3 Hepatocellular Cancer: Pathologic Considerations 45 Fig. 3.10 Nodule-in-nodule growth pattern in early HCC. The central nodule, less differentiated, will entirely replace the peripheral well-differentiated lesion that preceded it Ancillary Studies Various techniques, including immunohistochemistry, cytogenetics, fluorescent in- situ hybridization (FISH), and comparative genomic hybridization (CGH) [62, 63], can be used to confirm a diagnosis of HCC, distinguishing it from a metastasis or a peripheral cholangiocarcinoma (uncommonly), and, importantly, differentiating a well-differentiated HCC from benign hepatocellular proliferations such as hepato- cellular adenoma. We will focus on only a few ancillary tests in the context of the usual clinical dilemmas. Hepatocellular Carcinoma vs. Metastatic Adenocarcinoma and Cholangiocarcinoma Mucin Although mucin is noted in the lumen of acinar HCC [26], the intracytoplas- mic demonstration of mucin generally rules out this diagnosis. In such cases, the working differential diagnosis includes metastatic adenocarcinoma and cholangio- carcinoma. Using MUC antibodies against glycoprotein cores of mucin, HCCs are uniformly negative for MUC-1, MUC-2, and MUC-5AC. Conversely, MUC-1 and MUC-5AC are positive in 73 and 45% of cholangiocarcinomas respectively, as well as in gastrointestinal cancers likely to metastasize to the liver [64]. Albumin Albumin, exclusively synthesized by hepatocytes, is a highly specific marker of hepatocytic lineage [65]. Unfortunately, immunohistochemistry is not a well-suited 46 G.Y. Lauwers detection tool, because of the abundance of the protein in the serum. Less com- monly available, in-situ hybridization is a better technique, with albumin mRNA demonstrated in up to 96% of HCC [65]. Polyclonal CEA and CD10 Both polyclonal CEA and CD10 (neprilysin) antibodies have cross-reactivity with glycoprotein I and exhibit a canalicular distribution pattern. In both instances, their detection offers evidence of hepatocellular differentiation [66, 67]. Alpha-Fetoprotein Alpha-fetoprotein, an oncofetal glycoprotein and established serologic marker of HCC, is not a useful immunohistochemical marker, with a low sensitivity (15–60%) [68–70]. However, its specificity is close to 100%, after exclusion of rare lesions such as yolk sac tumors [71–73]. Hepatocyte Paraffin 1 Antibody (HepPar1) HepPar1 is a marker of both benign and neoplastic hepatocellular proliferations [74–76]. Its sensitivity is reported to be about 91%, with only 4% of non- hepatic tumors staining positively [76]. However, poorly differentiated HCCs can be negative, and occasional metastatic adenocarcinomas have been reported to be immunoreactive [76]. Cytokeratin Low molecular weight keratins, including CAM 5.2 and cytokeratins 8 and 18, usu- ally decorate neoplastic hepatocytes. Conversely, HCCs are negative for keratins 7 and 19, which stain cholangiocarcinomas. However, the diagnostic applicability of cytokeratin is limited by common overlap in the immunophenotype of HCC and CCs as well as metastases [71–73]. Adjunct Methods Used for Distinguishing Benign from Malignant Hepatic Tumors CD 34 “Capillarization” of sinusoids, as expressed by various degrees of CD34 immunore- activity, has been noted in hepatic adenoma, cirrhotic liver, adenomatous hyper- plasia, and HCC [62, 77, 78]. Diffuse CD34 sinusoidal reactivity would support a diagnosis of HCC [79] and can help differentiate dysplastic nodules and early HCCs from macroregenerative nodules [80]. However, there is considerable overlap in the staining profiles of hepatocellular lesions (benign and malignant), and therefore 3 Hepatocellular Cancer: Pathologic Considerations 47 caution is necessary. Of note, one series reported the lack of CD34 immunore- activity in a series of metastatic carcinomas to the liver, s uggesting a role in this situation [81]. Novel immunohistochemical markers have been developed with the goal of supple- menting the morphologic evaluation of transforming hepatocyte nodules. Heat Shock Protein 70 HSP70, a heat shock protein implicated in regulation of cellular apoptosis and cell cycle progression, is markedly upregulated in HCC. HSP70 immunoreactivity has been reported in the majority of HCCs, particu- larly in early and well-differentiated tumors (90 and 72%, r eportedly). However, the staining may be difficult to evaluate, as it can be patchy [82]. Glypican 3 Glypican 3 is a marker of the glypican family of hepatic sulfate proteoglycan linked to the cell surface. It is believed to play a negative role in cell proliferation and in inducing apoptosis. Glypican 3 is overexpressed in HCC with focal and weak staining in precursor lesions of HCC but diffuse staining in a large majority of HCC [82–86] (see Table 3.1 and Fig. 3.11). In most cases, the use of a panel of several markers is best practice to avoid misconstrued conclusions. However, in closing, it is important to emphasize that these markers are best used to support a methodical histologic evaluation of small hepatocytic lesions, but do not supersede it. Table 3.1 Glypican 3 expression in hepatocytic nodules [82–84, 86] % of positive cases Number of cases tested Benign Cirrhotic nodules 0–17 224 Macroregenerative nodules 0–17 127 Hepatocellular adenoma 0 22 Low-grade dysplastic nodules 0–8 47 Borderline and malignant High-grade dysplastic nodules 9–43 69 eHCC 50–60 40 Grade I HCC 56–90 63 Grade II HCC 64–83 166 Grade III HCC 57–89 77 Grade IV HCC 43 7 48 G.Y. Lauwers Fig. 3.11 Example of strong glypican 3 positivity in grade II HCC arising in cirrhotic lines (negative background) References 1. Nzeako UC, Goodman ZD, Ishak KG (1996) Hepatocellular carcinoma in cirrhotic and non- cirrhotic livers. A clinico-histopathologic study of 804 North American patients. Am J Clin Pathol 105:65–75 2. Smalley SR, Moertel CG, Hilton JF, Weiland LH, Weiand HS, Adson MA, Melton LJ, 3rd, Batts K (1988) Hepatoma in the noncirrhotic liver. Cancer 62:1414–1424 3 Hepatocellular Cancer: Pathologic Considerations 49 3. Bismuth H, Chiche L, Castaing D (1995) Surgical treatment of hepatocellular carcinomas in noncirrhotic liver: experience with 68 liver resections. World J Surg 19:35–41 4. Kishi K, Shikata T, Hirohashi S, Hasegawa H, Yamazaki S, Makuuchi M (1983) Hepatocellular carcinoma. A clinical and pathologic analysis of 57 hepatectomy cases. Cancer 51:542–548 5. Lauwers GY, Vauthey JN (1998) Pathological aspects of hepatocellular carcinoma: a critical review of prognostic factors. Hepatogastroenterology 45(Suppl 3):1197–1202 6. Yuki K, Hirohashi S, Sakamoto M, Kanai T, Shimosato Y (1990) Growth and spread of hepatocellular carcinoma. A review of 240 consecutive autopsy cases. Cancer 66: 2174–2179 7. Adachi E, Maeda T, Matsumata T, Shirabe K, Kinukawa N, Sugimachi K, Tsuneyoshi M (1995) Risk factors for intrahepatic recurrence in human small hepatocellular carcinoma. Gastroenterology 108:768–775 8. Liver Cancer Study Group of Japan (1990) Primary liver cancer in Japan. Clinicopathologic features and results of surgical treatment. Ann Surg 211:277–287 9. Izumi R, Shimizu K, Ii T, Yagi M, Matsui O, Nonomura A, Miyazaki I (1994) Prognostic factors of hepatocellular carcinoma in patients undergoing hepatic resection. Gastroenterology 106:720–727 10. Liver Cancer Study Group of Japan (1997) Classification of primary liver cancer. Kanehira & Co., Tokyo, p. 30 (in English) 11. Nagao T, Inoue S, Goto S, Mizuta T, Omori Y, Kawano N, Morioka Y (1987) Hepatic resection for hepatocellular carcinoma. Clinical features and long-term prognosis. Ann Surg 205:33–40 12. Arii S, Tanaka J, Yamazoe Y, Minematsu S, Morino T, Fujita K, Maetani S, Tobe T (1992) Predictive factors for intrahepatic recurrence of hepatocellular carcinoma after partial hepatectomy. Cancer 69:913–919 13. Eggel H (1901) Uber das primare carcinom der leber. Beitr Pathol Ann 30:506–604 14. Nagao T, Inoue S, Yoshimi F, Sodeyama M, Omori Y, Mizuta T, Kawano N, Morioka Y (1990) Postoperative recurrence of hepatocellular carcinoma. Ann Surg 211:28–33 15. Lai EC, You K-T, Ng IO, Shek TW (1993) The pathological basis of resection margin for hepatocellular carcinoma. World J Surg 17:786–791 16. Imamura H, Matsuyama Y, Tanaka E, Ohkubo T, Hasegawa K, Miyagawa S, Sugawara Y, Minagawa M, Takayama T, Kawasaki S, Makuuchi M (2003) Risk factors contributing to early and late phase intrahepatic recurrence of hepatocellular carcinoma after hepatectomy. J Hepatol 38:200–207 17. Lauwers GY, Terris B, Balis UJ, Batts KP, Regimbeau JM, Chang Y, Graeme-Cook F, Yamabe H, Ikai I, Cleary KR, Fujita S, Flejou JF, Zukerberg LR, Nagorney DM, Belghiti J, Yamaoka Y, Vauthey JN (2002) Prognostic histologic indicators of curatively resected hepatocellular carci- nomas: a multi-institutional analysis of 425 patients with definition of a histologic prognostic index. Am J Surg Pathol 26:25–34 18. Sakamoto M, Hirohashi S, Tsuda H, Shimosato Y, Makuuchi M, Hosoda Y (1989) Multicentric independent development of hepatocellular carcinoma revealed by analysis of hepatitis B virus integration pattern. Am J Surg Pathol 13:1064–1067 19. Toyosaka A, Okamoto E, Mitsunobu M, Oriyama T, Nakao N, Miura K (1996) Pathologic and radiographic studies of intrahepatic metastasis in hepatocellular carcinoma; the role of efferent vessels. HPB Surgery 10:97–104 20. Ikai I, Yamaoka Y, Yamamoto Y, Ozaki N, Sakai Y, Satoh S, Shinkura N, Yamamoto M (1998) Surgical intervention for patients with stage IV-A hepatocellular carci- noma without lymph node metastasis: proposal as a standard therapy. Ann Surg 227: 433–439 21. Kojiro M, Sugihara S, Kakizoe S, Nakashima O, Kiyomatsu K (1989) Hepatocellular carci- noma with sarcomatous change: a special reference to the relationship with anticancer therapy. Cancer Chemother Pharmacol 23(Suppl):S4–S8 50 G.Y. Lauwers 22. Kojiro M, Kawabata K, Kawano Y, Shirai F, Takemoto N, Nakashima T (1982) Hepatocellular carcinoma presenting as intrabile duct tumor growth: a clinicopathologic study of 24 cases. Cancer 49:2144–2147 23. Nakashima T, Kojiro M (1986) Pathologic characteristics of hepatocellular carcinoma. Semin Liver Dis 6:259–266 24. Ishak KG, Anthony PP, Sobin L (1994) Histological typing of tumours in the liver. Springer, Berlin 25. Denk H, Stumptner C, Fuchsbichler A, Muller T, Farr G, Muller W, Terracciano L, Zatloukal K (2006) Are the Mallory bodies and intracellular hyaline bodies in neoplastic and non-neoplastic hepatocytes related? J Pathol 208:653–661 26. Edmondson H, Steiner P (1954) Primary carcinoma of the liver; a study of 100 cases among 48,900 necropsies. Cancer 7:462–503 27. Haratake J, Takeda S, Kasai T, Nakano S, Tokui N (1993) Predictable factors for esti- mating prognosis of patients after resection of hepatocellular carcinoma. Cancer 72: 1178–1183 28. Adachi E, Maeda T, Kajiyama K, Kinukawa N, Matsumata T, Sugimachi K, Tsuneyoshi M (1996) Factors correlated with portal venous invasion by hepatocellular carcinoma: univari- ate and multivariate analyses of 232 resected cases without preoperative treatments. Cancer 77:2022–2031 29. Lai CL, Wu PC, Lam KC, Todd D (1979) Histologic prognostic indicators in hepatocellular carcinoma. Cancer 44:1677–1683 30. Yang SH, Watanabe J, Nakashima O, Kojiro M (1996) Clinicopathologic study on clear cell hepatocellular carcinoma. Pathol Int 46:503–509 31. Maeda T, Adachi E, Kajiyama K, Takenaka K, Sugimachi K, Tsuneyoshi M (1996) Spindle cell hepatocellular carcinoma. A clinicopathologic and immunohistochemical analysis of 15 cases. Cancer 77:51–57 32. Vauthey JN, Klimstra D, Franceschi D, Tao Y, Fortner J, Blumgart L, Brennan M (1995) Factors affecting long-term outcome after hepatic resection for hepatocellular carcinoma. Am J Surg 169:28–34 33. Nigam A, Zhurak M, Boitnott J, Goodman S, Abrams R, Sitzmann J (1995) Factors affect- ing survival in Western patients following curative resection for hepatocellular carcinoma [abstract]. Gastroenterology 108:A1235 34. Esnaola NF, Lauwers GY, Mirza NQ, Nagorney DM, Doherty D, Ikai I, Yamaoka Y, Regimbeau JM, Belghiti J, Curley SA, Ellis LM, Vauthey JN (2002) Predictors of microvas- cular invasion in patients with hepatocellular carcinoma who are candidates for orthotopic liver transplantation. J Gastrointest Surg 6:224–232; discussion 32 35. Craig JR, Peters RL, Edmondson HA, Omata M (1980) Fibrolamellar carcinoma of the liver: a tumor of adolescents and young adults with distinctive clinico-pathologic features. Cancer 46:372–379 36. Berman MA, Burnham JA, Sheahan DG (1988) Fibrolamellar carcinoma of the liver: an immunohistochemical study of nineteen cases and a review of the literature. Hum Pathol 19:784–794 37. El-Serag HB, Davila JA (2004) Is fibrolamellar carcinoma different from hepatocellular carcinoma? A US population-based study. Hepatology 39:798–803 38. Ringe B, Wittekind C, Weimann A, Tusch G, Pichlmayr R (1992) Results of hepatic resection and transplantation for fibrolamellar carcinoma. Surg Gynecol Obstet 175:299–305 39. Soreide O, Czerniak A, Bradpiece H, Bloom S, Blumgart L (1986) Characteristics of fibro- lamellar hepatocellular carcinoma. A study of nine cases and a review of the literature. Am J Surg 151:518–523 40. Stipa F, Yoon SS, Liau KH, Fong Y, Jarnagin WR, D’Angelica M, Abou-Alfa G, Blumgart LH, DeMatteo RP (2006) Outcome of patients with fibrolamellar hepatocellular carcinoma. Cancer 106:1331–1338 41. Kakar S, Burgart LJ, Batts KP, Garcia J, Jain D, Ferrell LD (2005) Clinicopathologic fea- tures and survival in fibrolamellar carcinoma: comparison with conventional hepatocellular carcinoma with and without cirrhosis. Mod Pathol 18:1417–1423 3 Hepatocellular Cancer: Pathologic Considerations 51 42. Kojiro M (1997) Pathology of hepatocellular carcinoma. Churchill Livingstone, New York 43. Goodman ZD, Ishak KG, Langloss JM, Sesterhenn IA, Rabin L (1985) Combined hepatocellular-cholangiocarcinoma. A histologic and immunohistochemical study. Cancer 55:124–135 44. Maeda T, Adachi E, Kajiyama K, Sugimachi K, Tsuneyoshi M (1995) Combined hepato- cellular and cholangiocarcinoma: proposed criteria according to cytokeratin expression and analysis of clinicopathologic features. Hum Pathol 26:956–964 45. Morcos M, Dubois S, Bralet MP, Belghiti J, Degott C , Terris B (2001) Primary liver carci- noma in genetic hemochromatosis reveals a broad histologic spectrum. Am J Clin Pathol 116: 738–743 46. Nakamura S, Suzuki S, Sakaguchi T, Serizawa A, Konno H, Baba S, Baba S, Muro H (1996) Surgical treatment of patients with mixed hepatocellular carcinoma and cholangiocarcinoma. Cancer 78:1671–1676 47. Theise ND, Yao JL, Harada K, Hytiroglou P, Portmann B, Thung SN, Tsui W, Ohta H, Nakanuma Y (2003) Hepatic ‘stem cell’ malignancies in adults: four cases. Histopathology 43:263–271 48. Tickoo SK, Zee SY, Obiekwe S, Xiao H, Koea J, Robiou C, Blumgart LH, Jarnagin W, Ladanyi M, Klimstra DS (2002) Combined hepatocellular-cholangiocarcinoma: a histopatho- logic, immunohistochemical, and in situ hybridization study. Am J Surg Pathol 26:989–997 49. International Working Party (1995) Terminology of nodular hepatocellular lesions. Hepatology 22:983–993 50. Borzio M, Fargion S, Borzio F, Fracanzani AL, Croce AM, Stroffolini T, Oldani S, Cotichini R, Roncalli M (2003) Impact of large regenerative, low grade and high grade dysplastic nodules in hepatocellular carcinoma development. J Hepatol 39:208–214 51. Anthony PP, Vogel CL, Barker LF (1973) Liver cell dysplasia: a premalignant condition. J Clin Pathol 26:217–223 52. Watanabe S, Okita K, Harada T, Kodama T, Numa Y, Takemoto T, Takahashi T (1983) Morphologic studies of the liver cell dysplasia. Cancer 51:2197–2205 53. Lee RG, Tsamandas AC, Demetris AJ (1997) Large cell change (liver cell dysplasia) and hepatocellular carcinoma in cirrhosis: matched case-control study, pathological analysis, and pathogenetic hypothesis. Hepatology 26:1415–1422 54. Borzio M, Borzio F, Croce A, Sala M, Salmi A, Leandro G, Bruno S, Roncalli M (1997) Ultrasonography-detected macroregenerative nodules in cirrhosis: a prospective study. Gastroenterology 112:1617–1623 55. Theise ND, Schwartz M, Miller C, Thung SN (1992) Macroregenerative nodules and hepa- tocellular carcinoma in forty-four sequential adult l iver explants with cirrhosis. Hepatology 16:949–955 56. Terasaki S, Kaneko S, Kobayashi K, Nonomura A, Nakanuma Y (1998) Histological features predicting malignant transformation of nonmalignant hepatocellular nodules: a prospective study. Gastroenterology 115:1216–1222 57. Kojiro M (2004) Focus on dysplastic nodules and early hepatocellular carcinoma: an Eastern point of view. Liver Transpl 10:S3–S8 58. Kondo Y, Niwa Y, Akikusa B, Takazawa H, Okabayashi A (1983) A histopathologic study of early hepatocellular carcinoma. Cancer 52:687–692 59. Sakamoto M, Hirohashi S, Shimosato Y (1991) Early stages of multistep hepatocarcinogene- sis: adenomatous hyperplasia and early hepatocellular carcinoma. Hum Pathol 22:172–178 60. Roncalli M (2004) Hepatocellular nodules in cirrhosis: focus on diagnostic criteria on liver biopsy. A Western experience. Liver Transpl 10:S9–S15 61. Arakawa M, Kage M, Sugihara S, Nakashima T, Suenaga M, Okuda K (1986) Emergence of malignant lesions within an adenomatous hyperplastic nodule in a cirrhotic liver. Observations in five cases. Gastroenterology 91:198–208 62. Wilkens L, Bredt M, Flemming P, Mengel M, Becker T, Klempnauer J, Kreipe H (2002) Comparative genomic hybridization (CGH) and fluorescence in situ hybridization (FISH) in the diagnosis of hepatocellular carcinoma. J Hepatobiliary Pancreat Surg 9:304–311 52 G.Y. Lauwers 63. Chen ZM, Crone KG, Watson MA, Pfeifer JD, Wang HL (2005) Identification of a unique gene expression signature that differentiates hepatocellular adenoma from well-differentiated hepatocellular carcinoma. Am J Surg Pathol 29:1600–1608 64. Lau SK, Weiss LM, Chu PG (2004) Differential expression of MUC1, MUC2, and MUC5AC in carcinomas of various sites: an immunohistochemical study. Am J Clin Pathol 122: 61–69 65. Krishna M, Lloyd RV, Batts KP (1997) Detection of albumin messenger RNA in hepatic and extrahepatic neoplasms. A marker of hepatocellular differentiation. Am J Surg Pathol 21:147–152 66. Ma CK, Zarbo RJ, Frierson HF, Jr, Lee MW (1993) Comparative immunohistochemical study of primary and metastatic carcinomas of the liver. Am J Clin Pathol 99:551–557 67. Borscheri N, Roessner A, Rocken C (2001) Canalicular immunostaining of neprilysin (CD10) as a diagnostic marker for hepatocellular carcinomas. Am J Surg Pathol 25:1297–1303 68. Kondo Y (1985) Histologic features of hepatocellular carcinoma and allied disorders. Pathol Annu 20(Pt 2):405–430 69. Thung SN, Gerber MA, Sarno E, Popper H (1979) Distribution of five antigens in hepatocel- lular carcinoma. Lab Invest 41:101–105 70. Fucich LF, Cheles MK, Thung SN, Gerber MA, Marrogi AJ (1994) Primary vs metastatic hepatic carcinoma. An immunohistochemical study of 34 cases. Arch Pathol Lab Med 118:927–930 71. Hurlimann J, Gardiol D (1991) Immunohistochemistry in the differential diagnosis of liver carcinomas. Am J Surg Pathol 15:280–288 72. Johnson DE, Herndier BG, Medeiros LJ, Warnke RA, Rouse RV (1988) The diagnostic utility of the keratin profiles of hepatocellular carcinoma and cholangiocarcinoma. Am J Surg Pathol 12:187–197 73. Minervini MI, Demetris AJ, Lee RG, Carr BI, Madariaga J, Nalesnik MA (1997) Utilization of hepatocyte-specific antibody in the immunocytochemical evaluation of liver tumors. Mod Pathol 10:686–692 74. Kakar S, Muir T, Murphy LM, Lloyd RV, Burgart LJ (2003) Immunoreactivity of Hep Par 1 in hepatic and extrahepatic tumors and its correlation with albumin in situ hybridization in hepatocellular carcinoma. Am J Clin Pathol 119:361–366 75. Fan Z, van de Rijn M, Montgomery K, Rouse RV (2003) Hep par 1 antibody stain for the differential diagnosis of hepatocellular carcinoma: 676 tumors tested using tissue microarrays and conventional tissue sections. Mod Pathol 16:137–144 76. Lugli A, Tornillo L, Mirlacher M, Bundi M, Sauter G, Terracciano LM (2004) Hepatocyte paraffin 1 expression in human normal and neoplastic tissues: tissue microarray analysis on 3,940 tissue samples. Am J Clin Pathol 122:721–727 77. Scott FR, el-Refaie A, More L, Scheuer PJ, Dhillon AP (1996) Hepatocellular carcinoma aris- ing in an adenoma: value of QBend 10 immunostaining in diagnosis of liver cell carcinoma. Histopathology 28:472–474 78. Kimura H, Nakajima T, Kagawa K, Deguchi T, Kakusui M, Katagishi T, Okanoue T, Kashima K, Ashihara T (1998) Angiogenesis in hepatocellular carcinoma as evaluated by CD34 immunohistochemistry. Liver 18:14–9 79. de Boer WB, Segal A, Frost FA, Sterrett GF (2000) Can CD34 discriminate between benign and malignant hepatocytic lesions in fine-needle aspirates and thin core biopsies? Cancer 90:273–278 80. Frachon S, Gouysse G, Dumortier J, Couvelard A, Nejjari M, Mion F, Berger F, Paliard P, Boillot O, Scoazec JY (2001) Endothelial cell marker expression in dysplastic lesions of the liver: an immunohistochemical study. J Hepatol 34:850–857 81. Gottschalk-Sabag S, Ron N, Glick T (1998) Use of CD34 and factor VIII to diagnose hepatocellular carcinoma on fine needle aspirates. Acta Cytol 42:691–696 82. Di Tommaso L, Franchi G, Park YN, Fiamengo B, Destro A, Morenghi E, Montorsi M, Torzilli G, Tommasini M, Terracciano L, Tornillo L, Vecchione R, Roncalli M (2007) 3 Hepatocellular Cancer: Pathologic Considerations 53 Diagnostic value of HSP70, glypican 3, and glutamine synthetase in hepatocellular nodules in cirrhosis. Hepatology 45:725–734 83. Shafizadeh N, Ferrell LD, Kakar S (2008) Utility and limitations of glypican-3 expression for the diagnosis of hepatocellular carcinoma at both ends of the differentiation s pectrum. Mod Pathol 21:1011–1018 84. Baumhoer D, Tornillo L, Stadlmann S, Roncalli M, Diamantis EK, Terracciano LM (2008) Glypican 3 expression in human nonneoplastic, preneoplastic, and neoplastic tissues: a tissue microarray analysis of 4,387 tissue samples. Am J Clin Pathol 129:899–906 85. Wang XY, Degos F, Dubois S, Tessiore S, Allegretta M, Guttmann RD, Jothy S, Belghiti J, Bedossa P, Paradis V (2006) Glypican-3 expression in hepatocellular tumors: diagnostic value for preneoplastic lesions and hepatocellular carcinomas. Hum Pathol 37:1435–1441 86. Kandil DH, Cooper K (2009) Glypican-3: a novel diagnostic marker for hepatocellular carcinoma and more. Adv Ana Pathol 16:125–129 . However, there is considerable overlap in the staining profiles of hepatocellular lesions (benign and malignant), and therefore 3 Hepatocellular Cancer: Pathologic Considerations 47 caution is necessary IV-A hepatocellular carci- noma without lymph node metastasis: proposal as a standard therapy. Ann Surg 227: 433–439 21. Kojiro M, Sugihara S, Kakizoe S, Nakashima O, Kiyomatsu K (1989) Hepatocellular. conventional hepatocellular carcinoma with and without cirrhosis. Mod Pathol 18:1417–1423 3 Hepatocellular Cancer: Pathologic Considerations 51 42. Kojiro M (1997) Pathology of hepatocellular