1. KCP-800
삼성서울병원 전공의 2년차
방희진

2. 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

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

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

5. 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

6. Cohesive clusters
Broad cord 또는 trabecular가 연결되고 가장자리가
Endothelium에 의해 wrapping

7. Small cluster나 single cell 도 흩어져있었습니다.

8. 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.

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

10. Intracytoplasmic vacuole 때문에 signet ring처럼 보이는 cell들도 있음

11. Eosinophilic granular cytoplasm
Multiple nuclei

12. vessel이 tissue fragment 사이를 관통함

13. Endothelial cell이 사이에 보임

14. Endothelial cell이 tumor nest를 감싸고 있음

15. Thinprep
Macronucleoli와 bubbly cytoplasm

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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+

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

24. Bronchoscopic biopsy
Eosinophilic abundant cytoplasm을 가지고 papillary or acinar
Vacuolated c

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

26. 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

27. 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

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

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