Focal Lesions in the Liver

Question 1

solid liver lesions

Answer 1

older patients = malignant with metastases

chronic liver disease = primary liver cancer

non cirrhotic patients = haemangioma

Question 2

benign

Answer 2

haemangioma
focal nodular hyperplasia
adenoma
liver cysts

Question 3

malignant

Answer 3

primary liver cancers - hepatocellular carcinoma, cholangiocarcinoma

metastases

Question 4

haemangioma

Answer 4

female>males

commonest liver tumour
hypervascualr
usually asymptmatic

Question 5

haemangioma - diagnosis

Answer 5

US - echogenic spot
CT - venous enhancement from periphery to centre
MRI - high intensity area
no need for FNA

Question 6

haemangioma - treatment

Answer 6

no need for treatment

Question 7

focal nodular hyperplasia (FNH)

Answer 7

benign nodule formation of normal liver tissue

congenital vascular anomaly - associated with Osler-weber-rendu and liver haemangioma

central scar containing a large artery, radiating branches to the periphery

hyperplastic response to abnormal arterial flow

sinusoids, bile ductules and kupffer cells present on histology

minimal pain

Question 8

focal nodular hyperplasia (FNH) - diagnosis

Answer 8

US - nodule with varying echogenicity
CT - hyper vascular mass with central scar
MRI - iso or hypo intense
FNA - normal hepatocytes and kupffer cells with central core

Question 9

focal nodular hyperplasia (FNH) - treatment

Answer 9

no treatment necessary

Question 10

hepatic adenoma

Answer 10

benign neoplasm composed of normal hepatocytes no portal tract, central veins or bile ducts

female>male
associated with contraceptive hormones

RUQ pain

rupture, haemorrhage or malignant transformation

transformation risk higher in males

Question 11

hepatic adenoma - diagnosis

Answer 11

US - filling defect
CT - diffuse arterial enhancement
MRI - hypo or hyper intense lesion
FNA - may be needed

Question 12

hepatic adenoma - treatment

Answer 12

stop hormones, weight loss

surgical excision

imaging after 6 months

Question 13

simple cyst

Answer 13

liquid collection lined by an epithelium
no biliary tree communication

solitary and uniloculated

asymptomatic

intracystic haemorrhage, infection, rupture, compression

Question 14

simple cyst - management

Answer 14

no follow up necessary
doubt = image in 3-6months

surgical intervention

Question 15

hydatid cyst

Answer 15

echinoccocus granulosus

endemic regions - Eastern Europe, central america, South America, Middle East and North Africa

disseminated disease or erosion of cyst into adjacent structures and vessels

Question 16

hydatid cyst - diagnosis

Answer 16

detection of anti-echinoccus antibodies

Question 17

hydatid cyst - mangement

Answer 17

surgery
conservative
radical
risks

medical = albendazole

percutaneous drainage

Question 18

polycystic liver disease

Answer 18

embryonic ductal plate malformation of the intrahepatic biliary tree

numerous cysts throughout liver parenchyma

Von meyenburg complexes (VMC)

polycystic liver disease

autosomal dominant polycystic kidney disease

Question 19

Von meyenburg complexes (VMC)

Answer 19

benign cystic nodules throughout the liver

cystic bile duct malformations, originating form the peripheral biliary tree

remanants develop into small hepatic cysts and usually remain silent during life

not gremlin genetically driven

incidental finding

Question 20

polycystic liver disease

Answer 20

liver function preserved renal failure rare

symptoms = size dependent

PPKCSH and SEC63

Question 21

autosomal dominant polycystic kidney disease

Answer 21

renal failure due to polycystic kidneys and non-renal extra-hepatic features are common in ADPKD

potential massive hepatic enlargement

PKD1 and PKD2

Question 22

liver abscess

Answer 22

high fever
leukocytosis
abdominal pain
complex liver lesion

history
abdominal or biliary infection
dental procedure

Question 23

liver abscess - management

Answer 23

initial empiric broad spectrum antibiotics

aspiration/drainage percutaneously

echocardiogram

operation if no clinical improvement

4 weeks antibiotic therapy with repeat imaging

Question 24

hepatocellular carcinoma (HCC)

Answer 24

most common primary liver cancer
men>female

risk factor = cirrhosis

Question 25

hepatocellular carcinoma (HCC)

Answer 25

weight loss and RUQ pain

asymptomatic

worsening of pre-exisiting chronic liver disease
acute liver failure

signs of cirrhosis
hard enlarger RUQ mass
liver bruit

Question 26

hepatocellular carcinoma (HCC) - labs

Answer 26

AFP (alpha fetoprotein)
>100mg/ml
elevation seen in 60-80%

Question 27

hepatocellular carcinoma (HCC) - diagnosis

Answer 27

presentation
elevated AFP
US
triphasic CT scan - very early arterial perfusion 
MRI
biopsy

Question 28

hepatocellular carcinoma (HCC) - prognosis

Answer 28

tumour size

extrahepatic spread

underlying liver disease and patient performance

Question 29

hepatocellular carcinoma (HCC) - LIVER TRANSPLANTATION

Answer 29

best available treatment

removes tumour and liver

only if single tumour less than 5cm or less than 3 tumours less than 3 cm each

recurrence rate is low

Question 30

hepatocellular carcinoma (HCC) - RESECTION

Answer 30

feasible for small tumours with preserved liver function (no jaundice or portal HTN)

recurrence rate is high

Question 31

hepatocellular carcinoma (HCC) - LOCAL ABLATION

Answer 31

for non resectable

advanced liver cirrhosis

alcohol injection
radio-frequency ablation

temporary measure only

Question 32

hepatocellular carcinoma (HCC) - chemoembolization

Answer 32

TransArterialChemoEmbolization
TACE

inject chemotherapy selectively in hepatic artery

inject an embolic agent

only in patients with early cirrhosis

no role for systemic chemotherapy

Question 33

fibro-lamellar carinoma

Answer 33

presents in young patients

not related to cirrhosis

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

Question 34

secondary liver metastases

Answer 34

common site for blood born metastases

mild cholestatic picture (ALP) with preserved liver function

Dx imaging for FNA

treatmetn depends on the primary cancer

resection or chemoebolization is possible