KCP-800 삼성서울병원 전공의 2년차 방희진

Patient history M/58 Chest pain Past history Chronic hepatitis B Liver mass -> S5 segmentectomy (2007) Dx: Hepatocellular carcinoma Lung mass -> Right upper lobectomy (2012) HBeAg(-), HBeAb(-), HBV DNA(-), AFP 1.3ng/ml EKG, cardiac enzyme: normal

Chest CT : Slight increase in extent of bronchial wall thickening and soft-tissue density at stump area in the right lower lobe

Right Lung : Lobulating mass was observed around stump site and RLL was almost obliterated by mass. Bronchial washing and Bx Bronchoscopy

Bronchial washing cytology 슬라이드입니다 Bronchial washing cytology 슬라이드입니다. Cellular smear이고 branching하는 trabecular 또는 papillary architecture 가진 tissue fragments들이 관찰되고 Papillary or trabecular architecture 또는 small clusters

Cohesive clusters Broad cord 또는 trabecular가 연결되고 가장자리가 Endothelium에 의해 wrapping

Small cluster나 single cell 도 흩어져있었습니다.

NC ratio 높고 cell border 뚜렷한 편. Round, polygonal cell. Cohesive NC ratio 높고 cell border 뚜렷한 편. Round, polygonal cell. Cohesive. nucleoli가 크고 뚜렷하다. Intracytoplasmic vacuole 보인다.

핵은 중앙이나 eccentric, round to oval, 여러 개의 큰 nucleoli, coarse granular chromatin. Cytoplasm은 scanty to moderate amount and granular.

Intracytoplasmic vacuole 때문에 signet ring처럼 보이는 cell들도 있음

Eosinophilic granular cytoplasm Multiple nuclei

vessel이 tissue fragment 사이를 관통함

Endothelial cell이 사이에 보임

Endothelial cell이 tumor nest를 감싸고 있음

Thinprep Macronucleoli와 bubbly cytoplasm

Microscopic feature High cellularity Papillary or branching trabecular tissue fragments enveloped by endothelial cells Transversing capillaries and endothelial cells Round to polygonal cells with high N/C ratio Single or multinucleation, coarsely granular chromatin Prominent macronucleoli Scant to abundant granular cytoplasm Intracytoplasmic vacuoles

Differential diagnosis Secondary malignancy (Past history of HCC) Metastatic hepatocellular carcinoma Primary lung malignancy (endobronchial lesion) Squamous cell carcinoma Adenocarcinoma Mucoepidermoid carcinoma Large cell neuroendocrine tumor Carcinoid tumor Cytologic feature와 liver와 lung mass 과거력, endobronchial mass 고려하여

Differential diagnosis Secondary malignancy (Past history of HCC) Metastatic hepatocellular carcinoma Primary lung malignancy (endobronchial lesion) Squamous cell carcinoma Adenocarcinoma Mucoepidermoid carcinoma Large cell neuroendocrine tumor Carcinoid tumor Cytologic feature와 liver와 lung mass 과거력, endobronchial mass 고려하여

Differential diagnosis Secondary malignancy (Past history of HCC) Metastatic hepatocellular carcinoma Primary lung malignancy (endobronchial lesion) Squamous cell carcinoma Adenocarcinoma Mucoepidermoid carcinoma Large cell neuroendocrine tumor Carcinoid tumor Cytologic feature와 liver와 lung mass 과거력, endobronchial mass 고려하여

Differential diagnosis Secondary malignancy (Past history of HCC) Metastatic hepatocellular carcinoma Primary lung malignancy (endobronchial lesion) Squamous cell carcinoma Adenocarcinoma Mucoepidermoid carcinoma Large cell neuroendocrine tumor Carcinoid tumor Cytologic feature와 liver와 lung mass 과거력, endobronchial mass 고려하여

Architecture of the tissue fragments Hepatocellular carcinoma Adenocarcinoma Cellularity High Variable, generally high Presentation Neoplastic cells isolated, in loosely cohesive groups or in tissue fragments Cells isolated, in loosely cohesive groups Architecture of the tissue fragments Syncytial arrangement-micro or macrotrabecular, or three-dimensional tissue fragments enveloped by endothelial cells; acinar or pseudoacinar pattern; transversing capillaries and endothelial cells within tissue fragments Syncytial tissue fragments with or without acinar pattern; papillary pattern with three-dimensional presentation Cells Variable in size, round to polygonal; well-defined cell borders; high N/C ratio Large round, polygonal to columnar, well to poorly defined cell borders; high N/C ratio Nucleus Single or multinucleation, central or eccentric round, oval; fine to coarsely granular chromatin with excessive clearing of parachromatin; single/multiple macro/micronucleoli; intranuclear cytoplasmic inclusions Central to eccentric; large round to oval; finely granular chromatin; micronucleoli to prominent macronucleoli Cytoplasm Variable, scant to abundant, granular, pale to dense, vacuolated; bile +/-; hyaline globule +/- Variable, scant to abundant, clear, pale, bubbly to dense; mucin vacuoles +/-; signet ring forms +/- IHC HepPar-1+, AFP+/-, CEA+, EMA+ EMA+, CEA+, TTF-1+;CK+ HCC와 Adc는 cytology에서 비슷하게 보임

Architecture of the tissue fragments Hepatocellular carcinoma Adenocarcinoma Cellularity High Variable, generally high Presentation Neoplastic cells isolated, in loosely cohesive groups or in tissue fragments Cells isolated, in loosely cohesive groups Architecture of the tissue fragments Syncytial arrangement-micro or macrotrabecular, or three-dimensional tissue fragments enveloped by endothelial cells; acinar or pseudoacinar pattern; transversing capillaries and endothelial cells within tissue fragments Syncytial tissue fragments with or without acinar pattern; papillary pattern with three-dimensional presentation Cells Variable in size, round to polygonal; well-defined cell borders; high N/C ratio Large round, polygonal to columnar, well to poorly defined cell borders; high N/C ratio Nucleus Single or multinucleation, central or eccentric round, oval; fine to coarsely granular chromatin with excessive clearing of parachromatin; single/multiple macro/micronucleoli; intranuclear cytoplasmic inclusions Central to eccentric; large round to oval; finely granular chromatin; micronucleoli to prominent macronucleoli Cytoplasm Variable, scant to abundant, granular, pale to dense, vacuolated; bile +/-; hyaline globule +/- Variable, scant to abundant, clear, pale, bubbly to dense; mucin vacuoles +/-; signet ring forms +/- IHC HepPar-1+, AFP+/-, CEA+, EMA+ EMA+, CEA+, TTF-1+;CK+

Final diagnosis Bronchial washing, right lower lobe : Smear : Metastatic hepatocellular carcinoma

Bronchoscopic biopsy Eosinophilic abundant cytoplasm을 가지고 papillary or acinar Vacuolated c

AFP Hepatocyte Ag Bronchus, right, bronchoscopic biopsy: Metastatic hepatocellular carcinoma

Liver, S5, segmentectomy (2007) Hepatocellular carcinoma, simple nodular type with extranodular growth : 1. Differentiation : Edmondson grade III>>II 3-4 cell thickness가진 trabecular와 sinusoid가 보이고 nuclear pleomorphism이 있는 HCC Abundant eosinophilic cytoplasm Liver, S5, segmentectomy (2007) Hepatocellular carcinoma, Edmondson grade III

1-2. Lung, right upper lobe and right middle lobe, right upper bilobectomy: . Metastatic hepatocellular carcinoma, lobar bronchi, filling lymphatics and growing along the lymphatic vessel, involving right superior pulmonary vein: (1) Size: 2.2x2.2x1.7 cm (2) Tumor present at lymphatics of vascular resection margin Lung, right upper lobe and right middle lobe, right upper bilobectomy (2012) Metastatic hepatocellular carcinoma, lobar bronchi, filling lymphatics and growing along the lymphatic vessel, involving right superior pulmonary vein

Lung은 HCC의 가장 흔한 meta site 50% Endobronchial meta는 매우 드뭄 7case 발표됨

Differentiating HCC from adenocarcinoma HCC > Adenocarcinoma Trabecular pattern Hepatocytic cells vs columnar/cuboidal cells Eosinophilic granular cytoplasm, lipid vacuoles, bile pigments Atypical stripped nuclei