4- liver tumours investigation & management Flashcards
what are examples of benign liver tumours?
- haemangioma
- focal nodular hyperplasia
- adenoma
- liver cysts
what are examples of malignant liver tumours?
- primary liver cancers (hepatocellular carcinoma & cholangiocarcinoma)
- metastases
what is haemangioma?
- commonest benign liver tumour
- hypervascular well demarcated capsule tumour
- usually asymptomatic
what is used for diagnosis of haemoangioma?
- ultrasound →echogenic spot, well demarcated
- CT →venous enhancement from periphery to centre
- MRI →high intensity
- no need for biopsy or treatment
what is focal nodular hyperplasia?
- benign liver tumour that forms in normal liver tissue = usually asymptomatic
- congenital vascular anomaly with central scar containing large artery radiating branches to periphery
- hyperplastic response to abnormal arterial flow
what does focal nodular hyperplasia look like on histology?
sinusoids, bile ductules, kupffer cells
what is diagnosis investigations for focal nodular hyperplasia?
- ultrasound →nodule with varying echogenicity
- CT →hypervascular mass with central scar
- MRI →iso ir hypo intense
- fine needle aspiration (for biopsy) →normal hepatocytes and kupffer cells with central core
what is hepatic adenoma?
= benign neoplasm composed of normal hepatocytes but no portal veins, central veins or bile ducts
- solitary fat containing lesion usually found on right lobe
what are risks of hepatic adenoma?
rupture, hemorrhage or malignant transformation →VERY RARE
what is common presentation of hepatic adenoma?
- asymptomatic or RUQ pain
- associated with contraceptive pill or anabolic steroids (driven by oestrogen)
- female
what do you do if someone has hepatic adenoma and on oral contraceptive pill?
you discontinue the oral contraceptive pill if develop adenoma →usually digresses
- then continue to do check up ultrasound/CT every 6 months
what investigations would you do for hepatic adenoma?
- ultrasound →filling defect
- CT →diffuse arterial enhancement
- MRI →hypo or hyper lesion
- fine needle aspiration (biopsy) →may be needed
what is treatment of male with adenocarcinoma?
surgical incision - as more likely to become malignant than female
what is important differences between adenoma and focal nodular hyperplasia?
adenoma = purely hepatocyte tumour & malignant degeneration
focal nodular hyperplasia = all liver ultrastructure including RES & bile ducts & no malignant risk
what is a simple cyst?
- Liquid collection lined by an epithelium
- No biliary tree communication
- Solitary and uniloculated
what is symptoms of simple cyst?
- Most of the time asymptomatic
- Symptoms can be related to
- Intracystic haemorrhage
- Infection
- Rupture (rare)
- Compression
what are hydatid cysts?
also fluid-filled sac that may present having spread or eroded into adjacent structures
- diagnosis includes & history and serological testing detection of anti-echinococcus
what is treatment of hydatid cysts?
surgery most common
- conservative = open cystectomy, marsupialization
- Radical = Pericystectomy, lobectomy
medical = albendazole
percutaneous drainage
what is polycystic liver disease?
- embryonic ductal plate malformation of intrahepatic biliary tree
- numerous cysts throughout liver parenchyma
what are 3 types of polycystic liver disease?
- Von Meyenburg complexes (VMC)
- Polycystic Liver disease
- Autosomal dominant Polycystic Kidney disease
what is von meyenburg complexes?
= type of polycystic liver disease
- on Meyenburg complexes (micro hamartomas) benign cystic nodules throughout the liver
- Cystic bile duct malformations, originating from the peripheral biliary tree
- Remnants develop into small hepatic cysts and usually remain silent during life
what is polycystic liver disease?
= type of polycystic liver disease
- liver function preserves, renal failure rare
- symptoms depend on size
what is autosomal dominant polycystic kidney disease?
= type of polycystic disease
- renal failure due to polycystic kidneys & non-renal extrahepatic features
- potential massive hepatic enlargement
what is management of polycystic liver disease?
- abdominal pain, abdominal distension, atypical symptoms due to voluminous cysts resulting in compression of adjacent tissue or failure of affected organ
- conservative treatment recommended to halt cyst growth to allow abdominal decompression
- pharmacological therapy = somatostatin (benefit for symptom relief & liver volume reduction)
what is presentation of liver abscess?
- high fever
- leukocytosis
- abdominal pain
- complex liver lesion
history →abdominal or biliary infection, dental procedure
what is management of liver abscess?
- intrinsic empiric broad spectrum antibiotics
- aspiration/drainage percutaneously
- echocardiogram
- operation if no clinical improvement →open drainage, resection
- 4 weeks antibiotic therapy repeat image
what are common malignant liver lesions?
- Hepatocellular carcinoma (HCC)
- Fibro-lamellar carcinoma of the liver
- Hepatoblastoma
- Intrahepatic cholangiocarcinoma
- Others
- METASTASES
what are clinical features of hepatocellular carcinoma?
- weight loss and RUQ pain
- asymptomatic
- worsening of pre existing chronic liver disease
what is AFP?
alfa fetoprotein = hepatocellular carcinoma tumour marker
what helps diagnosis of hepatocellular carcinoma?
- clinical presentation
- elevated AFP
- combination of ultrasound & CT (MRI and biopsy can then be used if needed)
what is important for prognosis hepatocellular carcinoma?
- tumour size
- extrahepatic spread
- underlying liver disease
- pt performance status (important)
what is treatment of hepatocellular carcinoma?
early stages think about resection or transplant but as worses then move onto palliative options
when is resection a feasible treatment option hepatocellular carcinoma?
- feasible if small tumour with preserved liver function but recurrence rate is higher than liver transplant
what is local ablation treatment option?
- for non resectable pt or advanced liver cirrhosis
- alcohol injection
- radiofrequency ablation
- temporary measure
what is chemoembolization treatment option?
→trans arterial chemoembolization = TACE
- inject chemo in hepatic artery
- inject embolic agent
- in patients with early cirrhosis
- no role for systemic chemo
what are fibrolamellar carcinoma?
- not related to cirrhosis
what are diagnostic findings of fibrolamellar carcinoma?
- AFP normal
- CT shows typical stellate scar with radial septal showing persistent enhancement
what are treatment options for fibrolamellar carcinoma?
- surgical resection or transplantation is standard of care
- TACE if unresectable tumour
what are second liver metastases?
- common site for blood borne metastases
- common primaries →colon, breast, lung, stomach, pancreas
- preserved liver function
what are malignant primary liver cancers?
- hepatocellular carcinoma
- fibrolamellar carcinoma
- hepatoblastoma
