Focal lesions in the liver Flashcards
what are solid liver lesions in older patients more likely to be?
= malignant with mets more common than primary liver cancer in the absence of liver disease
what are solid liver lesions in chronic liver disease patients more likely to be?
= primary liver cancer than mets or benign tumours
in non-cirrhotic patients, what is the most common solid liver tumour?
= haemangioma
what are the 2 classification of tumours in liver?
1) benign
2) malignant
give examples of benign tumours in the liver?
- haemangioma
- focal nodular hyperplasia
- adenoma
- liver cysts
give examples of malignant tumours in liver?
1) primary liver cancers
- hepatocellular carcinoma
- cholangiocarcinoma
= fibrolamellar carcinoma
= hepatobalstoma
(angiosarcoma and haemangioendothelioma)
2) metastases
who is more likely to acquire haemangioma - males/females?
females > males
what type of tumour is haemangioma?
= hyper-vascular tumour
describe the usual appearance of haemangioma?
- single small
- well demarcated capsule
describe the clinical features of haemangioma?
= asymptomatic
how would you diagnose a haemangioma?
- ultrasound
= echogenic spot - CT
= venous enhancements from periphery two centre - MRI
= high intensity area - no need for FNA
how would you treat hameangioma?
= no need for treatment
what is focal nodular hyperplasia (FNH)?
= benign nodule formation of normal liver tissue
what is focal nodular hyperplasia associated with?
= congenital vascular anomaly: associated with Osler-weber- Rendu and liver haemangioma
describe the classic appearance focal nodular hyperplasia?
- central sac conning large artery, radiating branches to periphery
why does hyperplasia occur in FNH?
= occurs in response to abnormal arterial flow
what is present histologically in FNH?
- sinusoids
- bile ductules
- Kupffer cells
who is FNH more common in?
young, middle aged women
describe the symptoms of FNH?
- asymptotic, may cause minimal pain
how do you diagnose FNH?
- 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
how do you treat FNH?
- no treat necessary
- pregnancy and hormones no change required
what are hepatic adenomas?
= benign neoplasms composed of normal hepatocytes NO portal tract, central veins or bile ducts
who is more likely to get hepatic adenomas?
= women
what is hepatic adenoma associated with?
- contraceptive hormones
- anabolic steroids
describe symptoms of hepatic adenoma?
- asymptomatic
- but you can get right upper quadrant pain
what may people with hepatic adenomas present with?
- rupture
- haemorrhage
- malignant transformation (risk higher in males)
what life are hepatic adenomas more common in?
= right lobe
what is associated with multiple adenomas (adenomatosis)?
= glycogen storage disease
how do you diagnose hepatic adenomas?
- US: Filling defect
- CT: Diffuse arterial enhancement
- MRI: Hypo or hyper intense lesion
- FNA: May be needed
how do you treat hepatic adenomas?
- 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
describe the difference between adenoma and focal nodular hyperplasia?
Adenoma
- hyper vascular
- hepatocyte tumour, cold on nuclear sulphur colloid scan
- maybe pain/bleeding
FNH
- hyper vascular
- contains all liver US including RES and bile ductules (isointense on sulfur colloid scan)
- maybe pain
- central scar
- no malignant risk
- minimal bleeding risk
what is a simple cyst?
= liquid collection lined by an epithelium
- no biliary tree communication
- solitary and uniloculated
are simple cysts symptomatic?
- usually NO
if there are symptoms, what are they related to?
- intra- cystic haemorrhage
- infection
- rupture
- compression
how do you manage simple cyss?
- no follow up required
- if doubt = imaging in 3-6months
- if symptomatic or uncertain diagnosis, then consider surgery
what are hydatid cysts?
= echinoccoccus granulosus
what may patients with hydatid cysts present with?
- disseminated disease
- erosion of cysts into adjacent structures and vessels
how is hydatid cysts diagnosed?
- history, appearance and serological testing detection an anti-echinnococcus antibody
how do you manage a hydatid cyst?
- Surgery: = Conservative: Open cystectomy, Marsupialization
= Radical: Pericystectomy, lobectomy
Medical: Albendazole
Percutaneous Drainage: PAIR
what are the risks of surgery of hydatid cyst?
- Operative morbidity
- anaphylaxis
- disseminaion of infection
what is polycystic liver disease?
= embryonic ductal plate malformation of intra-hepatic biliary tree
- numerous cysts through liver parenchyma
what are the 3 types if polycystic liver disease?
- Von Meyenburg complexes (VMC)
- Polycystic Liver disease (PCLD)
- Autosomal dominant Polycystic Kidney disease
(ADPKD)
what are VMC?
= benign cystic nodules through liver
- cystic bile duct malformations, origination from peripheral biliary tree
- remnants develop into small hepatic cysts and remain silent during life
describe PCLD?
- liver function preserved, renal failure rare
- symptoms depend on size of cyst
- PCLD gene = PRKCSH and SEC63
describe ADPKD?
= renal failure due to polycystic kidneys and non-renal extra hepatic features
- potential massive hepatic enlargement
- ADPKD genes - PKD1 and PKD2
how do you manage polycystic liver disease?
In advanced PCLD, ADPKD or liver failure;
= defenestration/aspiration
= liver transplantation
what pharmacological therapy is used for polycystic liver disease?
= somastatin analogues
- symptom relief and liver volume reduction
what are features that come along with liver abscess?
- high fever
- leukocytosis
- complex liver lesions
what are 2 key things to gleam in a history of liver abscess?
- abdominal or biliary infection
- dental procedure
how do you manage liver abscess?
- empiric broad spectrum antibiotics
(4 weeks of therapy) - aspiration /drainage percutaneously
- echocardiogram
- operation if no clinical improvement;
= open drainage
= resection
what is the most common primary liver cancer (malignant) and who is more likely to get it?
hepato-cellular carcinoma (HCC)
= men
what are risk factors for developing HCC?
= cirrhosis from any cause;
- hep B
- hep C
- alcohol
- aflatoxin
what are clinical features of HCC?
- weight loss
- right upper quadrant pain
- asymptomatic
- worsening pre-existing chronic liver disease
- acute liver failure
- signs of cirrhosis
- hard enlarged RUQ mass
- liver bruit
where can HCC metastasise?
- rest of liver
- portal vein
- lymph nodes
- brain
- bone
- lung
describe the lab tests of HCC?
- AFP (alfa fetoprotein) is a HCC tumour marker
values >100ng/ml suggestive of HCC
how do you diagnose HCC?
- presentation
- elevated AFP
- US
- triphasic CT scan: early arterial perfusion
- MRI
- biopsy
if HCC is stage O how would you treat it?
= resection
if HCC is early stage A, single tumour or 3nodules how would you treat it?
- liver transplantation
- percutaneous ethanol injection or radio-frequuency ablation
if HCC is intermediate sage , multi-lobular, PST O, how would you treat it?
= trans-arterial chemoembolisation
if HCC is advanced Stage C, portal invasion, N1, M1, PST 1-2, how would you treat it?
= sorafenib
how would you treat end stag D HCC?
= symptomatic treatment
- mean survival is < 3months
what is the best available treatment for HCC?
=liver transplant
- removes liver and liver
- can only be done if tumour is < 5cm or less than 3 tumours less than 3cm each
when is HCC resection feasible?
= for small tumours With preserved liver function (no jaundice or portal HTN)
when is HCC local ablation used?
- for non resectable patients
- for patients with advanced liver cirrhosis
- alcohol injection
what is TACE?
= trans-arterial chemo embolisation
what happens in TACE of HCC?
= chemo is injected selectively into hepatic artery
- then inject an embolism agent
who is allowed to receive TACE?
= only in patients with early cirrhosis
when are systemic therapies like sorafenib used?
= for advanced HCC thats is evolving
what is sorafenib?
= a multi-kinase inhibitor of vascular endothelial growth factor receptor, platelet derived growth receptor and Raf
who presents with fribo-lamellar carcinoma?
= young patients
- not related to cirrhosis
is AFP normal or raised in fibro-lamellar carcinoma?
= normal
what would a CT of fibro-lamellar carcinoma show?
= stellate scar with radial septa showing persistent. enhancement
how do you treat fibro-lamellar carcinoma?
= surgical resection or transplantation
how would you treat unresectable fibre-lamellar carcinomas?
= TACE
what are common sites of secondary liver mets?
- colon
- breast
- lung
- stomach
- pancreas
- melanoma
describe the ALP and live function in liver mets?
= mild cholestatic picture (ALP) with preserved liver function
how do you diagnose secondary liver mets?
- Dx imaging
- FNA
what is treatment of secondary liver mets dependent on?
= primary cancer
what could be possible in some cases with secondary liver mets?
- resection
- chemo-embolisation
