Focal Lesions in the Liver Flashcards
What are the benign focal lesions in the liver?
Haemangioma
Focal nodular hyperplasia
Adenoma
Liver cysts
What are the malignant focal lesions in the liver?
1. Primary liver cancers: Hepatocellular carcinoma Cholangiocarcinoma - Fibrolamellar carcinoma - Hepatoblastoma, inc. angiosarcoma and haemangioendothelioma
- Metastases from elsewhere
How common are haemangiomas?
Commonest liver tumour, with prevalence being higher in females
Features of haemangiomas?
Usually a single, small hypervascular tumour that is contained in a well-demarcated capsule; they are usually asymptomatic
Hypervascular refers to the high conc. of blood vessels, enabling rapid growth
Diagnostic methods of haemangiomas?
Ultrasound shows an echogenic spot that is well-demarcated
CT scan shows venous enhancement, from periphery to centre
MRI scan shows a high intensity area
There is no need for FNA (Fine Needle Aspiration - biopsy)
How are haemangiomas treated?
No need for treatment
What is Focal Nodular Hyperplasia (FNH)?
Benign nodule formation of normal liver tissue; there is a hyperplastic response to abnormal arterial flow
It can occur as a congenital vascular anomaly and has an assoc. with Osler-Weber-Rendu syndrome (autosomal dominant genetic disorder that leads to abnormal blood vessel formation) and with liver haemangiomas
Appearance of FNH?
Classically, a central scar containing a large artery, with branches radiating to the periphery
Histology of FNH?
Sinusoids, bile ductules and Kupffer cells are all present; they contain all the liver ultrastructure (they are isotense on sulfur colloid scan)
How common is FNH and what are the symptoms?
More common in young and middle-aged women; there is no relation to sex hormones
Usually asymptomatic but can cause minimal pain; there is minimal bleeding risk
Diagnosis of FNH?
Ultrasound shows a nodule with varying echogenecity
CT scan shows a hypervascular mass with a central scar
MRI scan shows iso/hypo intense
FNA shows normal hepatocytes and Kupffer cells with a central core
Treatment of FNH?
No treatment necessary, inc. in pregnancy and with hormones
What is a hepatic adenoma?
Benign neoplasm composed of normal HEPATOCYTES, with NO portal tract, central veins or bile duct (cold on nuclear sulfur colloid scan)
They usually occur in the right lobe
How common are hepatic adenomas?
More common in women and assoc. with contraceptive hormones and androgenic steroids (related to duration of use)
Multiple adenomas (adenomatosis) is rare and usually assoc. with glycogen storage disease
Symptoms of hepatic adenoma?
Usually asymptomatic (often an incidental finding) but may have RUQ pain and bleeding (size-related)
Presentation may be with rupture, haemorrhage or malignant transformation (rare)
Diagnosis of hepatic adenomas?
Ultrasound will show a filling defect
CT scan shows diffuse arterial enhancement
MRI scan shows hypo/hyper intense lesion
FNA may be needed
Treatment of hepatic adenomas?
Stop hormones and observe every 6 months for 2 years; if there is no regression, surgical excision is required
Males requires immediate resection, due to higher risk of malignant transformation
5 types of cystic lesions?
Simple Hydatid Atypical Polycystic Pyogenic or amoebic abscess
What is a simple cyst?
Collection of liquid lined by an epithelium; there is no biliary tree communication and they tend to be solitary, unilocular cysts
Symptoms of simple cyst?
Usually asymptomatic but symptoms can be related to: Intracystic haemorrhage Infection Rupture (rare) Compression
Management of simple cysts?
No follow-up necessary but, if there is doubt, image in 3-6 months
If asymptomatic or uncertain diagnosis (complex cystic lesion), consider surgical intervention
What is a hydatid cyst?
Cyst caused by Echinococcus granulosus (tapeworm parasite)
How common are hydatid cysts?
Endemic regions are eastern Europe, central and south America, Middle East and North Africa
Presentation of hydatid cyst?
May present with disseminated disease or erosion of cysts into adjacent structure and vessels, e.g: IVC
Diagnosis of hydatid cyst?
Appearance and history
Serological testing for anti-Echinococcus antibodies
Management of hydatid cysts?
Surgery is most common:
Conservative - open cystectomy or marsupialization (opening and drainage of cyst)
Radical - pericystectomy or lobectomy
Medications used inc. Albendazole (parasitic infection)
Percutaneous drainage
Risks of hydatid cyst surgery?
Operative morbidity
Anaphylaxis or dissemination of infection
What is polycystic liver disease?
Embryonic ductal plate malformation of the intrahepatic biliary tree, resulting in numerous cysts throughout the liver parenchyma
3 types of polycystic liver disease?
Von Meyenburg complexes (VMC) - not germ-line genetically driven
Polycystic liver disease
Autosomal dominant polycystic kidney disease
What occurs in VMC?
Von Meyenburg complexes (microhamartomas) are benign cystic nodules throughout the liver
There are cystic bile duct malformations, originating from the peripheral biliary tree, and remnants develop into small hepatic cysts (usually remain silent in life)
Comparison of polycystic liver disease (PCLD) and autosomal dominant polycystic kidney disease (ADPKD)?
PCLD:
Liver function is preserved (renal failure is rare)
Symptoms depend on size of cysts
PCLD gene, part. PRKCSH and SEC63
ADPKD:
Renal failure due to PCLD and non-renal, extra-hepatic features are common
Potential massive hepatomegaly
ADPKD genes, part. PKD1 and PKD2
Symptoms of PCLD?
Abdominal pain and distension
Atypical symptoms occur due to voluminous cysts causing compression of adjacent tissue/failure of affected organ
Management of PCLD?
Conservative treatment to halt cyst growth (allowing abdominal decompression and to ameliorate symptoms)
Rarely, invasive procedures are required in advanced PCLD, ADPKD or liver failure:
Defenestration/aspiration
Liver transplantation
Somatostatin analogues have beneficial effects with symptoms relief and liver volume reduction
Clinical features of a liver abscess?
High fever, abdominal pain and chronic malaise
Leukocytosis
Complex liver lesion
History may inc. abdominal/biliary infection, dental procedures or ERCP
Management of liver abscesses?
Initially, empirical broad-spectrum antibiotics are used
Aspiration/percutaenous drainage; if no improvement, open drainage or resection
4 weeks of antibiotic therapy and repeated imaging
Risk factors for hepatocellular carcinoma?
CIRRHOSIS, due to any cause: Hep B and C Alcohol Aflatoxin Other
Clinical features of HCC?
May be assymptomatic
Weight loss, RUQ pain and hard, enlarged RUQ mass
Liver bruit (rare)
Worsening of pre-existing chronic liver disease and acute liver failure
Where can HCC metastasis to?
Rest of the liver and portal vein
Lymph nodes
Lung
Bone
Brain
What is alfa fetoprotein (AFP)?
A HCC tumour marker, with values >100ng/ml being highly suggestive of HCC; elevation is seen in most patients
Howeve, this level tends to only be seen in those who are no longer candidates for curative therapy
Diagnosis of HCC?
Elevated AFP
Ultrasound
Triphasic CT scan can show very early arterial perfusion
MRI
Biopsy
Therapeutic pathways for different HCC patients?
If the single tumour is small + no evidence of portal hypertension or raised bilirubin, resection
If there are assoc. diseases or 3 nodules
When is liver transplantation used?
Best treatment as it removes tumour and the liver and recurrence rate is low; this is only done if the tumour is
When is resection used?
For small tumours with preserved LFTs, no jaundice and no portal hypertension
Recurrence rate is high
When is local, radiofrequency ablation used?
For non-resectable tumours or for those with advanced liver cirrhosis; this is TEMPORARY measure only
Can be used in conjunction with ethanol injections
What is transarterial chemoembolisation (TACE)?
Inject of chemotherapy selectively into the hepatic artery, followed by injection of an embolic agent
When is TACE used?
Only used in patients with early cirrhosis and it has no role in systemic chemotherapy
What is Sorafenib?
Multi-kinase inhibitor of vascular endothelial gf receptor, platelet-serived growth factor receptor and of Raf
Increases survival, minimally
How common is fibrolamellar carcinoma?
Presents in young patients (5-35 years) and is unrelated to cirrhosis
Diagnosis of fibro-lamellar carcinoma?
AFP is normal
CT scan shows a typical, STELLATE SCAR with radial septa showing perisistent enhancement
Treatment of fibro-lamellar carcinoma?
Surgical resection/transplantation is the standard of care
For patients with an unresectable tumour, TACE
Primary cancers that can metastasis to the liver?
Most common site for blood-borne metastases: Colon Breast Lung Stomach Pancreas Melanoma
Diagnosis of secondary liver metastases?
Dx imaging or FNA
Management of secondary liver metastases?
Treatment depends on the primary cancer
Sometimes, resection of chemoembolisation is possible
