外科病理学实践：诊断过程的初学者指南 | 第9章 肝
Diseases of hepatocytes: the viral hepatitides, autoimmune hepatitis, steatohepatitis and alcoholic disease, and drug toxicity
肝细胞疾病：病毒性肝炎、自身免疫性肝炎、脂肪性肝炎和酒精性疾病以及药物中毒
Diseases of the biliary system: autoimmune biliary diseases (primary sclerosing cholangitis and primary biliary cirrhosis), obstruction, atresia, transplant rejection, GVHD, and drugs
胆道系统疾病：自身免疫性胆道疾病（原发性硬化性胆管炎和原发性胆汁性肝硬化）、梗阻、闭锁、移植排斥、GVHD和药物
Diseases of the vasculature: transplant rejection, GVHD, and systemic vasculitides
血管系统疾病：移植排斥、GVHD和系统性血管炎
肝细胞成分（Hepatocellular compartment）
Portal inflammation: Inflammatory cells are present within the portal tract. In chronic hepatitis and autoimmune disorders, the infiltrate is predominantly mononuclear.
汇管区炎症：汇管区存在炎症细胞。慢性肝炎和自身免疫性疾病主要是单个核细胞浸润。
Interface activity (periportal hepatitis, piecemeal necrosis): Inflammation, usually lymphocytic, occurs in the limiting plate. This looks like portal inflammation spilling out into the hepatocytes (Figure 9.3). Note that the word activity when describing something in the liver does not mean neutrophils.
界面活动性炎症（汇管区周围肝炎，碎片性坏死）：炎症，通常为淋巴细胞性，发生在界板内。这看似汇管区炎症扩散到肝细胞（图9.3）。注意，当描述肝的某些东西时，“活动”一词并不意味着中性粒细胞。
Lobular inflammation: Inflammation, usually chronic, and/or necrosis of the hepatocytes are at a distance from the portal tracts. Also called spotty necrosis, this appears as little clusters of lymphocytes destroying individual hepatocytes out in the lobules. Do not count lymphocytes in the sinuses, which are physiologic.
小叶炎症：炎症（通常为慢性）和/或肝细胞坏死位于距离汇管区较远的位置。也称为斑点状坏死，表现为小叶中的小簇淋巴细胞破坏单个肝细胞。不要计数肝窦中的淋巴细胞，这是生理现象。
Vacuolar degeneration (balloon cell change): This is one way in which hepatocytes can die. The cytoplasm swells and becomes feathery and pale.
空泡变性（气球细胞改变）：这是肝细胞可能死亡的一种方式。细胞质膨胀，变成羽毛状和淡染。
Acidophilic bodies: This is another way in which hepatocytes die. These cells are similar to dyskeratotic cells in the skin; they are bright pink, rounded up, with pyknotic nuclei.
嗜酸小体：这是肝细胞死亡的另一种方式。这些细胞类似于皮肤中的角化不良细胞；它们呈明亮的粉红色，变圆，核固缩。
Fibrosis: Fibrosis is a general term indicating too much collagen. Fibrosis begins as an increase in collagen around the portal tract (portal fibrosis), and eventually spreads to connect adjacent portal tracts or central veins by thin webs of collagen (bridging fibrosis). The end stage of the process is cirrhosis, which is the division of the liver into individual nodules separated by thick bands of fibrosis (Figure 9.4).
纤维化：纤维化是指胶原蛋白过多的总称。纤维化开始于汇管区周围胶原的增多（汇管区纤维化），最终通过胶原的细网扩散到相邻的汇管区或中央静脉（桥接纤维化）。该过程的终末期是肝硬化，肝被分成由粗束纤维化分隔的单个结节（图9.4）。
Steatosis: Steatosis literally means fat in the hepatocytes. Steatosis can be physiologic in small amounts (< 5%), but 30%–60% involvement is considered moderate steatosis. Over 60% involvement is marked or severe disease. Macrovesicular steatosis means large single vacuoles in each hepatocyte and is typical of fatty liver, alcoholic disease, and nonalcoholic steatohepatitis. Pure microvesicular steatosis looks like foamy cytoplasm and is characteristic of mitochondrial injury such as in Reye’s syndrome.
脂肪变性：脂肪变性字面上是指肝细胞中的脂肪。少量的脂肪变性可能是生理性的（<5%），但一般认为，30%-60%受累是中度脂肪变性，60%以上受累是明显或严重的疾病。大泡性脂肪变性是指每个肝细胞中存在单个大空泡，是脂肪肝、酒精性疾病和非酒精性脂肪性肝炎的典型表现。单纯的微囊性脂肪变性看似泡沫状细胞质，是线粒体损伤的特征，如Reye综合征。
Steatohepatitis: Steatohepatitis is steatosis plus inflammation or injury. Neutrophils are not necessary for the diagnosis, but some evidence of hepatocyte injury is (Figure 9.5). This includes lobular inflammation, hepatocyte necrosis, pericellular fibrosis, balloon cells, and Mallory’s hyaline (see below).
脂肪性肝炎：脂肪性肝炎是脂肪变性加上炎症或损伤。中性粒细胞不是诊断所必需的，但肝细胞损伤的一些证据是必需的（图9.5）。这些证据包括小叶炎症、肝细胞坏死、细胞周围纤维化、气球细胞和Mallory透明小体（见下文）。
Mallory’s hyaline (Mallory bodies): Mallory bodies are irregular worm-like pink blobs of condensed cytoskeleton in the cytoplasm, especially within balloon cells (Figure 9.6). They are associated with steatohepatitis, especially alcoholic disease.
Mallory透明小体（Mallory小体）：Mallory小体是细胞质中不规则的蠕虫状粉红色凝缩细胞骨架，尤其是在气球细胞内（图9.6）。它们与脂肪性肝炎，尤其是酒精性疾病有关。
Megamitochondria: Megamitochondria are markedly enlarged mitochondria, which look like red blood cells entrapped in the hepatocyte cytoplasm.
巨线粒体：巨线粒体是明显增大的线粒体，看起来像陷入肝细胞质中的红细胞。
Iron accumulation: Abnormal levels of iron are detected with either hematoxylin and eosin or iron stain. If severe, iron accumulation may indicate hemochromatosis or be secondary to other hepatocellular processes.
铁累积：HE染色或铁染色检测到铁含量异常。如果严重，铁积累可能提示血色病或继发于其他肝细胞病变。
胆成分（Biliary compartment）
Cholestasis: Cholestasis is the backup of bile in the liver. This may be caused by ext rahepatic obstruction to flow, intrahepatic biliary disease, or impaired excretion by the hepatocytes themselves.
胆汁淤积症：胆汁淤积症是胆汁在肝中蓄积。这可能是由于肝外血流受阻、肝内胆道疾病或肝细胞自身排泄受损所致。
Bile duct proliferation: An increase in the number of bile duct profiles occurs in each portal tract; on average, there should be one to two per tract. Many of the new ductules are small, peripheral, and poorly formed. Bile duct proliferation occurs as a response to obstruction to flow. Other findings in obstruction include visible bile in hepatocytes or canaliculi, edema and inflammation (especially acute) in the portal tracts, eventually ductular atrophy, and finally widespread fibrosis (Figure 9.7).
胆管增殖：每个汇管区中胆管的数量增加；每个汇管区平均应该有一到两个。许多新生小导管是小的、位于周边的、形状不完好的。胆管增殖是对胆汁流出受阻的反应。梗阻的其他表现包括肝细胞或胆小管中可见胆汁、汇管区水肿和炎症（特别是急性炎症），最终导管萎缩，广泛纤维化（图9.7）。
Bile duct injury: Bile duct injury is identified by lymphocytes in the bile duct epithelium and vacuolar degeneration or dropout of the epithelial cells. The end stage is ductopenia. Injury to the bile ducts can indicate a biliary disease, such as autoimmune (primary biliary cirrhosis) or rejection. Bile duct injury is usually patchy, so multiple portal tracts must be examined.
胆管损伤：胆管损伤表现为胆管上皮中出现淋巴细胞、上皮细胞空泡变性或脱落。终末期为导管减少症。胆管损伤可能提示胆道疾病，如自身免疫性（原发性胆汁性肝硬化）或排斥反应。胆管损伤通常呈斑片状，因此必须检查多个汇管区。
Ductopenia: Ductopenia is loss of bile ducts, an indicator of chronic damage to the biliary system. Recognizing ductopenia, a diagnosis of absence, requires a conscious effort to look for bile ducts. Finding a bile duct in less than 80% of the portal tracts is abnormal.
胆管减少：胆管减少是胆管丢失，提示胆道系统的慢性损伤。胆管减少是通过发现胆管减少或消失而诊断的，需要有意识地努力寻找胆管。在不到80%的汇管区发现胆管是不正常的。
血管成分（Vascular compartment）
Venulitis (endothelitis): Venulitis is damage to the endothelium of the portal or central veins by inflammatory cells. It is usually an indication of rejection or GVHD.
静脉炎（内皮炎）：静脉炎是炎症细胞对门静脉或对中央静脉内皮的损害。通常提示排斥反应或GVHD。
Extramedullary hematopoiesis: Hematopoietic precursors (megakaryocytes are the most distinctive) are present in the liver sinuses. It is generally an indication of bone marrow disease (but is physiologic in fetuses and infants).
髓外造血：肝窦中存在造血细胞前体（巨核细胞是最独特的）。它通常提示骨髓疾病（但在胎儿和婴儿是生理性的）。
Acute cellular rejection: Acute rejection usually occurs 5–30 days after transplant, but can be longer. Changes include the following:
急性细胞排斥反应：急性排斥反应通常发生在移植后5-30天，但可能更长。改变包括：
Mixed portal tract inflammation, including lymphocytes, neutrophils, and eosinophils
混合性汇管区炎症，包括淋巴细胞、中性粒细胞和嗜酸性粒细胞
Venulitis
静脉炎
Bile duct inflammation and damage (Figure 9.8)
胆管炎症和损伤（图9.8）
Chronic rejection: Chronic rejection usually occurs after more than 1 year. Changes are primarily those of ductopenia and fibrosis.
慢性排斥反应：慢性排斥通常发生在1年以上。改变主要是导管减少和纤维化。
Primary biliary cirrhosis (occurs much more often in women than in men):
原发性胆汁性肝硬化（女性比男性更常见）：
Primary biliary cirrhosis is a chronic destructive intrahepatic cholangitis (inflammation of the intrahepatic bile ducts).
原发性胆汁性肝硬化是一种慢性破坏性肝内胆管炎（肝内胆管的炎症）。
Cirrhosis is an end-stage feature.
肝硬化是终末期特征。
It is associated with antimitochondrial antibody.
与抗线粒体抗体相关。
Findings are nonspecific and patchy but include inflammation and injury to the bile ducts, especially granulomatous, followed by proliferation and cholestasis, then eventually ductopenia and cirrhosis (Figure 9.9).
病理表现没有特异性，斑片状，但包括胆管炎症和损伤，尤其是肉芽肿，随后是增殖和胆汁淤积，最后是导管减少和肝硬化（图9.9）。
The etiology is direct damage to bile duct epithelium.
病因是直接损伤胆管上皮。
Primary sclerosing cholangitis (occurs more often in men than in women):
原发性硬化性胆管炎（男性多于女性）：
Primary sclerosing cholangitis is an inflammatory disease of the extrahepatic (and large intrahepatic) ducts.
原发性硬化性胆管炎是肝外（和肝内大）导管的炎症性疾病。
It leads to patchy stricturing lesions, visible on cholangiogram.
导致胆管斑片状狭窄性病变，造影可见。
It is associated with inflammatory bowel disease and p-ANCA.
与炎症性肠病和p-ANCA相关。
The histologic picture is also nonspecific but dominated by ductular proliferation and cholestasis.
组织学表现也没有特异性，但主要是导管增殖和胆汁淤积。
The etiology is unknown but may be a fibrotic process of the connective tissue surrounding the bile ducts, causing secondary stricture and damage.
病因不明，但可能是胆管周围结缔组织的纤维化过程，导致继发性狭窄和损伤。
肝细胞（Hepatocellular）
Focal nodular hyperplasia: Focal nodular hyperplasia is essentially an island of cirrhosis occurring in the background of a noncirrhotic liver. This is not a clonal process, so there is more than one cell type; in addition to hepatocytes are bile ducts and fibrous septae. There is no capsule but sometimes a central scar. The lesion is composed of nodules divided by bands of fibrosis and thick vessels.
局灶性结节性增生：局灶性结节性增生本质上是发生在非肝硬化背景下的肝硬化孤岛。这不是克隆性病变，所以有不止一种细胞类型；除肝细胞外，还有胆管和纤维间隔。没有包膜，但有时有中央瘢痕。病变由结节组成，结节由纤维束和厚壁血管分隔。
Adenoma: Adenomas are benign clonal neoplasms. They occur mainly in noncirrhotic livers of adult women taking oral contraceptive pills. Adenomas are circumscribed, partially encapsulated masses of uniform, bland-looking hepatocytes with no central veins or bile ducts (although there are diffuse prominent arterioles). The cells may be pale due to steatosis or glycogen or discolored with bile (which has no place to go). When visualized with reticulin stain, the hepatocyte plates are still only one to two cells thick (every cell touches reticulin).
腺瘤：腺瘤是良性克隆性肿瘤。主要发生在服用口服避孕药的成年妇女的非肝硬化肝。腺瘤表现为边界清楚的、部分包裹肿块，肝细胞均匀分布，形态学温和，没有中央静脉或胆管（尽管有弥漫分布的明显小动脉）。细胞可能因脂肪变性或糖原而淡染，或因胆汁而变色（胆汁无处可去）。当用网状纤维染色观察时，肝板仍然只有一到两层细胞厚度（每个细胞都接触网状纤维，译注，或网状纤维包围单个细胞）。
Well-differentiated hepatocellular carcinoma: Well-differentiated hepatocellular carcinoma (HCC) can be very difficult to distinguish from an adenoma histologically. However, HCC generally occurs in the setting of cirrhosis, unlike the adenoma. As with an adenoma, there are no bile ducts or central veins, and you may see intracellular bile (Figure 9.10). Nuclei may be large, hyperchromatic, and irregular. A reticulin stain shows a breakdown in architecture, and plates may be three or more cells in thickness.
高分化肝细胞癌：高分化肝细胞癌（HCC）在组织学上很难与腺瘤区分。然而，与腺瘤不同，肝癌通常发生于肝硬化。与腺瘤一样，没有胆管或中央静脉，可以看到细胞内胆汁（图9.10）。核可能增大，深染，不规则。网状纤维染色显示结构破坏，肝板厚度可能≥3层细胞厚度。
Poorly differentiated hepatocellular carcinoma: Poorly differentiated HCC can be very pleomorphic and hard to identify as hepatic. The presence of bile, if any, is still a give away.
低分化肝细胞癌：低分化肝细胞癌可能是多形性显著，很难识别为肝细胞癌。胆汁的存在，如果有的话，仍然是诊断线索。
Fibrolamellar hepatocellular carcinoma: Fibrolamellar HCC is a variant of well-differentiated HCC occurring in children and young adults. It is typified by oncocytic cells with prominent nucleoli in a dense fibrotic stroma.
纤维板层肝细胞癌：纤维板层HCC是发生于儿童和年轻成人的一种变异型高分化HCC。它的典型特征是在致密的纤维化间质中有显著核仁的嗜酸细胞。
胆（Biliary）
Bile duct adenoma: A bile duct adenoma is usually<1 cm and subcapsular (often sampled on frozen section), with a tangle of small simple tubules, with or without inflammation and fibrosis. It may produce mucin but not bile. Think of this as a benign biliary epithelial neoplasm (Figure 9.11).
胆管腺瘤：胆管腺瘤通常<1 cm且为被膜下（通常在冰冻切片上取样），伴简单小管的缠结，伴或不伴炎症和纤维化。它可能产生黏液，但不产生胆汁。将其视为良性胆管上皮肿瘤（图9.11）。
Bile duct hamartoma: Also called von Meyenburg complex, a bile duct hamartoma is also usually < 1 cm and subcapsular (often sampled on frozen section). However, it generally shows more dilated and angular tubules in a loose connective tissue stroma and often produces bile. Think of this as a disordered reduplication of the portal tract. The consequences of confusing the hamartoma with the adenoma are minimal.
胆管错构瘤：也称为von Meyenburg复合体，胆管错构瘤通常也是<1 cm且位于包膜下（通常在冰冻切片上取样）。然而，它通常显示出更扩张的和成角的小管，位于疏松的结缔组织间质中，并且经常产生胆汁。将其视为汇管区的无序重复。将错构瘤与腺瘤混淆的后果很轻微。
Cholangiocarcinoma: Cholangiocarcinoma is a primary malignancy of the bile ducts that appears as a nondescript adenocarcinoma infiltrating the liver. There is no definitive way to distinguish it from a metastatic lesion except by history. Although bile is not present in a cholangiocarcinoma, mucin is common, as is an intense desmoplastic response (Figure 9.12).
胆管癌：胆管癌是胆管的原发性恶性肿瘤，表现为浸润肝的非特殊腺癌。除了病史外，没有明确的方法将其与转移性病变区分开来。尽管胆管癌不存在胆汁，但常见黏液，也常见强烈的促结缔组织增生反应（图9.12）。
Vascular lesions
Cavernous hemangiomas are benign vascular lesions.
海绵状血管瘤是良性血管病变。
Epithelioid hemangioendotheliomas have a low malignant potential.
上皮样血管内皮瘤具有低度恶性潜能。
Angiosarcomas are malignant.
血管肉瘤是恶性。