Focal Liver Lesions

Question 1

A solid liver lesion in older patients in the absence of liver disease is most likely to be?

Answer 1

A malignant metastases

Question 2

A solid liver lesion in chronic liver disease patients is most likely to be?

Answer 2

Primary liver cancer

Question 3

What is the most common solid liver tumour in non cirrhotic patients?

Answer 3

Haemangioma

Question 4

What are the four kinds of benign liver tumours?

Answer 4

Haemangioma
Focal nodular hyperplasia
Adenoma
Liver cysts

Question 5

What are the two types of malignant liver tumours?

Answer 5

Primary liver cancers

Metastases

Question 6

What are the three kinds of primary liver cancer?

Answer 6

Hepatocellular carcinoma
Fibrolamelar carcinoma
Hepatoblastoma

Question 7

What are the clinical features of Haemangioma?

Answer 7

More common in females 
Hypervascular tumour 
Usually single small 
Well demarcated capsule
Usually asymptomatic

Question 8

How do you diagnose a Haemangioma?

Answer 8

Ultrasound = Echogenic spot, well demarcated 
CT = venous enhancement from periphery to centre 
MRI = High intensity area

Question 9

What is the treatment for Haemangioma?

Answer 9

None needed

Benign incidental fining which does not go on to develop into anything else

Question 10

What are the clinical features of Focal Nodular Hyperplasia?

Answer 10

Benign nodule foramen of normal liver tissue
Congenital vascular abnormality
Classically appears as a central scare contain a large artery with branches radiating to the periphery
Hyper plastic response to abnormal arterial flow
More common in young and middle age women
Usually asymptomatic, may cause minimal pain

Question 11

What would you see on histology of Focal Nodular Hyperplasia?

Answer 11

Sinusoids, bile ductules and Kupffer cells present

Question 12

How do you diagnose Focal Nodular Hyperplasia?

Answer 12

US = Nodule with varying echogenicty 
CT = Hypervascular mass with central scar 
MRI = Iso- or hypo- intense 
FNA = Normal hepatocytes and Kupffer cells with central core

Question 13

What is the treatment of Focal Nodular Hyperplasia?

Answer 13

None needed

Question 14

What are the clinical features of Hepatic Adenoma?

Answer 14

Benign neoplasm composed of normal hepatocytes with NO portal tract, central vein or bile ducts
More common in women
Associated with contraceptive hormones
Usually asymptomatic, with possible RUQ pain
rarely presents with rupture, haemorhhage or very rarely malignant transformation

Question 15

In which part of the liver are most Hepatic Adenomas found?

Answer 15

Right lobe

Question 16

What is a Hepatic Adenoma?

Answer 16

Most are solitary fat containing lesions

Question 17

What is Adenomatosis?

Answer 17

A rare condition of multiple adenomas associated with Glycogen Storage Disease

Question 18

How does use of OC contribute to Hepatic Adenomas?

Answer 18

Risk related to duration of use
The oestrogen component causes the adenoma
Regression can occur on stopping the OC

Question 19

How do you diagnose Hepatic Adenoma?

Answer 19

US = Filling defect
CT = Diffuse arterial enhancement 
MRI = Hypo or hyper intense lesion

Question 20

What is the treatment for Hepatic Adenomas?

Answer 20

Stop hormone
Observe every 6m for 2y
If no regression, then surgical excision

Question 21

What types of cyclic lesions can occur?

Answer 21

Simple
Hydatid 
Atypical
Polycystic 
Pyogenic or amoebic

Question 22

What are the clinical features of a simple cyst?

Answer 22

Liquid collection lined by epithelium
No biliary tree communication
Solitary and uniloculated

Question 23

What are the symptoms of a simple cyst?

Answer 23

Mostly asymptomatic 
Symptoms can be related to:
Intracystic haemorrhage 
Infection 
Rupture (rare)
Compression on adjacent structures

Question 24

How do you manage a simple cyst?

Answer 24

No follow up necessary
If in doubt, imaging in 3-6 months
If symptomatic, consider surgical intervention

Question 25

What is the cause of a Hydatid Cyst?

Answer 25

Echinoccocus granulosus | TAPEWORM

Question 26

How might a patient with a Hydatid Cyst present?

Answer 26

Disseminated disease | erosion of cysts into adjacent structures and vessels

Question 27

How do you diagnose a Hydatid Cyst?

Answer 27

History Appearance Serological testing detection of anti-Echinococcus antibodies

Question 28

What treatment is available for Hydatid Cysts?

Answer 28

Surgery = Conservative or Radical Medical = Albendazole Percutaneous Drainage = PAIR

Question 29

What types of surgery are available to treat Hydatid Cysts?

Answer 29

Conservative = Open cystectomy Marsupialisation Radical = Pericystectomy Lobectomy

Question 30

What risks are associated with Hydatid Cysts?

Answer 30

Operative morbidity Anaphylaxis Dissemination of infection

Question 31

What is Polycystic Liver Disease?

Answer 31

Embryonic ductal plate malformation of the intrahepatic biliary tree Numerous cysts throughout liver parenchyma

Question 32

What are the three types of Polycystic Liver Disease?

Answer 32

Von Meyenburg Complexes Polycystic Liver Disease (PCLD) Autosomal Dominant Polcystic Kidney Disease (ADPKD)

Question 33

What are Von Meyenburg Complexes?

Answer 33

Microhamartomas = Benign cystic nodules thought the liver Cystic bile duct malformations, originating in the peripheral biliary tree Remnants develop into small hepatic cysts and usually remain silent during life

Question 34

What are the differences between PCLD ad ADPKD?

Answer 34

PCLD = Liver function preserved and renal failure rare Symptoms depend on cyst size ADPKD = Potential massive liver enlargement Renal failure, extra hepatic features (e.g. hypertension, cardiac valve abnormalities, abdominal aneurysms) are common

Question 35

What is the management for Politic Liver Disease?

Answer 35

Conservative treatment to halt cyst growth and alleviate symptoms Invasive procedures generally only needed in associate liver failure or cirrhosis Pharmacological therapy with somatostatin may aid symptom relief

Question 36

What are the clinical features of a liver abscess?

Answer 36

High fever Leukocytosis Abdominal pain Complex liver lesion

Question 37

What may be found in the history of someone with a liver abscess?

Answer 37

Abdominal or biliary infection | Dental procedure

Question 38

What is the management for a liver abscess?

Answer 38

Initial empire broad spectrum antibiotics Aspiration/drainage percutaneously Echocardiogram to look for signs of endocarditis 4 weeks antibiotic therapy with repeat imaging Operation if no improvement (open drainage or resection)

Question 39

What is the most important risk factor for Hepatocellular Carcinoma?

Answer 39

Cirrhosis (from any cause)

Question 40

What are the clinical features of Hepatocellular Carcinoma?

Answer 40

``` Weight loss RUQ pain Asymptomatic Worsening of pre-existing chronic liver disease Acute liver failure ```

Question 41

What may be seen on examination of a patient with Hepatocellular Carcinoma?

Answer 41

Signs of cirrhosis Hard enlarged RUQ mass Liver bruit (rare)

Question 42

What are the metatastic sites for Hepatocellular Carcinoma?

Answer 42

``` Rest of liver Portal vein Lymph nodes Lung Bone Brain ```

Question 43

Which tests might you run to diagnose Hepatocellular Carcinoma?

Answer 43

Labs of lier cirrhosis | Alpha Fetoprotein - HCC tumour marker (secreted by tumours)

Question 44

How do you diagnose Hepatocellular Carcinoma?

Answer 44

``` Clinical presentation Elevated AFP US Triphasic CT scan = very early arterial perfusion MRI Biopsy ```

Question 45

Which factors contribute to the prognosis of Hepatocellular Carcinoma?

Answer 45

Tumour size Extrahepatic spread Underlying liver disease Pt performance status

Question 46

How is liver transplantation used in treatment of Hepatocellular Carcinoma?

Answer 46

Removes tumour and liver | Only if one single tumour

Question 47

How is resection used in the treatment of Hepatocellular Carcinoma?

Answer 47

Feasible for small tumours with preserved liver function (no jaundice or portal hypertension) High recurrence rate

Question 48

How is local ablation used in the treatment of Hepatocellular Carcinoma?

Answer 48

For non resectable patients, or those with advanced liver cirrhosis Alcohol injection or radiofrequency ablation Temporary measure only

Question 49

How is chemoembolisation used in the treatment of Hepatocellular Carcinoma?

Answer 49

Reserved for patients with well preserved liver function | Inject chemotherapy selectively in hepatic artery, then inject embolic agent - Tumour dies of ischaemic necrosis

Question 50

What systemic therapies can be used in the treatment of Hepatocelular Carcinoma?

Answer 50

Sorafenib = | Survival advantage in advanced HCC, but common GI side effects

Question 51

When does Fibre-Lemellar Carcinoma commonly present?

Answer 51

Young patients (5-35)

Question 52

What are the clinical features of Fibre-Lamellar Carcinoma?

Answer 52

Unrelated to cirrhosis AFP is normal CT = Typical stellate scar with radial septa showing persistent enhancement

Question 53

What is the treatment for Fibre-Lamellar Carcinoma?

Answer 53

Surgical resection to transplantation is standard | TACE for patients with unresectable tumour

Question 54

What are the common primaries for secondary liver metastases?

Answer 54

``` Colon Breast Lung Stomach Pancreas Melanoma ```

Question 55

What are the clinical features of Secondary Liver Metastases?

Answer 55

Mild cholestatic picture (raised ALP) with preserved liver function May present with jaundice or weight loss

Question 56

How do you diagnose Secondary Liver Metastases?

Answer 56

Imaging | FNA

Question 57

What is the treatment for Secondary Liver Metastases?

Answer 57

Dependent on primary carcinoma | In some cases, resection or chemoembolisation is possible