Focal Liver Lesions Flashcards
A solid liver lesion in older patients in the absence of liver disease is most likely to be?
A malignant metastases
A solid liver lesion in chronic liver disease patients is most likely to be?
Primary liver cancer
What is the most common solid liver tumour in non cirrhotic patients?
Haemangioma
What are the four kinds of benign liver tumours?
Haemangioma
Focal nodular hyperplasia
Adenoma
Liver cysts
What are the two types of malignant liver tumours?
Primary liver cancers
Metastases
What are the three kinds of primary liver cancer?
Hepatocellular carcinoma
Fibrolamelar carcinoma
Hepatoblastoma
What are the clinical features of Haemangioma?
More common in females Hypervascular tumour Usually single small Well demarcated capsule Usually asymptomatic
How do you diagnose a Haemangioma?
Ultrasound = Echogenic spot, well demarcated CT = venous enhancement from periphery to centre MRI = High intensity area
What is the treatment for Haemangioma?
None needed
Benign incidental fining which does not go on to develop into anything else
What are the clinical features of Focal Nodular Hyperplasia?
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
What would you see on histology of Focal Nodular Hyperplasia?
Sinusoids, bile ductules and Kupffer cells present
How do you diagnose Focal Nodular Hyperplasia?
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
What is the treatment of Focal Nodular Hyperplasia?
None needed
What are the clinical features of Hepatic Adenoma?
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
In which part of the liver are most Hepatic Adenomas found?
Right lobe
What is a Hepatic Adenoma?
Most are solitary fat containing lesions
What is Adenomatosis?
A rare condition of multiple adenomas associated with Glycogen Storage Disease
How does use of OC contribute to Hepatic Adenomas?
Risk related to duration of use
The oestrogen component causes the adenoma
Regression can occur on stopping the OC
How do you diagnose Hepatic Adenoma?
US = Filling defect CT = Diffuse arterial enhancement MRI = Hypo or hyper intense lesion
What is the treatment for Hepatic Adenomas?
Stop hormone
Observe every 6m for 2y
If no regression, then surgical excision
What types of cyclic lesions can occur?
Simple Hydatid Atypical Polycystic Pyogenic or amoebic
What are the clinical features of a simple cyst?
Liquid collection lined by epithelium
No biliary tree communication
Solitary and uniloculated
What are the symptoms of a simple cyst?
Mostly asymptomatic Symptoms can be related to: Intracystic haemorrhage Infection Rupture (rare) Compression on adjacent structures
How do you manage a simple cyst?
No follow up necessary
If in doubt, imaging in 3-6 months
If symptomatic, consider surgical intervention
What is the cause of a Hydatid Cyst?
Echinoccocus granulosus
TAPEWORM
How might a patient with a Hydatid Cyst present?
Disseminated disease
erosion of cysts into adjacent structures and vessels
How do you diagnose a Hydatid Cyst?
History
Appearance
Serological testing detection of anti-Echinococcus antibodies
What treatment is available for Hydatid Cysts?
Surgery = Conservative or Radical
Medical = Albendazole
Percutaneous Drainage = PAIR
What types of surgery are available to treat Hydatid Cysts?
Conservative =
Open cystectomy
Marsupialisation
Radical =
Pericystectomy
Lobectomy
What risks are associated with Hydatid Cysts?
Operative morbidity
Anaphylaxis
Dissemination of infection
What is Polycystic Liver Disease?
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
Polycystic Liver Disease (PCLD)
Autosomal Dominant Polcystic Kidney Disease (ADPKD)
What are Von Meyenburg Complexes?
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
What are the differences between PCLD ad ADPKD?
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
What is the management for Politic Liver Disease?
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
What are the clinical features of a liver abscess?
High fever
Leukocytosis
Abdominal pain
Complex liver lesion
What may be found in the history of someone with a liver abscess?
Abdominal or biliary infection
Dental procedure
What is the management for a liver abscess?
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)
What is the most important risk factor for Hepatocellular Carcinoma?
Cirrhosis (from any cause)
What are the clinical features of Hepatocellular Carcinoma?
Weight loss RUQ pain Asymptomatic Worsening of pre-existing chronic liver disease Acute liver failure
What may be seen on examination of a patient with Hepatocellular Carcinoma?
Signs of cirrhosis
Hard enlarged RUQ mass
Liver bruit (rare)
What are the metatastic sites for Hepatocellular Carcinoma?
Rest of liver Portal vein Lymph nodes Lung Bone Brain
Which tests might you run to diagnose Hepatocellular Carcinoma?
Labs of lier cirrhosis
Alpha Fetoprotein - HCC tumour marker (secreted by tumours)
How do you diagnose Hepatocellular Carcinoma?
Clinical presentation Elevated AFP US Triphasic CT scan = very early arterial perfusion MRI Biopsy
Which factors contribute to the prognosis of Hepatocellular Carcinoma?
Tumour size
Extrahepatic spread
Underlying liver disease
Pt performance status
How is liver transplantation used in treatment of Hepatocellular Carcinoma?
Removes tumour and liver
Only if one single tumour
How is resection used in the treatment of Hepatocellular Carcinoma?
Feasible for small tumours with preserved liver function (no jaundice or portal hypertension)
High recurrence rate
How is local ablation used in the treatment of Hepatocellular Carcinoma?
For non resectable patients, or those with advanced liver cirrhosis
Alcohol injection or radiofrequency ablation
Temporary measure only
How is chemoembolisation used in the treatment of Hepatocellular Carcinoma?
Reserved for patients with well preserved liver function
Inject chemotherapy selectively in hepatic artery, then inject embolic agent - Tumour dies of ischaemic necrosis
What systemic therapies can be used in the treatment of Hepatocelular Carcinoma?
Sorafenib =
Survival advantage in advanced HCC, but common GI side effects
When does Fibre-Lemellar Carcinoma commonly present?
Young patients (5-35)
What are the clinical features of Fibre-Lamellar Carcinoma?
Unrelated to cirrhosis
AFP is normal
CT = Typical stellate scar with radial septa showing persistent enhancement
What is the treatment for Fibre-Lamellar Carcinoma?
Surgical resection to transplantation is standard
TACE for patients with unresectable tumour
What are the common primaries for secondary liver metastases?
Colon Breast Lung Stomach Pancreas Melanoma
What are the clinical features of Secondary Liver Metastases?
Mild cholestatic picture (raised ALP) with preserved liver function
May present with jaundice or weight loss
How do you diagnose Secondary Liver Metastases?
Imaging
FNA
What is the treatment for Secondary Liver Metastases?
Dependent on primary carcinoma
In some cases, resection or chemoembolisation is possible
