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Year : 2009  |  Volume : 52  |  Issue : 2  |  Page : 288-289
Fine needle aspiration cytology of fibrolamellar hepatocellular carcinoma: Recognizing the oncocytic hepatocyte


Department of Pathology, GB Pant Hospital, New Delhi, India

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How to cite this article:
Gulati G, Saran RK. Fine needle aspiration cytology of fibrolamellar hepatocellular carcinoma: Recognizing the oncocytic hepatocyte. Indian J Pathol Microbiol 2009;52:288-9

How to cite this URL:
Gulati G, Saran RK. Fine needle aspiration cytology of fibrolamellar hepatocellular carcinoma: Recognizing the oncocytic hepatocyte. Indian J Pathol Microbiol [serial online] 2009 [cited 2020 Apr 8];52:288-9. Available from: http://www.ijpmonline.org/text.asp?2009/52/2/288/48955


Sir,

We encountered a 25-year-old Indian female with a history of pain in the right upper abdomen for 6 months with a mildly deranged aspartate aminotransferase level of 56IU/mL (5-43IU/mL) and a prolonged prothrombin time of 16s (control, 12s). The rest of the liver function tests were within the normal range. Viral and autoimmune markers were negative. On ultrasonogram, liver enlargement was noted with a 67mm × 64mm hypoechoic lesion in the right lobe with no evidence of background cirrhosis and, on magnetic resonance imaging, a "central radiating scar" was identified. Serum alpha feto protein levels were <5ng/mL.

An ultrasound-guided fine needle aspiration was performed from the lesion. The hematoxylin-eosin- and Papanicolaou - stained smears were moderately cellular and showed a dispersed population and few loose clusters of large polygonal cells with abundant cytoplasm and sharply defined cell borders (oncocytic hepatocytes) [Figure 1a] and [Figure 1b]. At a higher power, the nuclear abnormalities in the form of coarse chromatin, irregular nuclear membrane and prominent nucleoli were evident even though the nuclear-cytoplasmic (N/C) ratio of these cells remained low [Figure 1c]. Intermixed benign hepatocytes were also noted with round regular nuclei, fine chromatin and conspicuous nucleoli. The "oncocytic hepatocytes" were 3-5 times larger than the benign hepatocytes. Occasional eosinophilic collagenous stromal fragments with crushing artefact were also noted. Based on these cytological features, a diagnosis of fibrolamellar variant of hepatocellular carcinoma (FL HCC) was rendered.

FL HCC is rare, accounting for less than 1% of the primary liver cancers, more commonly seen in Europe and in the United States and rarely in Asia. [1] This HCC subtype became recognized as a distinct pathologic entity from the classic type of HCC based on its clinical presentation and survival advantage. [2],[3] It typically presents in younger age groups and is associated with better prognosis, affecting men and women equally. There are no large-scale prevalence studies of this tumor in India and the largest series of six cases was reported by Singhal et al. in 2002. [4] He studied liver resection specimens over a period of 17 months, which included 24 cases of HCC. Another case report described the unusual presentation of the tumor with non-bacterial thrombotic endocarditis. [5]

Cytologically, FL HCC is characterized by the oncocytic hepatocyte. [6] As in oncocytes described in other organs, the abundant granular cytoplasm is due to the presence of numerous mitochondria. Histologically dense lamellar tissue divides nodules of oncocytic hepatocytes and forms a central scar. Although this stroma is necessary for diagnosis on histopathology, it may or may not be evident on smears.

Perez Guillermo et al. [6] demonstrated that a single cell aspirated from an FL HCC is three times the size of a normal hepatocyte and 1.60 times the size of a single cell aspirated from a well-differentiated HCC. Although it is an HCC variant, cytologically, it lacks the classical features of HCC such as cohesive trabecular arrangement of cells with endothelial-lined capillaries traversing the clusters, abundant bare nuclei and high N/C ratios at the more poorly differentiated end of the HCC spectrum.

We report this case to demonstrate the importance of recognizing the cytological feature of the "oncocytic hepatocyte" and making a diagnosis of malignancy despite the absence of other classical features of HCC. It is of particular importance for cytopathologists in India and Asia because there is a lack of experience with this tumor due to its epidemiological rarity in this region.

 
   References Top

1.El-Serag HB, Davila JA. Is fibrolamellar carcinoma different from hepatocellular carcinoma? A US population-based study. Hepatology 2004;39:798-803.  Back to cited text no. 1    
2.Craig JR, Peters RL, Edmondson HA, Omata M. Fibrolamellar carcinoma of the liver: A tumor of adoloescents and young adults with distinctive clinicopathological features. Cancer 1980;46:372-9.  Back to cited text no. 2  [PUBMED]  
3.Berman MA, Burnham JA, Sheahan DG. Fibrolamellar carcinoma of the liver: An immunohistochemical study of nineteen cases and a review of the literature. Hum Pathol 1988;19:784-94.  Back to cited text no. 3  [PUBMED]  
4.Singhal D, Vasdev N, Gupta S, Soin AS, Nayak NC, Nundy S. ­Fibrolamellar hepatocellular carcinoma: Not a rare tumor in India and a possible new marker. J Gastroenterol Hepatol 2002;17:A67.  Back to cited text no. 4    
5.Vaideeswar P, Pandit MJ, Deshpande JR, Sivaraman A, Vora IM. ­Fibrolamellar carcinoma of the liver: An unusual presentation. J Postgrad Med 1993;39:159-61.  Back to cited text no. 5  [PUBMED]  Medknow Journal
6.Pιrez-Guillermo M, Masgrau NA, Garcνa-Solano J, Sola-Pιrez J, de Agustνn y de Agustνn P. Cytologic aspect of fibrolamellar hepatocellular carcinoma in fine-needle aspirates. Diagn Cytopathol 1999;21:180-7.  Back to cited text no. 6    

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Correspondence Address:
Geetika Gulati
Department of Pathology, Room No 328, 3rd Floor, Academic Block, GB Pant Hospital, New Delhi - 110 002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.48955

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    Figures

  [Figure 1a], [Figure 1b], [Figure 1c]

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