Diagnostic considerations of nodules in the cirrhotic liver: A case-based perspective

A 59-year-old man with cirrhosis due to hepatitis C virus and prior alcohol abuse, followed with the current clinical protocol of serum markers and imaging for surveillance of hepatocellular carcinoma (HCC), was found to have a nodule worrisome for HCC by imaging. The patient underwent transarterial chemoembolization of this nodule, followed by liver transplant; the pathologic examination of the explanted liver confirmed central necrosis in the nodule with viable HCC at the periphery, as well as numerous dysplastic nodules.This case illustrates current practice based on American Association for the Study of Liver Diseases (AASLD) guidelines. Small (1-2 cm) nodules in cirrhosis are first evaluated by imaging, and only if there are atypical, nondiagnostic findings are they considered for biopsy evaluation. This practice has thus replaced the traditional "gold standard" of histopathologic evaluation of nodules in cirrhosis. One consequence of this practice is a marked decrease in pathologists' experience with biopsies of "atypical" nodules in cirrhosis. Recent studies have highlighted the use of various immunohistochemical stains in evaluations of biopsies of small nodules in cirrhosis. In this review, we discuss histologic criteria of dysplastic nodules and the use of a diagnostic algorithm.