Diagnosis and mangement of liver masses in pregnancy TOG 2016

Question 1

How common are benign liver masses in general population?

Answer 1

20%
Mostly liver cysts

Question 2

What is 1st line imaging for liver mass in pregnancy, what is its sensitivity?

Answer 2

Non contrast USS
>90%

Question 3

What is 2nd line for investigating liver mass in pregnancy?

Answer 3

MRI liver with gadolinium contrast

Question 4

What bloods test can and cannot be used in pregnancy to investigate a liver mass?

Answer 4

Can use
- LFT, bilirubin, Alk Phos, ALT, Y-GT, LDH
- Viral serology (Hep B & C, a1-antitrypsin, wilsons, autoantibody screen)

Cannot use tumour markers
CA19-9 and CEA

Question 5

Can liver biopsy be performed?

Answer 5

Generally not advised due to risk bleeding and seeding of cancer.

Can be performed for tissue Dx of cancer if no easier alternative methods

Question 6

If liver mass is highly suspicious of cancer how to stage?

Answer 6

Staging MRI chest/abdo/pelvis

Can help indicate if primary or secondary

Question 7

What are the main types of malignant liver masses?

Answer 7

Primary - hepatocellular carcinoma, cholangiocarcinoma

Secondary

Question 8

What is the most common benign tumour of the liver?

Answer 8

Hepatic haemangioma
2-20%

Question 9

Describe hepatic haemoangioma

Answer 9

Slow growing
Oestrogen receptor - accelerated growth pregnancy and OCP.
Well circumscribed/hyperechoic, can grow up to 20cm
Risk of bleeding

Question 10

Management of hepatic haemangioma?

Answer 10

<5cm monitor
Intervention delayed until postpartum - embolisation, surgical enucleation/resection

Question 11

What is the 2nd most common bengin liver lesion? Who is it most common in?

Answer 11

Focal nodular hyperplasia
3% adults
80-90% cases in females in reproductive years

Question 12

Describe focal nodular hyperplasia

Answer 12

78% solitary nodule
84% around 5cm but can be as big as 15cm
Hypoechoic/isoechoic mass with mental stellate scar radiating peripherally, well circumsized

Very rare risk of rupture, no malignant transformation.

Question 13

Management of focal nodular hyperplasia

Answer 13

Interval radiological assessment, stability of the lesion

Question 14

Are hepatic adenomas common? Who are they most commonly identified in?

Answer 14

Rare
Young females with Hx OCP use.
1-1.3/100,000 not used OCP 30-40/100,00 used OCP

Question 15

Describe hepatic adenomas

Answer 15

Solitary 32%
Multiple (2-9) 45%
Adenomatosis (10+) 23%
Average 8cm, up to 30cm

High vascular, think walled
High risk of rupture: lifetime risk haemorrhage 27%, rupture 15%. Greatest risk >10cm.
Highest risk 3rd trimester
Risk malignant transformation 4-10%

Question 16

Management of hepatic adenoma

Answer 16

Non preg: Elective surgical resection if >5cm
Stop OCP

Can consider surgery in pregnancy if high risk of haemorrhage

Question 17

If known hepatic lesion, what should be considered pre-pregnancy?

Answer 17

Discuss with obstetrician and hepatic surgeon.

Question 18

What is the preferred management of acute hepatic haemorrhage in pregnancy?

Answer 18

Interventional radiology

Question 19

Which lesion greatest risk of rupture?

Answer 19

hepatic adenomas