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    Liver resection for intrahepatic tumours

    Background

    Resections of liver may be undertaken to excise benign lesions (focal nodular hyperplasia, adenomas), primary malignant tumours (hepatocellular carcinomas), intrahepatic cholangiocarcinomas and metastatic disease.1-4

    Hilar cholangiocarcinomas are defined anatomically as tumours located in the extrahepatic biliary tree proximal to the origin of the cystic duct, up to and including the second branches of the right and left hepatic ducts.4 Specific staging information required for these tumours should be considered.5 See separate protocol.

    Total hepatectomies at the time of liver transplant may also be submitted for histology.2 See separate protocol.

    Liver specimens usually require a range of special and immunohistochemical stains.

    This protocol includes liver resection for hepatocellular carcinoma, intrahepatic cholangiocarcinoma and metastatic tumours. See other protocols for hilar cholangiocarcinoma and transplant hepatectomy specimens.

    Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. See overview page for more detail on identification principles.

    • No
      • Non-routine fixation (not formalin), describe
    • Yes
      • Special studies required, describe and ensure samples are taken prior to fixation.
      • Copper analysis
      • Iron analysis
      • Cytogenetics
      • Flow cytometry
      • Electron microscopy
      • Microbiology
      • Trials
      • Research
    • Not performed
    • Performed, describe type and result
      • Frozen section
      • Imprints
      • Other, describe

    See general information for more detail on specimen handling procedures.

    Inspect the specimen and dictate a macroscopic description.


    External Inspection

    Orientate and identify anatomical features of the specimen including the surgical margins, vascular pedicle (if indicated by surgeon) and liver capsule.

    Record additional orientation or designation provided by operating clinician:

    • Absent
    • Present
      • Method of designation (e.g. suture, incision)
      • Featured denoted

    Photograph the intact specimen.

    Describe the following features of the specimen:

    Procedure

    Record as stated by the clinician.
    • Segmental resection, record the segments if known
    • Non-anatomical (wedge) resection
    • Partial hepatectomy
    • Total hepatectomy

    Anatomical components included (more than one may apply) and dimensions (mm)

    Describe and measure the anatomical components present.

    • Liver, in three dimensions (antero-posterior x medio-lateral x supero-inferior)
    • Gallbladder, in two dimensions see also gallbladder protocol
    • Other tissue received, specify and measure according to relevant protocol.
    Record the length and diameter of:
    • Common bile duct
    • Right hepatic duct
    • Left hepatic duct
    • Hepatic duct bifurcation
    • Common hepatic duct
    • Cystic duct

    Specimen weight (g)

    • Record

    Liver capsule

    • Normal
    • Abnormal
      • Breached by tumour
      • Nodular
      • Evidence of previous biopsy or surgery, e.g. scar or sutures

    Specimen integrity

    • Intact
    • Disrupted, describe

    Dissection

    Paint the relevant surgical margin(s) with ink and record the colour(s) applied.

    Slice perpendicularly to the parenchymal resection plane (preferably horizontally to facilitate correlation with radiology if necessary) at 5-10mm intervals.

    After sectioning the specimen may require longer fixation in larger quantity of formalin.

    Photograph the dissected specimen, specifically the slice(s) that best illustrate the salient features below.


    Internal Inspection

    Describe the cut surface appearance including the following items:

    Tumour

    • Absent
    • Present

    Check carefully for the presence of tumour at the circumferential surface of the tissue surrounding the biliary tree (peritoneal surface right and anteriorly; surgical plane left and posteriorly).1,5

    Distance to capsule and margins (mm)

    • Distance of capsular surface to closest tumour
    • Distance of tumour to closest resection margin, if orientated, specify margin

    Macroscopic involvement of vessels

    • Describe if present

    Vascular invasion is an important prognostic factor.6,7

    For each tumour, describe:

    Tumour size (mm)

    • Maximum dimension

    Satellite tumours (if primary liver tumour)8,9

    • No
    • Yes

    Satellite nodules appear as smaller nodules surrounding a dominant mass, separated by an interval of non-tumoral liver parenchyma.8

    Background parenchyma

    • Normal
    • Abnormal (more than one may apply)
      • Cirrhotic
      • Fibrotic
      • Fatty change
      • Nutmeg (chronic congestion)

    Retrieved from resection specimen

    • Describe site(s)
    • Number retrieved
    • Maximum diameter of each (mm)

    Separately submitted

    • For each pot, record specimen number and designation
    • Collective size of tissue in three dimensions (mm)
    • Number of lymph nodes submitted
    • Maximum diameter of each (mm)

    Lymph nodes are not commonly included in liver resection specimens except for the cystic lymph node.


    Processing

    Dissect the specimen further and submit sections for processing according to the illustrations provided.

    Submit all lymph nodes and identify the site of each.

    Record details of each cassette.

    An illustrated block key similar to those below may be useful.

    Block allocation key

    Cassette id Site No. of pieces
    A Vascular margin/hilar vessels, shave section  
    B Tumour and closest surgical/vascular margin  
    C-D Tumour, full face  
    E Tumour, interface with background liver  
    F Tumour closest to capsule (if <10mm)  
    G Background liver  
    H+ Lymph nodes  
     

    Acknowledgements

    A/Prof Bastiaan de Boer for his contribution in reviewing and editing this protocol.


    References

    1. Lester SC. Manual of Surgical Pathology, Saunders Elsevier, Philadelphia, 2010.
    2. Goodman ZD, Terracciano LM and Wee A. Tumours and tumour-like lesions of the liver. In: MacSween’s Pathology of the Liver, Burt AD, Portmann BC and Ferrell LD (eds), Churchill Livingstone Elsevier, 2012;761–852.
    3. Ishak KG, Goodman ZD and Stocker JT. Atlas of Tumour Pathology. Tumours of the Liver and Intrahepatic Bile Ducts. 3rd series, Fascicle 31. Armed Forces Institute of Pathology, Washington, 2001. 
    4. Deoliveira ML, Schulick RD, Nimura Y, Rosen C, Gores G, Neuhaus P and Clavien PA. New staging system and a registry for perihilar cholangiocarcinoma. Hepatology 2011;53(4):1363-1371.
    5. John AR, Khan S, Mirza DF, Mayer AD, Buckels JA and Bramhall SR. Multivariate and univariate analysis of prognostic factors following resection in HCC: the Birmingham experience. Dig Surg 2006;23(1-2):103-109.
    6. Shah SA, Tan JC, McGilvray ID, Cattral MS, Cleary SP, Levy GA, Greig PD and Grant DR. Accuracy of staging as a predictor for recurrence after liver transplantation for hepatocellular carcinoma. Transplantation 2006;81(12):1633-1639.
    7. Plessier A, Codes L, Consigny Y, Sommacale D, Dondero F, Cortes A, et al. Underestimation of the influence of satellite nodules as a risk factor for post-transplantation recurrence in patients with small hepatocellular carcinoma. Liver transpl 2004;10(2 Suppl 1):S86-90.
    8. Kim SH, Choi SB, Lee JG, Kim SU, Park MS, Kim do Y, et al. Prognostic factors and 10-year survival in patients with hepatocellular carcinoma after curative hepatectomy. J Gastrointest Surg 2011;15(4):598-607.

    Jump To

      Liver 1

      Partial hepatectomy, capsular surface

      Liver 2

      Partial hepatectomy, resection margin

      Liver 3

      Partial hepatectomy, cut surface

      Liver 14

      Partial hepatectomy dissection

      Liver 6

      Partial hepatectomy, cut surface close-up with tumour

      Liver 7

      Partial hepatectomy, inked

      Liver 8

      Partial hepatectomy, serially sectioned

      Liver 9

      Liver wedge resection, capsular surface

      Liver 10

      Liver wedge resection cut surface

      Liver 13

      Partial hepatectomy, bile duct margin

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      22-Mar-2019
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