Focal Lesions in the liver Flashcards
In non cirrhotic patients what is the most common solid liver tumour?
haemangioma
Name some benign liver lesions?
Haemangioma
Focal nodular hyperplasia
Adenoma
Liver cysts
Name some malignant liver lesions?
- Primary liver cancers
- Hepatocellular carcinoma
- Cholangiocarcinoma
Fibrolamellar carcinoma
Hepatoblastoma
Angioscarcoma
Haemangioendothelioma - Metastases
How is Haemangioma diagnosed and treated?
US: echogenic spot, well demarcated
CT: venous enhancement from periphery to center
MRI: high intensity area
NO TREATMENT REQUIRED
more common in females
Describe Focal Nodular Hyperplasia (FNH) ?
Hyperplastic response to abnormal arterial flow
Sinusoids, bile ductules and Kupffer cells present on histology – normal liver tissue
More common in young and middle age women
Usually asymptomatic, may cause minimal pain
How is Focal Nodular Hyperplasia (FNH) diagnosed and treated?
US: Nodule with varying echogenicity
CT: Hypervascular mass with central scar
MRI: Iso or hypo intense
FNA: Normal hepatocytes and Kupffer cells with central core
NO TREATMENT REQUIRED
What are the features of Hepatic Adenomas?
Benign neoplasm composed of normal hepatocytes no portal tract, central veins or bile ducts
More common in women
Associated with contraceptive pill hormones and anabolic steroids
Usually asymptomatic but may have RUQ pain
May present with rupture, hemorrhage, or malignant transformation (very rare)
Malignant transformation risk higher in males
What are multiple adenomas associated with?
Glycogen Storage Diseases
What are the diagnostic methods for hepatic adenoma?
US: Filling defect
CT: Diffuse arterial enhancement
MRI: Hypo or hyper intense lesion
FNA: May be needed
What are the treatments for hepatic adenoma?
Stop hormones, weight loss
Males (irrespective of size) : surgical excision
Females : imaging after 6months
<5cm or reducing in size - annual MRI
>5cm or increase in size - for surgical excision
What are the clinical features of the simple cyst?
Liquid collection lined by an epithelium No biliary tree communication Solitary and uniloculated Most of the time asymptomatic Symptoms can be related to Intracystic haemorrhage Infection Rupture (rare) Compression
What is the management of a simple cyst?
No follow up usually needed
If doubt, imaging in 3-6 months
If symptomatic or uncertain diagnosis (complex cystic lesion), then consider surgical intervention
Describe the features of a Hydatid Cyst ?
Echinoccocus granulosus
Patients may present with disseminated disease, or erosion of cysts into adjacent structures and vessels (IVC)
Comes from regions like east europe, central and south america etc..
What is the diagnostic procedures for a Hydatid Cyst?
history
appearance
serologic testing-detection of anti-Echinococcus antibodies
What is the management for a Hydatid Cyst?
Surgery:
Most common
Conservative:
Open cystectomy, Marsupialization
Radical:
Pericystectomy, lobectomy
Risks: Operative morbidity, anaphylaxis, dissemination of
infection
Medical: Albendazole
Percutaneous Drainage: PAIR
What is Polycystic Liver Disease (PLD)?
Embryonic ductal plate malformation of the intrahepatic biliary tree
Numerous cysts throughout liver parenchyma
What are the three types of Polycystic Liver Disease?
Von Meyenburg complexes (VMC)
Polycystic Liver disease
Autosomal dominant Polycystic Kidney disease
What are Von Meyenburg complexes (VMC) ?
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
Describe autosomal dominant polycystic kidney disease (ADPKD)?
Renal failure due to polycystic kidneys and non-renal extra-hepatic features are common in ADPKD
ADPKD genes – PKD1 and PKD2
Describe Polycystic liver disease (PCLD)?
Liver function preserved
Sometimes renal failure
PCLD gene – PRKCSH and SEC63
What is the management of Polycystic liver disease?
Conservative treatment - to halt cyst growth to allow abdominal decompression and ameliorate symptoms
Invasive procedures are required only in selective patient group with advanced PCLD, ADPKD or liver failure
- Defenestration/aspiration
- Liver transplantation
What is the Clincial presentation of Polycystic liver disease?
abdominal pain
abdominal distension
atypical symptoms due to voluminous cysts resulting in compression of adjacent tissue or failure of the affected organ
What is the typical clinical presentation of liver abscesses?
High fever Leukocytosis – high white cell Abdominal Pain Complex liver lesion History of: – Abdominal or biliary infection – Dental procedure
What is the management of liver abscesses?
Initial empiric broad spectrum antibiotics
Aspiration/drainage percutaneously
Echocardiogram
Operation if no clinical improvement:
- Open drainage
- Resection
4 weeks antibiotic therapy with repeat imaging
What is the most common malignant liver tumour?
Hepatocellular carcinoma (HCC)
What are the risk factors for HCC?
The most important risk factor is cirrhosis from any cause: Hepatitis B (integrates in DNA) Hepatitis C Alcohol Aflatoxin
What are the signs and symptoms of HCC?
Wt loss and RUQ pain (most common)
Asymptomatic
Worsening of pre-existing chronic liver disease
Acute liver failure
O/E:
Signs of cirrhosis
Hard enlarged RUQ mass
Liver bruit (rare)
What is an HCC tumour marker?
AFP (Alfa fetoprotein)
Values > 100ng/ml highly suggestive of HCC
How is HCC diagnosed?
Clinical presentation Elevated AFP US Triphasic CT scan: very early arterial perfusion MRI Biopsy
What is the best management of HCC?
liver transplant
only if single tumour less than 5cm or less than 3 tumours less than 3cm each
Apart from tansplant, what are the other ways of managing HCC?
Resection - feasible for small tumours with preserved liver function
(no jaundice or portal HTN)
Local ablation - for non resectable patients
For patients with advanced liver cirrhosis
Alcohol injection
Radiofrequency ablation
Temporary measure only
Chemoembolization -
TransArterial ChemoEmbolization - TACE
Inject chemotherapy selectively in hepatic artery
Then inject an embolic agent
Only in patients with early cirrhosis
What are the characteristics of Fibro-Lamellar Carcinoma?
Presents in young pt (5-35)
AFP is normal
CT shows typical stellate scar with radial septa showing persistent enhancement
Surgical resection or transplantation is the standard of care for fibrolamellar carcinoma
TACE for patients with unresectable tumour
What are the most common sites of primaries for secondary liver metasteses?
colon, breast, lung, stomach, pancreas and melanoma
