma with focal hepatocyte necrosis.
No steatosis, inflammation or fibrosis identified. |
| 2 | DZI20-206-Case-2 DZI20-206-Case-2 | liver tx bx | 10% macrovesicular steatosis
No inflammation or fibrosis seen. 10% macrovesicular steatosis
No inflammation or fibrosis seen. |
| 3 | DZI20-206-Case-3 DZI20-206-Case-3 | liver tx bx | Mild centrilobular steatosis (10%) with no necrosis or fibrosis. Mild centrilobular steatosis (10%) with no necrosis or fibrosis. |
| 4 | DZI20-206-Case-4 DZI20-206-Case-4 | liver tx bx | Mild cholestasis and grade 1 steatosis without steatohepatitis (see note).
Note: The biopsy shows mild cholestasis with a few canalicular bile plugs. Portal tracts show mild mixed inflammation with lymphocytes and a few neutrophils. Mild ductular reaction is present in a few portal tracts. The lobules show grade 1 steatosis without ballooning degenration and focal mononuclear inflammation. Mild cholestasis and grade 1 steatosis without steatohepatitis (see note).
Note: The biopsy shows mild cholestasis with a few canalicular bile plugs. Portal tracts show mild mixed inflammation with lymphocytes and a few neutrophils. Mild ductular reaction is present in a few portal tracts. The lobules show grade 1 steatosis without ballooning degenration and focal mononuclear inflammation. |
| 5 | DZI20-206-Case-5 DZI20-206-Case-5 | liver tx bx | Patchy portal expansion with mild portal mononuclear infiltrate.
Note: The biopsy shows no significant steatosis. A few portal tracts are expanded and there is mild portal and focal lobular mononuclear inflammation. No acidophil bodies are noted. A few polarizable crystals, probably talc, are seen in portal areas. The findings are compatible with an HCV-positive donor liver. Patchy portal expansion with mild portal mononuclear infiltrate.
Note: The biopsy shows no significant steatosis. A few portal tracts are expanded and there is mild portal and focal lobular mononuclear inflammation. No acidophil bodies are noted. A few polarizable crystals, probably talc, are seen in portal areas. The findings are compatible with an HCV-positive donor liver. |
| 6 | DZI20-206-Case-6 DZI20-206-Case-6 | liver tx bx | Hepatic parenchyma with absent macrovesicular steatosis and mild microvesicular steatosis (<30%).
No inflammation, necrosis or fibrosis identified. Hepatic parenchyma with absent macrovesicular steatosis and mild microvesicular steatosis (<30%).
No inflammation, necrosis or fibrosis identified. |
| 7 | DZI20-206-Case-7 DZI20-206-Case-7 | liver tx bx | Grade 1 steatosis without steatohepatitis, (see note). (maybe more fat??)
Note: Both biopsies show grade 1 of 3 macrovesicular steatosis (5 to 33%) along with microvesicular steatosis predominantly in zone 3. Classical hepatocyte ballooning is not present. Lobular inflammation is patchy; the inflammation consists of mononuclear cells and neutrophils. Portal tracts show minimal non-specific inflammation. Special stains are performed on both parts A and B. Trichrome stain shows portal expansion and rare foci with delicate sinusoidal fibrosis in zone 3 (in part B) (modified Brunt stage 1a of 4). Iron stain shows no stainable iron and PASD stain shows no PASD positive globules. Grade 1 steatosis without steatohepatitis, (see note). (maybe more fat??)
Note: Both biopsies show grade 1 of 3 macrovesicular steatosis (5 to 33%) along with microvesicular steatosis predominantly in zone 3. Classical hepatocyte ballooning is not present. Lobular inflammation is patchy; the inflammation consists of mononuclear cells and neutrophils. Portal tracts show minimal non-specific inflammation. Special stains are performed on both parts A and B. Trichrome stain shows portal expansion and rare foci with delicate sinusoidal fibrosis in zone 3 (in part B) (modified Brunt stage 1a of 4). Iron stain shows no stainable iron and PASD stain shows no PASD positive globules. |
| 8 | DZI20-206-Case-8 DZI20-206-Case-8 | liver tx bx | "LIVER PARENCHYMAL WITH MILD PORTAL CHRONIC INFLAMMATION, SEE NOTE.
NO STEATOSIS OR FIBROSIS ARE IDENTIFIED.
Note: Sections through the liver reveal a mild portal inflammatory infiltrate composed predominantly of lymphocytes. Rare eosinophils are also identified. There is no fibrosis (trichrome stain). A PAS/D stain shows no intracytoplasmic globules." "LIVER PARENCHYMAL WITH MILD PORTAL CHRONIC INFLAMMATION, SEE NOTE.
NO STEATOSIS OR FIBROSIS ARE IDENTIFIED.
Note: Sections through the liver reveal a mild portal inflammatory infiltrate composed predominantly of lymphocytes. Rare eosinophils are also identified. There is no fibrosis (trichrome stain). A PAS/D stain shows no intracytoplasmic globules." |
| 9 | DZI20-206-Case-9 DZI20-206-Case-9 | liver tx bx | Liver parenchyma with approximately 30-40% macrovesicular fat.
No iron or PAS/D positive globules are present.
Trichrome stain shows focal pericentral fibrosis. Liver parenchyma with approximately 30-40% macrovesicular fat.
No iron or PAS/D positive globules are present.
Trichrome stain shows focal pericentral fibrosis. |
| 10 | DZI20-206-Case-10 DZI20-206-Case-10 | liver tx bx | Nodular and fibrotic liver, consistent with cirrhosis, with cholestasis and confluent necrosis of several nodules.
Note: The liver shows architectural effacement with conversion of the parenchyma into micronodules, essentially a micronodular cirrhosis on Trichrome. Several of the nodules are entirely necrotic or infarcted, accounting for about 10% of the biopsy (less of the tissue is necrotic on permanent sections than on the frozen slide). The nodules also show canalicular cholestasis. No iron or PAS/D positive globules are present. Elastic and reticulin stains were performed to assess whether the fibrous bands were collapse due to necrosis rather than old scarring. While collapse of parenchyma is probably accentuating the appearance of fibrosis, the overall appearance, together with the trichrome, reticulin and elastic stains, suggests cirrhosis. Nodular and fibrotic liver, consistent with cirrhosis, with cholestasis and confluent necrosis of several nodules.
Note: The liver shows architectural effacement with conversion of the parenchyma into micronodules, essentially a micronodular cirrhosis on Trichrome. Several of the nodules are entirely necrotic or infarcted, accounting for about 10% of the biopsy (less of the tissue is necrotic on permanent sections than on the frozen slide). The nodules also show canalicular cholestasis. No iron or PAS/D positive globules are present. Elastic and reticulin stains were performed to assess whether the fibrous bands were collapse due to necrosis rather than old scarring. While collapse of parenchyma is probably accentuating the appearance of fibrosis, the overall appearance, together with the trichrome, reticulin and elastic stains, suggests cirrhosis. |
