Hepatology - Liver tumours Flashcards
What are the most common types of liver tumours?
The most common malignant tumours are metastatic, particularly those from the gastrointestinal tract, breast and bronchus. Primary liver tumours may be benign or malignant (HCC being the most common). Liver cysts and haemangiomas are common and may be confused with tumours on initial imaging, they usually need no further treatment.
What is the aetiology of hepatocellular carcinoma (HCC)?
Majority of HCCs occur in patients with chronic liver disease or cirrhosis (present in 75-90% of cases), particularly due to viral hepatitis. Other aetiological factors include aflatoxin (a metabolite of fungus found in groundnuts), androgenic steroids and possibly the contraceptive pill.
What are the clinical features associated with HCC?
Weight loss, anorexia, fever, ascites, and abdominal pain occur. The rapid development of symptoms in a patient with cirrhosis is highly suggestive of HCC. Because of surveillance HCC is being found increasingly in asymptomatic patients with known cirrhosis. A focal lesion in the liver in a patient with cirrhosis is highly likely to be HCC.
How should I investigate suspected HCC?
Serum AFP may be raised but is normal in at least a third of patients.
US or CT scanning shows large filling defects in 90% of cases.
MRI or angiography is useful in cases where there is diagnostic uncertainty.
Biopsy is only performed when there is diagnostic uncertainty, as there is a risk of tumour seeding in the percutaneous needle biopsy tract. For instance, in a patient with cirrhosis and a liver mass greater than 2cm in diameter, the lesion is almost certainly HCC and biopsy is not indicated.
How should I manage HCC?
Surgical resection or liver transplantation is occasionally possible. Hepatic resection is the treatment of choice for non cirrhotic patients, but recurrence rates are high. Transplantation in the presence of cirrhosis removes oth the cirrhosis and the tumour.
Percutaneous ablative therapies using ethanol injection or high frequency US probes will produce necrosis of the tumour. Transarterial chemoembolization involves the injection of a chemotherapeutic agent and Lipiodol into the hepatic artery. It is used in the treatment of unresectable tumours. Chemotherapy given intravenously has a very limited role.
What is the prognosis of HCC?
Median survival is only 6-12 months.
What is fibrolamellar hepatocellular carcinoma?
This rare variant occurs in young adults, in the absence of hepatitis B infection and cirrhosis. The tumours are often large at presentation and the AFP is usually normal. Treatment is by surgical resection.
What is the most common benign tumour of the liver?
Cavernous haemangioma
Best diagnosed with enhanced CT
Rare cause of intraperitoneal haemorrhage
Causes include:
- OCPs
- Anabolic steroids
- Von Gierke glycogenolysis
