Liver - focal liver lesions Flashcards
What are solid liver lesions in older patients most likely to be?
Malignant - usually metastases if the patient does not have liver disease (then it is more likely to be a primary liver cancer)
What is the most common solid liver tumour in non cirrhotic patients?
Haemangioma
What are the causes of a benign focal liver lesions? (4)
Haemangioma
Focal nodular hyperplasia
Adenoma
Liver cysts
What are the 2 causes of malignant focal lesions of the liver?
Primary liver cancers
Metastases
What are the types of primary liver cancers? (6)
Hepatocellular carcinoma Cholangiocarcinoma Fibrolamellar carcinoma Hepatoblastoma Angiosarcoma Haemangioendothelioma
Clinical features of haemangioma:
- more common in M or F?
- blood supply?
- size/ number of them?
- border?
- symptoms?
Females Hypervascular tumour Usually single and small Well demarcated capsule usually asymptomatic
Diagnosis of haemangioma?
US: echogenic spot, well demarcated
CT: venous enhancement from periphery centre
MRI: high intensity area
No need for FNA
Treatment for haemangioma?
No need for treatment
What is a focal nodular hyperplasia?
Benign nodule formation of normal liver tissue (hyper plastic growth of normal hepatocytes)
What is usually the cause of a focal nodular hyperplasia?
What 2 other conditions is FNH therefore associated with?
Congenital vascular anomaly - hyperplastic response to abnormal arterial flow
Osler-Weber-Rendu
Liver haemangioma
What is the classical appearance of a focal nodular hyperplasia?
Central scar containing a large artery, radiating branches to the periphery (Hub and spoke) - not always
What 3 things are present on histology focal nodular hyperplasia?
Sinusoids
Bile ductules
Kupffer cells
What age groups and gender are focal nodular hyperplasia more common in?
Young and middle age women (no relation with sex hormones)
Symptoms of focal nodular hyperplasia?
Usually asymptomatic, amy cause minimal pain
Diagnosis of focal nodular hyperplasia?
US: nodule with varying echogenicity
CT: hypervascular scar with central scar
MRI: Iso or hypo intense
FNA: normal hepatocytes and cupful cells with central core
Treatment of focal nodular hyperplasia?
No treatment necessary
no change required regarding pregnancy and hormones - some older texts give mixed message
What is a hepatic adenoma?
Benign neoplasm composed of normal hepatocytes - most are solitary fat containing lesions
No portal tract, central veins or bile ducts
Clinical features of hepatic adenoma: Which sex is it more common in? What is it commonly associated with? Symptoms? What can it rarely present with?
Females
Contraceptive hormones
Usually asymptomatic but may have RUQ pain - symptoms are size related
May present with rupture, haemorrhage or malignant transformation (very rare)
What lobe of the liver are hepatic adenomas commonly found in?
The right lobe
What is multiple adenomas called?
What is this associated with?
Adenomatosis
Glycogen storage diseases
What has been identified within adenomas that confer malignant risk?
Identifiable oncogene mutations
How are hepatic adenomas related to Oral Contraceptive?
Related to duration of OC use (>2 years) and oestrogen component, but adenomas have been described with even 6 months of OS use
What can happen do hepatic adenomas after discontinuation of Oral contraceptives?
Regression
Diagnosis of hepatic adenoma?
US: filling defect
CT: diffuse arterial enhancement
MRI: hypo or hyper intense lesion
FNA: may be needed
Treatment for a hepatic adenoma?
Stop hormones
Observe every 6m for 2y
if no regression then surgical excision
New guidelines suggest that male patients should have them removed straight away as they are more prone to developing a malignant transformation
Difference between an adenoma and focal nodular hyperplasia appearance?
Adenoma = purely a hepatocyte tumour which is cold on nuclear sulfur colloid scan
Focal nodular hyperplasia = contains all the liver ultrastructure including ES and bile ductules (isointense on sulfur colloid scan) - central scar
Malignant risk with adenoma and focal nodular hyperplasia?
Adenoma = malignant degeneration
Focal nodular hyperplasia = no malignant risk
Type of cystic lesions of the liver? (5)
Simple Hydatid Atypical Polycystic lesion Pyogenic or amoebic abcess
Clinical features of a simple cyst:
- Appearance
- Biliary tree communication?
- Symptoms?
-liquid collection lined by an epithelium - solitary and uniloculated
- no biliary tree communication
Most of the time asymptomatic but symptoms can be experienced in relation to:
-intracsytic haemorrhage
-infection
-rupture (rare)
-compression
Management of a simple cyst?
No follow up necessary
if in doubt, image in 3-6 months
If symptomatic or uncertain of diagnosis (complex cystic lesion), then consider surigcal intervention
What organism causes hydatid cysts?
Echinoccus granulosus
Where are endemic regions for hydatid cysts?
Eastern europe central america south america middle east north africa
How can patients with hydatid cysts present?
Disseminated disease
erosion of cysts into adjacent structures and vessels (IVC)
How is a hydatid cyst diagnosed?
Based on history, appearance and serologic testing-detection of anti-echinococcus antibodies
Possible management for hydatid cysts? (3)
Surgery - most common form of treatment
medical
precutaneous drainage
What are the 2 types of treatment that can be given for a hydatid cyst?
Conservative
Radical
Types of conservative surgery for hydatid cyst? (2)
Open cystectomy
Marsupialization (slit cut in cyst to allow it to continually drain)
Types of radical surgery for a hydatid cyst?
Pericystecomy
Lobectomy
Risks of surgery for a hydatid cyst?
Operative morbidity
Anaphylacis
Dissemination of infection
Medical treatment for a hydatid cyst?
Albendazole
What does PAIR stand for (percutaneous drainage)?
Puncture
Aspiration
Injection
Respiration
What causes polycystic liver disease?
Embryonic ductal plate malformation of the intrahepatic biliary tree - numerous cysts throughout liver parenchyma
What are the causes of numbers cysts throughout the liver parenchyma?
Von meyenburg complexes
Polycystic liver disease
Autosomal dominant polycystic kidney disease
What is von memenburg complexes?
Microhamartomas - 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 - incidental finding
Difference between polycystic liver disease and autosomal dominant polycystic kidney disease?
Liver function is preserved and renal failure rare in polycystic liver disease where as renal failures common in polycystic kidney disease often with extra-kidney manifestations
Treatment of polycystic liver disease with symptoms due to volume of tumours?
Conservative treatment to half cyst growth - invasive procedures are only required in severe cases (aspiration/ liver transplant)
What type of pharmacological therapy leads to a beneficial outcome in polycystic liver disease by relieving symptoms and reducing liver volume?
Somatostatin analogues
Clinical features of a liver access?
High fever Leukocytosis Abdominal pain Complex liver lesion History of abdo or biliary infection or dental procedure
Management of liver abscess?
Initial empiric broad spectrum antibiotics
Aspiration/ drainage percutaneously
Echocardiogram
Operation if no clinical improvement (open drainage/ resection)
4 week antibiotic therapy with repeat imaging
What is the most common primary liver cancer?
Hepatocellular carcinoma
Most important risk factor for hepatocellular carcinoma?
Cirrhosis of any cause
Most common symptoms of HCC?
Weight loss and RUQ pain (can be asymptomatic)
What is a tumour marker for HCC?
Alfa fetoprotein - values greater than 100ng/ml = highly susceptive of HCC
Treatment of HCC if a small tumour with no evidence of raised portal pressure?
Resection
Treatment of HCC if single tumour less than 5cm or less than 3 tumour less than 3cm each?
Liver transplant
Treatment of HCC if multiple tumour and evidence of dissemination?
Palliative, local ablation, chemoembolisaiton
Treatment of a non-resectable patient e.g. advanced liver cirrhosis?
Local ablation - alcohol injection, radio frequency ablation - temporary measure only
What is chemoembolisation?
TransArterial ChemoEmbolisation = inject chemo selectively into hepatic artery then inject an embolic agent (only for patients with early cirrhosis
What systemic therapy can be given for advanced HCC?
Sorafenib - multikinase inhibitor of vast endothelial gf receptor
What is the type of lung cancer that is often seen in young patients (5-35) and is not related to cirrhosis - also causes a normal AFP?
Firbo-Lamellar carcinoma
What is the standard treatment for Fibre-Lamellar carcinoma?
Surgical resection or transplantation
