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Liver TumorsLiver Tumors
ObjectiveObjective1.1. Identify the most important features of Identify the most important features of
common benign liver tumorscommon benign liver tumors
2.2. Know the risk factors, diagnosis, and Know the risk factors, diagnosis, and management of hepatocellular management of hepatocellular carcinoma (Primary Liver cancer)carcinoma (Primary Liver cancer)
ClassificationClassification
HemangiomaHemangioma
Focal nodular Focal nodular hyperplasiahyperplasia
AdenomaAdenoma
Liver cystsLiver cysts
1.1. Primary liver Primary liver cancerscancersHepatocellular Hepatocellular carcinomacarcinoma
Fibrolamellar carcinomaFibrolamellar carcinoma
HepatoblastomaHepatoblastoma
2. Metastases2. Metastases
Benign Malignant
Benign Liver LesionsBenign Liver Lesions1.1. HemangiomaHemangioma
2.2. Focal nodular hyperplasiaFocal nodular hyperplasia
3.3. AdenomaAdenoma
4.4. CystsCysts
HemangiomaHemangiomaClinical FeaturesClinical Features
The commonest liver tumorThe commonest liver tumor
5% of autopsies5% of autopsies
Usually single smallUsually single small
Well demarcated capsuleWell demarcated capsule
Usually asymptomaticUsually asymptomatic
HemangiomaHemangiomaDiagnosis and ManagementDiagnosis and Management
DiagnosisDiagnosisUS: echogenic spot, well demarcatedUS: echogenic spot, well demarcatedCT: venous enhancement from periphery to CT: venous enhancement from periphery to centercenterMRI: high intensity areaMRI: high intensity areaNo need for FNAC or BiopsyNo need for FNAC or Biopsy
TreatmentTreatmentNo need for treatmentNo need for treatment
CT/HemangiomaCT/Hemangioma
Focal Nodular Hyperplasia (FNH)Focal Nodular Hyperplasia (FNH)Clinical FeaturesClinical Features
Benign nodule formation of normal liver Benign nodule formation of normal liver tissuetissue
Central stellate scarCentral stellate scar
More common in young and middle age More common in young and middle age womenwomen
No relation with sex hormonesNo relation with sex hormones
Usually asymptomaticUsually asymptomatic
May cause minimal painMay cause minimal pain
Focal Nodular Hyperplasia (FNH)Focal Nodular Hyperplasia (FNH)Diagnosis and ManagementDiagnosis and Management
DiagnosisDiagnosis::US: Nodule with varying echogenicityUS: Nodule with varying echogenicityCT: Hypervascular mass with central scarCT: Hypervascular mass with central scarMRI: iso or hypo intense MRI: iso or hypo intense FNA: Normal hepatocytes and Kupffer cells with FNA: Normal hepatocytes and Kupffer cells with central core.central core.
TreatmentTreatment::No treatment necessaryNo treatment necessaryPregnancy and hormones OKPregnancy and hormones OK
CT/FNHCT/FNH
Hepatic AdenomaHepatic AdenomaClinical featuresClinical features
Benign neoplasm composed of normal Benign neoplasm composed of normal hepatocytes no portal tract, central veins, hepatocytes no portal tract, central veins, or bile ductsor bile ductsMore common in womenMore common in womenAssociated with contraceptive hormonesAssociated with contraceptive hormonesUsually asymptomatic but may have RUQ Usually asymptomatic but may have RUQ painpainMat presents with rupture, hemorrhage, or Mat presents with rupture, hemorrhage, or malignant transformation (very rare) malignant transformation (very rare)
Hepatic AdenomaHepatic AdenomaDiagnosis and ManagementDiagnosis and Management
DXDXUS: filling defectUS: filling defectCT: Diffuse arterial enhancementCT: Diffuse arterial enhancementMRI: hypo or hyper intense lesionMRI: hypo or hyper intense lesionFNA : may be neededFNA : may be needed
TxTxStop hormonesStop hormonesObserve every 6m for 2 yObserve every 6m for 2 yIf no regression then surgical excisionIf no regression then surgical excision
AdenomaAdenoma
Liver CystsLiver CystsMay be single or multipleMay be single or multiple
May be part of polycystic kidney diseaseMay be part of polycystic kidney disease
Patients often asymptomaticPatients often asymptomatic
No specific management requiredNo specific management required
Hydated cystHydated cyst
Malignant Liver LesionsMalignant Liver Lesions
Malignant Liver TumorsMalignant Liver Tumors
1.1. Hepatocellular carcinoma (HCC)Hepatocellular carcinoma (HCC)
2.2. Fibro-lamellar carcinoma of the liverFibro-lamellar carcinoma of the liver
3.3. HepatoblastomaHepatoblastoma
4.4. Intrahepatic cholangiocarcinomaIntrahepatic cholangiocarcinoma
5.5. OthersOthers
HCC: IncidenceHCC: IncidenceThe most common primary liver cancerThe most common primary liver cancer
The most common tumor in Saudi menThe most common tumor in Saudi men
Increasing in US and all the worldIncreasing in US and all the world
HCC: Risk FactorsHCC: Risk FactorsThe most important risk factor is The most important risk factor is cirrhosiscirrhosis
from any cause:from any cause:
1.1. Hepatitis B (integrates in DNA)Hepatitis B (integrates in DNA)
2.2. Hepatitis CHepatitis C
3.3. AlcoholAlcohol
4.4. AflatoxinAflatoxin
5.5. OtherOther
HCC: Clinical FeaturesHCC: Clinical FeaturesWt loss and RUQ pain (most common)Wt loss and RUQ pain (most common)AsymptomaticAsymptomaticWorsening of pre-existing chronic liver disWorsening of pre-existing chronic liver disAcute liver failureAcute liver failure
O/E:O/E:Signs of cirrhosisSigns of cirrhosisHard enlarged massHard enlarged mass
HCC: MetastasesHCC: MetastasesRest of the liverRest of the liver
Portal veinPortal vein
Lymph nodesLymph nodes
LungLung
BoneBone
BrainBrain
HCC: Systemic FeaturesHCC: Systemic FeaturesHypercalcemiaHypercalcemia
HypoglycemiaHypoglycemia
HyperlipidemiaHyperlipidemia
HyperthyroidismHyperthyroidism
HCC: labsHCC: labsLabs of liver cirrhosisLabs of liver cirrhosis
AFP (Alfa feto protein)AFP (Alfa feto protein)
Is an HCC tumor markerIs an HCC tumor marker
Values more than 100ng/ml are highly Values more than 100ng/ml are highly suggestive of HCCsuggestive of HCC
Elevation seen in more than 70% of ptElevation seen in more than 70% of pt
HCC: DiagnosisHCC: DiagnosisClinical presentationClinical presentation
Elevated AFPElevated AFP
USUS
Triphasic CT scan: very early arterial Triphasic CT scan: very early arterial perfusionperfusion
MRIMRI
BiopsyBiopsy
US: HCCUS: HCC
CT: Venous PhaseCT: Venous Phase
CT: Arterial PhaseCT: Arterial Phase
HCC: PrognosisHCC: PrognosisTumor sizeTumor size
Extrahepatic spreadExtrahepatic spread
Underlying liver diseaseUnderlying liver disease
Pt performance statusPt performance status
HCC: Liver HCC: Liver TransplantationTransplantation
Best available treatmentBest available treatment
Removes tumor and liverRemoves tumor and liver
Only maximum 3 tumors with largest less Only maximum 3 tumors with largest less than 6 cm of total size less than 8than 6 cm of total size less than 8Recurrence rate is lowRecurrence rate is low
Not widely availableNot widely available
costlycostly
HCC: ResectionHCC: ResectionFeasible for small tumors with preserved Feasible for small tumors with preserved liver function (no jaundice or portal HTN)liver function (no jaundice or portal HTN)
Recurrence rate is highRecurrence rate is high
HCC: Local AblationHCC: Local AblationFor non resectable ptFor non resectable pt
For pt with advanced liver cirrhosisFor pt with advanced liver cirrhosis
Alcohol injectionAlcohol injection
Radiofrequency ablationRadiofrequency ablation
Temporary measure onlyTemporary measure only
Radio Frequency AblationRadio Frequency Ablation
Ethanol InjectionEthanol Injection
HCC: ChemoembolizationHCC: ChemoembolizationInject chemotherapy selectively in hepatic Inject chemotherapy selectively in hepatic arteryartery
Then inject an embolic agentThen inject an embolic agent
Only in pt with early cirrhosisOnly in pt with early cirrhosis
No role for systemic chemotherapyNo role for systemic chemotherapy
ChemoembolizationChemoembolization
Fibro-Lamellar CarcinomaFibro-Lamellar CarcinomaPresents in young pt (5-35)Presents in young pt (5-35)
Not related to cirrhosisNot related to cirrhosis
AFP is normalAFP is normal
CT shows typical stellate scar with radial CT shows typical stellate scar with radial septa showing persistant enhancementsepta showing persistant enhancement
Secondary Liver Secondary Liver MetastasesMetastases
The most common site for blood born The most common site for blood born metastasesmetastasesCommon primaries : colon, breast, lung, Common primaries : colon, breast, lung, stomach, pancreases, and melanomastomach, pancreases, and melanomaMild cholestatic picture (ALP, LDH) with Mild cholestatic picture (ALP, LDH) with preserved liver functionpreserved liver functionDx imaging or FNADx imaging or FNATreatment depends on the primary cancerTreatment depends on the primary cancerIncase of metastasis from intestinal cancer or Incase of metastasis from intestinal cancer or neuroendocrine cancer. Surgery can offer cure.neuroendocrine cancer. Surgery can offer cure.
SummarySummary
HemangiomaHemangioma
Focal nodular Focal nodular hyperplasiahyperplasia
AdenomaAdenoma
Liver cystsLiver cysts
1.1. Primary liver Primary liver cancerscancersHepatocellular Hepatocellular carcinomacarcinoma
Fibrolamellar carcinomaFibrolamellar carcinoma
HepatoblastomaHepatoblastoma
2. Metastases2. Metastases
Benign Malignant