HEPATIC TUMORS
Anatomy and physiology
The blood supply of the liver:-the hepatic artery-the portal vein
The blood is drained from the liver by three major veins: the left, right, and middle hepatic vein
Anatomy and physiology
the intrahepatic distribution of the …
… hepatic artery, … portal vein …. and biliary tree
division of the liver in 2 lobes and 8 segments
Consequence:-there are 2 types of hepatic resections:
Anatomy and physiology
segmental resection
lobe resection
Classification
Hepatictumors
Primarytumors
Secondarytumors
(metastasis)
Maligntumors
Benigntumors
Hepatocarcinoma
Cholangiocarcinoma
Focal nodular hyperplasia
Hepatic adenoma
Cavernous hemangioma
Cystic liver masses
History
-the majority of hepatic tumours = asymptomatic
-if symptomatic:- dull right upper quadrant pain
- fullness or bloating
- nausea or vomiting
- systemic complaints:- malaise- fever- weight loss- increasing abdominal girth
Diagnosis
Anamnesis could reveal some risk factors:-hepatitis virus infection or cirrhosis-travel to areas where hepatitis B or C is endemic-alcohol use -exposure to hepatotoxins-use of oral contraceptives or hormone replacement
therapy for patients suspected of having primary liver tumors such as hepatocellular carcinoma (HCC)
-patient's history of prior malignancy for patients with suspected metastatic lesions
Diagnosis
Physical examination
± a palpable mass - depending on the stage of the lesion
-splenomegaly and ascites- frequently seen in patients with portal
hypertension (suggesting an advanced cirrhosis).
Diagnosis
Laboratory evaluation -liver function studies-coagulation parameters-hematologic parameter
-in patients with suspected metastatic disease:appropriate tumor markers should be
obtained(carcinoembryonic antigen, CA 19-9)
-in patients with HCC the serum alpha-fetoprotein (AFP) level
= the most useful laboratory test -in patients with cholangiocarcinoma
serum carcinoembronic antigen levels
Diagnosis
Computed tomography scans
=highly sensitive; rapid acquisition; three-dimensional
reconstructions-lesions: solid or cystic-the smallest detectable
lesion size: 1 cm
Diagnosis
Arterial phase of a three-phase computed tomography scan of hepatic
metastases from colorectal carcinoma
Magnetic resonance imaging
-more sensitive than CT
-usefull differentiating between a benign and a malignant liver tumor
Diagnosis
A three-fase (arterial, portal and venous) MRI of a HCC
The heterogeneity is characteristic of the lesion, which is both hypervascular and
fibrotic.
Transcutaneous ultrasonography is used
-to detect the presence of liver tumors
-to guide percutaneous biopsies of liver tumors
-to guide therapy for selected tumors(direct injection or ablation techniques)
Diagnosis
Intraoperative ultrasonography-detect the number, extent, and association of tumors
with intrahepatic blood vessels in both primary and metastatic liver tumors
-performed laparoscopically or during an open procedure
Diagnosis
Positron emission tomography
=a nuclear medicine study that
-18F-flurodeoxyglucose (FDG) is injected intravenously
-metabolically active tissues (brain, neoplastic cells) absorbs the radiotracer
-a detector and processor is used to interpret and quantify the uptake
Diagnosis
PET scan confirming hypermetabolic activity of lesions identified on
corresponding CT scans.Black arrows = hepatic metastases White arrows = portal and para-aortic lymph node metastases
Diagnostic Laparoscopy=the final step in evaluation of
a hepatic neoplasm for resectability before resection
Diagnosis
Hepatic Resection
Surgical resection remains the optimal choice for the treatment of solid tumors of the liver
– segmental rsection or lobe (right or left) resection
Treatement options
Transplantation
= an option for HCC and some selectic metastatic tumors
Criteria for selection of the patients were adopted by the United Network for Organ Sharing (UNOS)
Treatement options
Radiofrequency Ablation
= the application of a high-frequency alternating current -ultrasound is used to guide the placement of the needle
Treatement options
Alternative Ablative Techniques
-interstitial laser hyperthermic ablation-microwave coagulation therapy (MCT)
Treatement options
Cavernous hemangioma
=the most common benign tumor of the liver
-most patients are asymptomatic-symptoms: pain, early satiety, nausea, vomiting, and fever±hepatomegaly
-needle biopsy = contraindicated (risk of hemorrhage)-CT scan: precontrast hypodense mass followed by
postcontrast peripheral enhancement, centripetal filling, and delayed emptying
-the tagged red blood cell scan confirms the diagnosis with a “hot spot”
-symptomatic cavernous hemangiomas are enucleated and the feeding artery is ligated
Types of masses
Cavernous hemangioma
Types of masses
CT scan
Hepatocellular adenoma
=the most common benign liver tumor in young womenlong-term oral contraceptive use = predisposing factor
-symptomatology:abdominal pain (50%)patients may present emergently with rupture,bleeding, and shock
-resection is indicated if the mass is symptomatic, greater than 6 cm in size, shows progression in size with serial CT scans,or is associated with elevated serum AFP levels
Types of masses
Hepatocellular adenoma
Types of masses
Three-phase computed tomography scan of a hepatic adenoma. left: arterial phase; center: portal phase; right: venous phase.
Focal nodular hyperplasia
-hyperplastic response around a vascular malformation
-usually symptomatic; detected incidentally by ultrasound or CT scan
-symptomatic patients complain of abdominal discomfort
-bleeding complications and malignant transformation are rare
-treatement:asymptomatic focal nodular hyperplasia should be observed
lesions with substantial symptoms are resected
Types of masses
Focal nodular hyperplasia
Types of masses
Focal nodular hyperplasia on
cross-sectional MRI
Cystic liver masses
Solitary congenital hepatic cysts=usually asymptomatic and do not need surgery.-symptomatic cysts are treated with laparoscopic unroofing
Polycystic liver disease-occurs with polycystic kidney and may be associated with
intracranial berry aneurysms-when symptomatic, they are treated surgically with excision
or unroofing
Types of masses
Cystic liver masses
Pyogenic liver abscess=consequence of other infections
cholangitis surgerygastrointestinal sepsis bacterial endocarditis
-predisposing factors: cirrhosis HIVdiabetes metastases
-the typical presentation: right upper quadrant pain chillsfever weight loss
-treatement:-ultrasound-guided external drainage and antibiotics-laparotomy and drainage may be required in some cases
Types of masses
Cystic liver masses
Amebic liver abscess -caused by Entamoeba histolytica-the typical presentation: a single, large abscess, in the
dome of the right lobe of the liver-predisposing factors:
a history of travel to an endemic areaa history of alcoholism
-serologic tests are available to confirm the diagnosis ELISA and immunofluorescence tests
-treatement: metronidazole 750 mg three times dailylarge amebic abscesses need drainage due to the danger of intrapericardial rupture
Types of masses
Cystic liver masses
Hydatid cysts of the liver (echinococcal cysts)
arise from infestation by the tapeworm Echinococcus granulosus.
Types of masses
Hepatocellular carcinoma
-predisposing factors:hepatitis B and Ccirrhosisexposure to hepatotoxins (aflatoxin, thorotrast)
-symptomatology a long period = asymptomatic when symptomatic:painful hepatomegalyanorexiaweight losshemorrhage causes sudden, severe pain or produces shock
Types of masses
Hepatocellular carcinoma
-AFP levels are elevated-the triad:
liver mass + positive hepatitis serology + high AFP levels =hepatocellular carcinoma
MRI and CT scan-vascular involvement and extrahepatic disease
Intraoperative ultrasound-evaluation of vascular involvement to decide extent of surgical resection
Treatement:-hepatic resections (whenever possible)
often cirrhosis (with a low hepatic function) don’t allow the resection
-radiofrequency ablation-cryotherapy for central lesions-chemotherapy - indicated
for lesions greater than 5 cm and for multicentric lesions
Types of masses
Cholangiocarcinoma
-develops from the biliar epithelium
-there three types:peripheral cholangiocarcinomascholangiocarcinomas that arise from the
right or left hepatic ducthilar cholangiocarcinomas
-diagnostic and treatement-similar with HHC
Types of masses
Secondary hepatic malignancies
Metastatic cancers of the liver-more common than primary cancer
-the main primary malignancies:colorectal cancer lymphomasbreast cancer renal cell carcinomalung cancer pancreatic islet cell tumorsmelanomas carcinoid
Resection, when possible, is indicated for - primary colonic carcinoma- symptomatic carcinoid- renal cell carcinoma.
Types of masses
Types of masses
HYDATID CYST
Hydatid disease or echinococcosis
=a zoonosis that occurs primarily in sheep-grazing areas of the world … -endemic in Mediterranean countries,
the Middle East, the Far East, South America, Australia, New Zealand East Africa
… but it is present worldwide because the dog is a definitive hosthumans contract the disease from dogsthere is no human-to-human transmission
Etiology
Etiology
Echinococcus granulosus= a tapeworm that live into the bowel of the dog or other canide
Eggs are passed (up to thousands of ova daily) and deposited with the dog’s feces
eggsOther species of this tapeworm:
E. multilocularisE. oligartus
Etiology
Echinococcus granulosus= a tapeworm that live into the bowel of the dog or other canide
Eggs are passed (up to thousands of ova daily) and deposited with the dog’s feces
The biologic cycle of Echinicoccus
-the definitive host = the dog
the adult tapeworm is
attached to the villi of the ileum
-the worm’s eggs are deposited in the dog’s feces
-sheep are the usual interme-diate host
-humans are an accidental intermediate host
The biologic cycle of Echinicoccus
The biologic cycle of Echinicoccus
In the human duodenum, the parasitic embryo releases an oncosphere containing hooklets that penetrate the mucosa, allowing access to the bloodstream of portal vein. In the blood, the oncosphere reaches the liver (most commonly) or lungs, where the parasite develops its larval stage known as the hydatid cyst.
Consequence of infestation
in the duodenum the parasitic embryo is released
humans (incidentaly)
contaminated water or food
eggs eliminated by dog
the parasitic embryo pass trrough the intestinal wall into the portal bloodstream
Liver Hidatid cyst of the liver
right atrium
pulmonary circulation Hydatid cyst of the lung
left atrium
sistemic circulation any otherlocation
50-60%
20-30%
10-20%
The structure of the hydatid cyst
-three weeks after infection a hydatid cyst begin to develop-the cyst grows slowly (2 cm diameter/year) in a spherical manner-the pericyst develops around the hydatid cysta fibrous capsule derived from host tissues-the cyst wall itself has two layers:
an outer gelatinous membrane (ectocyst)an inner germinal membrane (endocyst)
-the content of the hydatid cyst:the hydatid fluid
(clear like water – if the cyst is uncomplicated)brood capsules scoleces (hydatid sand)
The structure of the hydatid cyst
The structure of the hydatid cyst
the pericyst
The structure of the hydatid cyst
the ectocyst
The structure of the hydatid cyst
a fragment of the
endocyst
daughter cysts
Evolution of the hydatid cyst
The cyst grows slowlyRupture into …
… the biliary tree… bronchial tree… the peritoneal cavity… pleural cavity… pericardial cavity
Free ruptures can result in disseminated echinococcosis and/or a potentially fatal anaphylactic reactionInfection of a hydatid cyst can occur pyogenic abscessCalcification of the cyst = seldom (in years, if the parasite die)
Symptomatology
-asymptomatic until complications occur
-the most common symptomsabdominal paindyspepsiavomiting
-hepatomegaly = the most frequent sign-jaundice and fever - seldom
Diagnosis
-serologic tests evaluate antibody response-ultrasound
= the most commonly used
splitting of the cystic wall parasitic membrane into the cyst
Diagnosis
-ultrasound
comb the honey tumor-like hidatid cyst
Diagnosis
-ultrasound
calcified cyst
Diagnosis
CT or MRI-similar findings like ultrasonography-detailed hepatic anatomic relationships to the cyst
Endoscopic retrograde cholangio-pancreatographyPercutaneous transhepatic cholangiography
-in patients with suspected biliary involvement
Treatement
-the treatment of hepatic hydatid cysts is primarily surgical
-the abdomen is explored, the liver mobilized and the cyst exposed
-packing off of the abdomen to prevent the diffuse seeding
-the cyst is aspirated and flushed with a scolicidal agent (hypertonic saline)
-the cyst is then unroofed
-then …
Treatement
-then … a number of possibilities:pericystectomydrainage of the cystomentoplastyor even liver resection
-sometimes major biliary repairs or approaches through the common bile duct may be necessary-laparoscopic techniques for drainage and unroofing are possible for the uncomplicated cyst-after operation: antiparasitic agents (albendazole or mebendazole)
Treatement
In the past, aspiration of hydatid cysts was contraindicated
-risk of rupture and uncontrolled spillage
In recent years percutaneous aspiration and injection of scolicidal was reported with a good rate of success (70%)
HEPATIC TRAUMA
Mechanism of injury
-compressive injuries from the overlying ribs-penetrating wounds in the right thoracoabdominal area
laceration of the liver in a car accident
hemorrhage
Diagnosis
-in hypotensive patients who have suffered blunt abdominal or multisystem trauma
an ultrasonography visualization of fluid (blood!) or a hepatic injury
a diagnostic peritoneal lavage reveals blood into the peritoneal cavity(the most likely sources of hemorrhage are
injuriesto the liver, spleen or mesentery)
Diagnosis
-in hemodynamically stable patient and without peritonitis - a spiral contrast CT
intraperitoneal fluid (blood)magnitude of injury to the liver or other organthe presence or absence of active
hemorrhage
nonoperative or operative management is chosen
-penetrating wounds to the abdomen in patients with peritonitis, hypotension or evisceration mandate laparotomy.
Classification
Grade Description of injuryIHaematomaLaceration
Subcapsular, non-expanding, less than 10 percent of surface areaCapsular tear, non-bleeding, parenchymal depth less than 1 cm
IIHaematomaLaceration
Subcapsular, non-expanding, 10–50 per cent of surface area; or intraparenchymal, non-expanding, less than 2 cm in diameterCapsular tear, active bleeding, parenchymal depth 1–3 cm, less than10 cm in length
IIIHaematoma
Laceration
Subcapsular, more than 50 per cent of surface area or expanding;ruptured subcapsular haematoma with active bleeding;intraparenchymal haematoma larger than 2 cmParenchymal depth more than 3 cm
IVHaematomaLaceration
Ruptured intraparenchymal haematoma with active bleedingParenchymal disruption of more than 25–50 percent of hepatic lobe
VLacerationVascular
Parenchymal disruption of more than 50 per cent of hepatic lobeJuxtahepatic venous injuries
VIVascular Hepatic avulsion
The Liver Injury Scale
Treatement
Nonoperative management-80-85% of patients with hepatic trauma are hemodinamic stable -nonoperative management is appropriate after a contrast CT-patients are kept at bed rest-the vital signs are monitored-in stable patients a repeat spiral CT is appropriate at 5 to 7 days to evaluate the evolution of lesion
Laparotomy could become necessary if …-a falling hematocrit-continuing need for transfusion -new onset peritonitis and/or hypotension
Treatement
Operative management
Simple techniques of hemostasis-5 min of compression-application of topical hemostatic agents
cellulosemicrofibrillar collagen hemostatfibrin sealant
-simple suture hepatorrhaphy
Treatement
Operative management
Advanced techniques of hemostasis•extensive hepatorrhaphy•hepatotomy with selective vascular ligation•viable omental pack•resectional debridement with selective vascular ligation•absorbable mesh compression•formal resection•selective hepatic artery ligation•intrahepatic balloon tamponade•perihepatic packing
Treatement
Operative management
The Pringle maneuver controls arterial and portal vein hemorrhage from the liver. Any hemorrhage that continues must come from
the hepatic veins.
Treatement
Operative management
Manual compression of large hepatic injuries
temporarily controls blood loss in hypovolemic
patients until the circulating blood volume
can be restored.
Treatement
Operative management
Perihepatic packing is often effective in managing
extensive parenchymal injuries.
Treatement
Operative management
intrahepatic balloon tamponade
Treatement
Operative management
Hepatotomy with selective ligation
Treatement
Operative management
Resection and suture of the
hepatic parenchima
Treatement
Operative management
Hepatic resection and perihepatic packing