Focal lesions in the liver Flashcards
What are are solid liver lesions in older patients likely to be?
Malignant, with metastases more common than primary liver cancer
What are solid liver lesions in patients with chronic liver disease (cirrhosis or active Hep B) likely to be?
Primary liver cancer than metastases or benign tumours
What are solid liver lesions in non cirrhotic patients likely to be?
Heamangioma
What are the benign focal lesions of the liver?
Haemangioma
Focal nodular hyperplasia
Adenoma
Liver cysts
What are the malignant focal leisons of the liver?
Primary liver cancer: hepatocellular carcinoma, cholangiocarcinoma (fibrolamellar carcinoma, heptpblastoma)
Metasatses
What are the clinical features of a haemanagioma?
Commonest liver tumour
Hypervascular tumour
Usually single and small in a well demarcarted capsule
Usually asymptomatic
How is a haemangioma diagnosed?
US: echogenic spot, well demarcated
CT: venous enhancement from periphery to center
MRI: high intensity area
What is the treatment for a haemangioma?
No need for treatment
What are the clinical features of focal nodular hyperplasia?
Benign nodule formation of normal liver tissue
Congenital vascular anomaly; associated with osler-weber-rendu and liver haemangioma
What does it classically look like?
Central scar containing a large artery, radiating branches to the periphery
Hyperplastic response to abnormal arterial flow
What does a focal nodular hyperplasia look like histologically?
Sinudoids, bile ductules and Kupffer cells
Who is FNH likely to affect?
Young and middle aged woman but has no relation with sex hormones
How is FNH diagnosed?
US: nodule with varying echogenicity
CT: hypervascualr mass with central scar
MRI: Iso or hypo intense
FNA: normal hepatocytes and kupffer cells with central core
What is the treatment for FNH?
No treatment necessary
What are the clinical features of a hepatic adenoma?
Benign neoplasm composed of normal hepatocytes with no portal tract, central veins or bile ducts
Who is hepatic adenoma likely to affect?
More common in women and is associated with OC
What can hepatic adenomas present with?
Usually asymptomatic but may have RUQ pain
May present with rupture, hemorrhage or malignant transformation
What lobe are hepatic adenomas likely to be found in?
Usually in the right lobe
How are hepatic adenomas diagnosed?
US: filling defect
CT: diffuse arterial enhancement
MRI: Hypo or hyper intense lesion
FNA: May be needed
How are hepatic adenomas treated?
Stop hormones (OC or anaebolic steroids)
Males - surgical excision
Females - imagin after 6 months
What is the difference between adenomas and FNH?
FNH has no malignant risk whereas adenomas do
Adenomas can cause pain and bleed
FNH contains all the lvier ultrastructures whereas adenomas are made up purely of hepatocytes
What are the clinical features of simple cysts?
Liquid collection lined by an epithelium
No biliary tree communication
Solitary and unilocaulated
Most of the time asymptomatic
What can symtoms of a simple cyst be related to?
Intracystic haemorrhage
Infection
Rupture
Compression
How are simple cysts managed?
No FU necessary
If in doubt, image in 3-6 months
If symptomatic then consider drainage
What are the clinical features of a hydatid cytst?
Echinoccocus granulosus
Present with disseminated disaese or erosion of cysts into adjacent structures and vessels (IVC)
What is the clinical diagnosis of a hydatid cyst based on?
History, appearance, and serological testing detection of enti-echinococcus antibodies
How are hydatis cytsts managed?
Surgery: open cystectomy, lobectomy
Medical: albendazole
Percutaenous drainage
What is polycystic liver disease?
Embryonic ductal plate malformation of the intraheaptic biliary tree
Numerous cycsts thorughout the liver parenchyma
What are the three different types of polycystic liver disease?
Von meyenburg complexes
Polycystic liver disease
Austosomal dominant polycystic kidney disease
What are von meyenburg complexes?
Benign cystic nodules throughout the liver
Cystic bile duct malformation, originating from the peripheral biliary tree
Remnants develop into small hepatic cysts and usually remain silent
What are the features of polycystic liver disease?
Liver function preserved and renal failure is rare
Symptoms depend on size of cysts
What are the features of autosomal dominant polycystic kidney disease?
Renal failure due to polycystic kidneys and non-renal extra-hepatic features
Potential massivae hepatic enlargement
How is polycystic liver disease managed?
Conservative treatment to halt cyst growth to allow abdo decompression
invasive procedures only required with advanced disaese
Pharma treatment with somatostatin analogues for symtom relief and liver volume reduction
What are the symptoms of polycystic liver disease?
Abdo pain
Abdo distention
Atypical symtoms of voluminous cysts resulting in compression of adjacent tissue or failure of the affected organ
What are the clinical features of a liver abscess?
High fever
Leukocytosis
Abdo pain
Complex liver lesion
What will the history look like in liver abscess?
Abdo or biliary infection
Dental procedure
How are liver abscesses managed?
Initial emperic broad spectrum antibiotics
Aspiration/ drainage percutaneously
Echocardiogram
Operation if no clinical improvement: open drainage, reseciton
4 week antibiotic therapy with repeat imaging
What is the most common primary liver cancer?
Hepatocellular carcinoma
What are the risk factors for hepatocellular carcinoma?
Cirrhosis from any cause:
Hep B, Hep C, Alcohol, Aflatoxin
What are the clinical features of HCC?
Wt loss and RUQ pain Worsening of pre-existing chronic liver disease Acute liver failure Signs of cirrhosis Hard enlarged RUQ mass Liver bruit (rare)
Where are HCC likely to metastases to?
Rest of the liver Portal vein Lymph nodes Lung Bone Brain
What labs should be done to confirm the diagnosis fo HCC?
AFP - HCC tumour marker, values over 100ng/ml
Labs of liver cirrhosis
How is HCC diagnosed?
Clinical presentation Elevated AFP US Triphasic CT MRI Biopsy
How is the prognosis determined for HCC?
Tumour size
Extrahepatic spread
Underlying disease
Pt performance status
What is the best available treatment for HCC?
Liver transplantation
Resection for small tumours with preserves liver function (no jaundice of portal HTN)
What else can be done to treat HCC?
Radio-frequency ablation
Chemoembolization - inject chemo into hepatic artery, then inject an emoblic agent
Sorafenib
What are the features of a fibro-lamellar carcinoma?
Presents in younger patients
Not related to cirrhosis
AFP normal
What are the CT findings of a fibro-lamellar carcinoma?
Stellate scar with radial septa showing persistent enhancement
What is the standard of care for fibro-lamellar carcinoma?
Surgical resection or transplantation
What are common primaries that metastasise to the liver?
Colon, breast, lung, stomach, pancreas, melanoma
