Liver Flashcards
LIVER
What is true about the falciform ligament?
A) Embryologically important B) Divides R and L lobes of liver C) Bifurcation of CHD lies at the base D) Middle hepatic vein lies at the base E) First thing divided when performing a left lateral segmentectomy
A
Base or free edge contains round ligament = ligamentum teres. Contains obliterated unpaired umbilical veins. Brings blood from placenta to liver
LIVER
Worldwide, what is the most common cause of hepatocellular carcinoma
A) Clonorchis sinensis
B) Hepatitis B
C) OCP
D) Immunosuppression
B
LIVER
Patient presents with hepatic metastasis from colon cancer. Which is most favorable?
A) 6 month interval from colon cancer to liver metastasis
B) Satellite lesions around hepatic tumor
C) Extra hepatic tumor
D) Favorable stage of primary lesion
E) 2 mm margin around liver lesion
D
Fong Criteria
-Seven factors found to be significant and independent predictors of poor long term outcome by multivariate analysis: Postivie margin, Extrahepatic diseases, Node positive primary, Disease free interval from primary to mets < 12 months, # of hepatic tumors, Largest hepatic tumor > 5 cm, CEA >200
LIVER
After liver trauma, at the time of pack remove, which should you not do:
A) Debride necrotic tissue B) Ligate injured bile ducts C) Remove GB with a 2 cm stone D) Drain E) Remove and replace packs
C
LIVER–Rush
Which of the following statements about the anatomy of the liver is true?
A. R lobe extends to the umbilical fissure and falciform ligament
B. L lobe ends at the falciform ligament
C. Quadrate lobe is a portion of the medial segment of the R lobe
D. L lobe contains the anterior and lateral segments
E. The lateral segment of L lobe in the American system consists of segments II and III
E
Surgical anatomy is based on distribution of hepatic veins and portal structures
American and French system
Cantilies line = longitudinal plane that extends from gallbladder fossa to IVC
AKA Portal fissure, which contains middle hepatic veins and bifurcation of portal vein
American = liver broken down into 4 segments, each lobe containing 2 segments
R lobe = anterior and posterior
L lobe = medial (quadrate) and lateral divided by falciform
Caudate independent of R and L lobes b/c it receives portal and arterial supply from both sides and drains directly into IVC
French = two lobes are broken down into eight segments
Formed by three vertical planes (scissurae) created by R, middle and L hepatic veins
4 sectors are divided by a plane created by branching portal system
L lobe –> medial and lateral segments by L hepatic vein
-Lateral segment: Segment II and III
-Medial segment: Segment IV
R Lobe–> Anteromedial and posterolateral sectors divided by vertical plane containing R hepatic vein
-Anteromedial: Segment V and VIII
-Posterolateral: Segment VI and VII
LIVER– Rush
Which of the following statements is true about the hepatic arterial supply?
A. Aberrant hepatic arterial anatomy is present in <5% of all patients
B. Cystic artery is usually a branch off the proper hepatic artery
C. A “replaced” R hepatic artery arises from the SMA
D. The hepatic artery provides 75% of blood flow to the liver
E. The hepatic artery lies dorsal to the portal vein within the hepatic hilum
C
Hepatic artery supply normally derived from celiac axis by common hepatic artery, which becomes hepatic artery proper after giving off GDA branch and subsequently bifurcates into R and L hepatic branches
Hepatic artery lies ventral to the portal vein. Bile duct is lateral to hepatic artery.
Middle hepatic artery is usually a branch off the L hepatic artery and the cystic artery is a branch off the R hepatic artery. Variability in hepatic artery anatomy in up to 50% of patients. 15% R hepatic artery arises from SMA (replaced R hepatic artery) and found in R dorsal border of hepatoduodenal ligament. 10% L hepatic artery originates from L gastric and located in gastrohepatic ligament.
Arterial blood supply accounts for 25% of hepatic blood flow but 50% of oxygenated blood. Portal vein accounts for 75% of hepatic blood flow but 50% of oxygenated blood.
LIVER–Rush
Which of the following statements about the anatomy of the hepatic veins is true?
A. The left hepatic vein drains the entire L lobe
B. Veins from the caudate lobe enter the IVC directly
C. Middle hepatic vein usually drains into R hepatic vein
D. There are valves in the hepatic venous system
E. Hepatic veins have prominent hyperechoic walls on U/S
B
Hepatic veins begin in liver lobules as central veins that coalesce to form R, L and middle hepatic veins, which drain to IVC. Defined by three vertical scissurae
R vein–> largest, drains most of R lobe
L vein–> drains left lateral segment and a portion of the medial segment
Middle vein–> drains inferoanterior portion of right lobe and inferomedial segment of L lobe. Joins L hepatic vein in 80% and enters IVC in 20%
Human hepatic venous system has no valves.
Portal veins have prominent hyperechoic walls
LIVER–Rush
Which of the following statement is true about the portal vein?
A. It is formed by the junction of the IMV and splenic vein
B. It is the most dorsal structure in the hepatoduodenal ligament
C. Contains the valves of Mirizzi
D. R portal vein typically branches later than the L portal vein
E. Carries deoxygenated blood and provides only 10% of the liver’s oxygenation
B
Portal vein formed dorsal to pancreatic neck by junction of SMV and splenic vein. Ascends posterior to CBD and hepatic artery in hepatoduodenal ligament. Make up the portal triad.
No valves in the portal system.
Portal vein bifurcates just outside the liver. R portal vein has anterior and posterior branches that diverge only a short distance from bifurcation and quickly dive into liver parenchyma. L portal vein has a longer transverse portion (pars transversus) and then angulates anteriorly in the umbilical fissure (pars umbilicus), where it gives off medial branches to segment IV and lateral branches to segments II and III
Portal vein provides 75% hepatic blood flow and 50-70% of liver’s oxygenation
LIVER–Rush
Which of the following hepatic resections involves dissection in the plane of the falciform ligament or umbilical fissure?
A. R lobectomy B. R trisegmentectomy C. L lobectomy D. L lateral segmentectomy E. None of the above
E
Anatomic resection, non anatomic resection, enucleation procedures
Anatomic--> American or French R lobectomy: Seg V, VI, VII, VIII R trisegmentectomy: Seg IV, V, VI, VII, VIII L lobectomy: Seg II, III, IV L lateral segmentectomy: Seg II, III
Umbilical fissure is a segmental plane between the medial and lateral segments of L lobe of liver. Portion of L branch of portal vein known as pars umbilicus, runs in the inferior portion of the umbilical fissure
Dissection never carried out directly in segmental fissure. L lateral segmentectomy is L of fissure. R trisegmentectomy is to the R of the fissure
Liver–Rush
Which of the following characteristics is typically seen on U/S imaging of the hepatic portal vein branches?
A. Hyperechoic vessel walls B. Hepatofugal blood flow C. Diastolic reversal of blood flow D. Location between hepatic segments E. Vertical orientation
A
Portal vein and its branches have prominent hyperechoic walls. Attributed to accompanying intrahepatic branches of hepatic artery and bile duct, which are not seen individually on U/S. Transversely oriented and larger caliber centrally. Located within anatomic liver segments. Portal flow is toward the liver (hepatopedal). Flow is low velocity with minor undulations and continued forward flow during diastole. Horizontally oriented.
Hepatic veins appear “wall-less”. Anechoic or hypoechoic tubular structures. Vertically oriented and increase in caliber as they course to IVC. Found between segments. Flow is hepatofugal and varies according to cardiorespiratory cycle. Vertically oriented.
LIVER–Rush
40F arrives in ER complaining of RUQ pain. Vitals and labs are normal. U/S demonstrates a hyperechoic liver with a geographic hypoechoic area adjacent to gallbladder. What does this finding probably represent?
A. Duplication of the gallbladder B. Reverberation artifact C. Focal fatty sparing D. Hepatic abscess E. Bowel gas
C
Fatty infiltration of liver produces hyperechoic parenchymal pattern on U/S. Not unusual to have focal areas of fatty sparing within steatotic liver. Typically appear as zonal hypoechoic regions and are generally found adjacent to the gallbladder or anterior to the porta hepatis
Duplication of gallbladder is rare
Reverberation artifact are echoes within cystic structures.
Sonographic appearance of hepatic abscesses is variable, depending on cause and duration. Pyogenic abscesses are usually complex, with cystic characteristics and internal echoes caused by debris and septations.
Bowel gas is highly reflective and impedes U/S.
LIVER–Rush
Which of the following is true regarding the hepatic functional unit?
A. The center of the hepatic lobule is the portal triad
B. Blood flows from the hepatic vein to the portal triad
C. Zone III is the most susceptible to hypoxic injury
D. Hepatocytes in zone I have the lowest oxygen tension
E. Bile flows toward the centrilobular hepatic venule
C
Functional histologic unit of the liver is the acinus. At the center is the portal triad, which consists of a terminal branc of the portal vein (portal venule) along with a hepatic arterial and bile ductule. Blood from the terminal portal venule goes into the hepatic sinusoids, around which hepatocytes are located. Eventually, blood returns to central vein leading to the terminal hepatic venule at the periphery of the acinar unit
Hepatocytes of the acinus are divided into three zones. Zone I closest to afferent portal venule and zone III closest to efferent central hepatic venule. Zone II is between two points
Within the acinus, there is a gradient of solute concentration and oxygen tension that is greatest near the portal venule at the center of the acinus. Hepatocytes in Zone I are more exposed to oxygen and less subject to hypoxia than are hepatocytes in zone III. Explains histologic pattern of centrilobular necrosis following ischemia
Hepatic venule is at the center of the histologic hepatic lobule. Each hepatic lobule is surrounded by several peripheral acini. Bile is formed within the hepatocytes and empties into terminal canaliculi, which coalesce into bile ducts. Bile them flows toward portal triad
LIVER
Most common organisms for splenic and liver abscesses in immunocompromised?
A. Candida
B. Staph aureus
C. Klebsiella
D. Pseudomonas
A in answer key but maybe c?
Candida is most common in immunocompromised but not sure if it is the most common organism. Most common organisms are E. coli and Klesiella. Pseudomonas is most common in biliary malignancies
LIVER
How should a patient who had Dukes C cancer two years previously be followed for recurrence of liver mets?
A. Liver enzymes B. CEA C. US D. CT E. Radionuclide imaging
D
Dukes classification A Invades mucosa B Invades muscularis propria C Lymph node involvement D Metastatic disease
Follow up
-History and physical
Every 3-6 mo for 2 y, then every 6 mo for a total of 5 y
-CEA
Every 3-6 mo for 2 y, then every 6 mo for a total of 5 y
-Chest/abdominal/pelvic CT
Annually for up to 5 y for patients at high risk for recurrence
-Colonoscopy
In 1 y except if no preoperative colonoscopy due to obstructing lesion, colonoscopy in 3-6 mo
If advanced adenoma, repeat in 1 y
If no advanced adenoma, repeat in 3 y, then every 5 yv
-PET-CT scan is not routinely recommended
LIVER
During sigmoid resection, you find a lone 2.5 cm on the free edge of left lobe of the liver. What do you do?
A. Sigmoid resection and wedge of liver
B. Sigmoid resection and post op chemo
C. Sigmoid resection and delayed L lobectomy
D. Sigmoid resection and liver resection at 3 months
A
Resect liver prechemo if solitary and easy to do
Best option: sigmoid resection, post op chemo then liver resection
LIVER
Most common reason for liver transplant in children
A. Benign and malignant tumours B. Biliary sclerosis C. Billiary atresia D. Inborn errors of metabolism E. Post necrotic cirrhosis
C
Kasai hepatoportoenterostomy does not cure biliary atresia, which will progress in > 70% of infants who undergo procedure. Rate with which disease progresses, as evidenced by cirrhosis and portal HTN, is variable but may be expedited by recurrent cholangitis. 80% who have a Kasai procedure can live up to 10 years before transplant is needed. In infants who undergo transplant, outcomes are good with 10 year graft survival and overall survival at 73% and 86%
LIVER
Most common early complication of liver trauma
A. Sepsis
B. Bleeding
C. Liver failure
D. Resp failure
B
LIVER
Young female collapses at home while watching TV. In ER, US shows abdominal fluid and a liver lesion. Most likely dx
A. Adenoma
B. Hemorrhagic cyst
C. Hemangioma
D. FNH
A
Uncommon benign lesions associated with OCP. Associated with glycogen storage disease, diabetes, steroids, and pregnancy. Usually solitary but may be multifocal. Low potential for malignancy.
Adenomas are at higher risk of rupture and malignant transformation when > 5 cm
LIVER–Rush
Alkaline phosphatase is primarily located in which portion of the hepatocyte plasma membrane?
A. Sinusoidal membrane B. Basolateral membrane C. Canalicular membrane D. Basement membrane E. None of the above
C
Plasma membrane of hepatocyte has different regions with structures designed for different functions
Sinusoidal membrane–> borders perisinusoidal space of Disse, covered with microvilli which increase absorptive area and allow proteins, solutes and other substances to be transported across the hepatocyte
Basolateral membrane–> flat, connect adjacent hepatocytes and is important for attachment and cellular interactions
Canalicular membrane–> specialize in bile formation and transport of substances into bile, separated from pericellular space by tight junctions. Contains ALP and 5’ nucleotidase. Therefore high levels of ALP with extrahepatic duct obstruction
LIVER–Rush
During fasting, the liver provides energy substrates by all bunt which of the follow mechanisms?
A. Glycogenolysis B. Glycolysis C. Gluconeogenesis from alanine D. Gluconeogenesis from lactate E. Formation of ketone bodies from fatty acids
B
In fed state, glucose converted to glycogen for storage.
Liver obtains energy from keto acids rather than glucose, can use glycolysis during periods of glucose excess
During fasting, liver provides glucose by breakdown of stored glycogen (glycogenolysis). Glucose is critical to RBCs, CNS and kidneys. Glycogen stores depleted after 48 hrs, liver generates glucose from other sources like alanine, other amino acids, lactate and glycerol by gluconeogenesis. Lipolysis occurs during prolonged fasting and fatty acids releases from adipose stores are oxidized in hepatocytes to form ketone bodies, an important alternative fuel for brain and muscle
LIVER–Rush
The reticuloendothelial function of the liver is primarily dependent on which of the following cells?
A. Hepatocytes B. Kupffer cells C. Histiocytes D. Ito cells E. All of the above
RES functions to clear circulation of particulate matter and microbes. Consists of fixed phagocytize cells located primarily in liver, lung and spleen
Located along the lining of the hepatic sinusoids (along with sinusoidal epithelial cells), positioned to phagocytize and process gut antigens from sphlachnic and systemic circulation. Play a role in production and control of cytokines and inflammatory regulators.
Histiocytes are macrophages in connective tissue
Ito cells aka hepatic stellate cells are perisinusoidal cells involved in collagen and vitamin A metabolism
LIVER–Rush
Which of the following proteins is not primarily synthesized in the liver?
A. Albumin B. Fibrinogen C. von Willebrand factor D. Transferrin E. Factor VII
C
Liver is primary or sole source for numerous plasma proteins including, albumin, alpha globulins, and other transport proteins such as transferrin, hepatoglobulin, ferritin, ceruloplasmin
Eleven proteins involved in hemostasis are synthesized in the liver. Includes factor I (fibrinogen), the vitamin k dependent factors (II, VII, IX, X) and all of the procoagulation factors except von Willebrand factor (which is synthesized in vascular endothelial cells)
Because factor VII has the shorted half life (5-7 hrs), measurements of factor VII are useful for determining liver failure
Liver–Rush
The cytochrome p450 system transforms compounds by all of the following mechanisms except:
A. Oxidation B. Hydrolysis C. Conjugation D. Reduction E. Both A and C
C
Liver is responsible for biotransformation of many endogenous and exogenous substances. Detoxifies potentially injurious substances and facilitates elimination.
In some instances, hepatic biotransformation produces more toxic metabolites.
Two mechanics the liver accomplishes biotransformation: oxidation, reduction, and hydrolysis (phase I reactions) and conjugation (phase II).
Cytochrome p450 catalyzes phase I reactions.
Second mechanism involves an array of enzymes that conjugate substances with other endogenous molecules. Known as phase II. Converts hydrophobic substances into hydrophilic ones that are water soluble and can be eliminated in bile or urine
Liver is also principal site of conversion of ammonia to urea via the urea cycvia the, which is a separate process.
LIVER–Rush
The liver is integral in which of the following steps in vitamin D metabolism?
A. Intestinal absorption B. 1 Hydroxylation C. 25 Hydroxylation D. Formation of cholecalciferol E. Both A and C
Vitamin D is either produced in the skin when 7 dehydrocholesterol reacts with UV B light to form cholecalciferol or is ingested.
Liver is integral to metabolism of fat soluble vitamins (A, D, E, K). Requires fatty acid micellization for adequate intestinal absorption, which requires bile salts made in the liver
Liver also plays role in activation steps, 25 hydroxylation. It then undergoes 1 hydroxylation in the kidneys to arrive at its metabolically active form, which is important in the homeostasis of calcium and phosphate
Liver–Rush
In a patient with obstructive jaundice, which of the following enzymes is usually elevated?
A. ALP B. Leucine aminopeptidase C. GGT D. 5' Nucleotidase E. All of the above
E.
AST, ALT and LDH are indicators of integrity of the cell membrane and elevated levels reflect hepatocyte injury with leakage. Levels are usually mildly or moderately elevated in pure obstructive jaundice
ALP, 5’ nucleotidase, leucine aminopeptidase, and GGT reflect the excretory capacity of the liver. Levels are typically elevated in presence of extrahepatic biliary obstruction or intrahepatic cholestasis. Elevations also seen in patients with hepatic parenchymal disease or liver tumors
Transferrin and albumin levels decrease with liver disease b/c they reflect changes in liver function and nutritional status.
LIVER–Rush
Which of the following operative techniques limits blood loss during major hepatic resection?
A. Portal triad clamping
B. Normothermic total hepatic vascular isolation
C. Total hepatic vascular isolation with venovenous bypass
D. Anesthesia with low CVP
E. All of the above
E
Hemorrhage is a major hazard during division of hepatic parenchyma and life threatening hemorrhage is most commonly from hepatic veins.
Intraoperative technique to avoid this problem. Disadvantage of any vascular occlusion is potential for ischemic injury to the liver, particular in patients with underlying hepatocellular disease.
Occlusion of portal triad (Pringle) can be useful for limiting bleeding from hepatic artery and portal vein. Periods of occlusion should not exceed 20 mins.
Total hepatic vascular isolation requires occlusion of IVC above and below the liver, in addition to the Pringle maneuver. Can be complex and not well tolerated.
Venovenous bypass, which has been commonly used during liver transplant, a has also been applied to major hepatic resections at some centres.
Attempts to protect liver during vascular occlusion via local hepatic hypothermia or systemic steroids have not been successful.
Anesthesia with low CVP minimizes hepatic venous bleeding by fluid restriction, head down positioning, and vasodilator effects of anaesthetics. Low CVP during hepatic resection decreases need for perioperative blood transfusion. Has low rates of mortality and post operative renal compromise.
LIVER–Rush
Resection of hepatic metastasis has most clearly benefited patients with which of the following cancers?
A. Colon B. Breast C. Stomach D. Pancreas E. Lung
A
Resection of hepatic mets from CRC provides clear survival advantage over any other tx and should be performed when possible. 5 yr survival is 25% and as high as 40% in favourable subgroups.
Resection of metastatic neuroendocrine tumor (e.g. Carcinoid, insulinoma, gastrinoma) can be valuable fro controlling symptoms of excessive endocrine secretion
Hepatic resection for mets from portal sites (e.g. Stomach, pancreas and biliary) or nonportal sites (e.g. Lung, breast, melanoma, gyne,. H&N, and renal) has been more limited and results have not been as encouraging. Occasionally resection of isolated hepatic met is curative. However natural hx of noncolorectal primary is such that isolated mets to liver rarely develop.
Hepatic resection for direct, contiguous growth of the primary tumor (stomach and biliary) into liver sometimes produces long term survivors
LIVER–Rush
50F incidentally found to have a 4 cm hepatic cyst with no internal echoes on U/S. Which of the following would be the most appropriate management?
A. Observation of the cyst
B. Tamoxifen to prevent enlargement
C. Resection b/c of risk for hemorrhage
D. Percutaneous aspiration for cytologic study
E. MRI for further characterization of cyst
A
Simple, non parasitic hepatic cysts are presumed to be congenital. Single or multiple. More common in women. Usually asymptomatic. Absence of internal echoes is diagnostic of simple rather than complex cyst, a cystic neoplasm or solid lesion. No further intervention is indicated for asymptomatic liver cysts when diagnosis is certain on U/S, CT or MRI. If dx of simple cyst is made on U/S, no need for MRI. Complications such as hemorrhage or infection are rare. Not premalignant. Exogenous hormones are not recognized to be harmful, nor antihormonal therapy indicated.
Occasionally large cysts are symptomatic from local pressure, which may cause biliary obstruction. Tx is operative resection or unroofing. Open or laparoscopic. Percutaneous drainage or injection of alcohol or other sclerosing agents does not suffice and is not recommended. If cyst is found to communicate with bile ducts, either excision or Roux-en-y cystgastrostomy
LIVER–Rush
30M Hispanic man visiting from Mexico come to ER with a hx of 2 was of RUQ pain and tenderness, F/C, and diarrhea. He is febrile to 102.9. His HR and bp are 120 beats/min and 100/75 mm Hg. Lab results including a WBC of 16, AST 50 and ALT 93. U/S of abdo shows a 4x7 round, hypoechoic, non homogenous lesion with a smaller adjacent lesion measuring 2x2 cm. Which of the following is the most appropriate course of action?
A. Observation
B. Open surgical drainage
C. Broad spectrum abx and percutaneous drain
D. Serologic testing for Entameoba histolytica and oral flatly
E. Therapeutic FNA
Pyogenic and amebic liver abscess may present similarly with fever and pain
Pyogenic–> E. coli or other gram neg bacteria. Strep, anaerobes and Bacteroides. Most frequent source is contiguous infection in biliary tract (i.e. Cholangitis). Other sources include infectious foci within PV drainage system, direct extension from perihepatic sites, and hematogenous spread. R lobe most commonly affected (streaming effect from PV). ~20% are cryptogenic. Dx on clinical findings and hepatic imaging and may be confirmed by FNA. Tx usually requires operative drain or percutaneous approaches. Abx alone may suffice for multiple, small abscesses.
Amebic are cause by protozoan entamoeba histolytica which is spread feco-orally. Ingested cysts pass into intestines, where trophozoite is released and transmitted to colon. Invade colonic mucosa and reach liver via PV. In liver, results in liquefaction necrosis (anchovy paste). Usually Protozoa not isolated from abscess b/c they are located in peripheral rim of tissue. Dx requires hepatic imaging (U/s or CT) and serologic testing for E. histolytica antibodies, as well as Hx & Px. This patient is from an endemic region who has signs and symptoms of liver abscess. Lack of rim enhancement on imaging suggests dx of amebic abscess rather than pyogenic abscess. Hepatic amebiasis is rx with amebicidal drugs, which flagyl being the choice. Percutaneous aspiration may be indicated if does not respond to tx or dx is in question. Percutaneous or operative drainage is also indicated in the presence of secondary bacterial infection, which occurs in 10%
LIVER–Rush
50F complains of 4 month hx of RUQ pain and nausea. Her VS are stable and she is afebrile. Her physical exam is unremarkable except for hepatomegaly. U/S of the abdomen shows an 8 cm well circumscribed cyst with a rosette appearance. What is the preferred tx of this patient?
A. Pericystectomy B. Percutaneous catheter drainage C. Transperitoneal surgical drainage D. Metronidazole E. Albendazole
A
Echinococcus granulosus is responsible for most hydatid disease of the liver. Usually a unilocular process involving the R lobe, although may manifest as multiple cysts. Complications include intrabiliary, intraperitoneal, or intrapleural rupture, secondary infection, anaphylaxis and mass replacement of liver.
Calcified wall and can be dx serologically by indirect hemagglutination tests, complement fixation tests, serum immunoelectrophoresis and formerly the Casoni skin test
CT and U/S may demonstrate daughter cysts (hydatid sand) or granddaughter cysts (rosette appearance) within the cyst
Tx is primarily surgical. Percutaneous aspiration is contraindicated b.c of risk of intraperitoneal dissemination
Principles of surgical therapy are to avoid spillage and remove the entire germinal layer (pericyst). Resection is usually accomplished with pericystectomy. Anatomic hepatic resection is not generally required but may be used. Surgery in addition to preop and postop benzimadole has been shown to be effective
20% of echinococcal cysts exhibit biliary communication, assessment by pre-op ERCP or intraop cholangiography is important in any patient with jaundice, cholangitis, elevated liver enzymes or bile noted during resection. Scolicidal agents should be used with caution b/c of risk of sclerosing the bile ducts in the event the agent finds its way into the biliary system.
LIVER–Rush
28 y.o. asymptomatic, white woman is incidentally found to have a 3.5 cm hypervascular lesion with a central scar in the right lobe of her liver On delayed images, there is increased uptake of contrast in the scar in comparison with surrounding liver parenchyma. She is healthy and takes no meds. Liver enzyme and AFP are within normal limits. Which of the following is the most appropriate management of this patient?
A. Open Liver Resection B. Open Surgical Therapy C. Observation D. Chemoradiation E. Hepatic Artery Embolization
C
Patient has focal nodular hyperplasia which is often found incidentally on imaging or during laparotomy. Benign liver tumor that predominantly occurs in women in 30-50s.
Similar to hepatic adenoma with important differentiating clinical and histologic features as well as therapeutic indications. Both occur most commonly in women of childbearing age, however HA is assoc with OCP, anabolic steroids and glycogen storage diseases. HA is usually symptomatic (80%) and is assoc w/rupture and bleeding in a substantial portion of patients whereas FNH is asymptomatic and found incidentally. HA has potential for malignant transformation, whereas the risk of malignancy in FNH is unlikely but uncertain. Histologically, HA consists of hepatocytes without bile ducts or Kupffer cells. FNH contains Kupffer cells along with a central stellate scar surrounded by fibrous tissue. Scanning for Kupffer cell activity with technetium 99m labeled soulful colloid is useful in differentiating the lesions.
B/c of asymptomatic nature of this patient, small size and negligible risk for malignant transformation, observation is appropriate. Surgical resection is reserved for symptomatic patients or when dx is uncertain
