Liver lesions (benign and malignant) Flashcards
You find a solid liver lesion in an older patient without liver disease. What is the most likely cause?
Malignant metastasis from elsewhere in the body.
You find a solid liver lesion in a chronic liver disease patient (cirrhosis or active hep B). What is the most likely cause>
Primary liver cancer
You find a solid liver tumour in a non cirrhotic young patient. WHat is the cause?
Haemangioma- benign
What is a hepatoma?
Cancer of the liver
Why are liver lesions a common clinical problem and why can this cause anxiety?
All cirrhotic patients are screened for hepatomas.
Imaging for abdo pain or abnormal LFT’s
Imaging for respiratory problems
Body scanning for health checks.
ALL can pick up an INCIDENTAL lesion in the liver but most are benign and asymptomatic but cause cancer anxiety.
What percentage of the population have a focal liver lesion?
5-10%
Most are benign
What are the 4 types of benign liver lesion?
Haemangioma
Focal Nodular Hyperplasia
Adenoma
Liver cysts
What are the types of primary liver cancers?
Hepatocellular carcinoma
Cholangiocarcinoma (Fibrolamellar carcinoma, Hepatoblastoma (Angiosarcoma and Haemangioendothilioma))
What is the most common benign liver tumour?
Haemangioma.
Found in 5% of autopsies
Female > Male
What are the characteristics of haemangioma?
Hypervascular tumour
Usually singular and small
Well demarcated capsule
Asymptomatic
How is a Haemangioma diagnosed?
USS: echogenic spot and well demarkated
CT; Venous enhancement from periphery to center
MRI: High intensity area
NO biopsy needed
What is the treatment for Haemangioma?
No treatment
What are the characteristics of Focal Nodular Hyperplasia?
Benign nodule formation of normal liver tissue.
Central scar with radiating branches to periphery (hub and spoke)
Hyperplastic response to abnormal arterial flow
What congenital vascular anomalies are associted with Focal Nodular Hyperplasia?
Osler-Weber-Rendu
Liver haemangioma
(in 20% of cases)
What cells are seen at histology with focal nodular hyperplasia?
All liver cells- sinusoids, Bile ductules and Kupffer cells
In which demographic is focal nodular hyperplasia most common?
Young and middle aged women but NO association with sex hormones or pill
How is focal nodular hyperplasia diagnosed?
USS: nodule with varying echogenicity
CT: Hypervascular mass with central scar- light up
MRI: Iso or hypo intense
Biopsy: normal hepatocytes and Kupffer cells with central core.
What treatment is for focal nodular hyperplasia?
No treatment required
What are the characteristics of hepatic adenomas?
Benign neoplam compossed of ONLY normal hepatocytes (no portal tract, cental veins or bile ducts)
Solitary fat containing lesion
Which benign lesion is associated with malignant transformation which is more common in males?
Hepatic adenoma
Which benign liver lesion is associated with sex hormones?
Hepatic adenoma.
Contraceptive pill and anabolic steroids.
In which demographic is hepatic adenoma most common and where is the most common site?
Most common in women 10:1
Mostly found in the right liver lobe
How does hepatic adenoma present?
Usually asymptomatic May have RUQ pain or present with rupture, haemorrhage or malignant transformation (rare)
Adenomatosis is the state of multiple adenomas, what is this associated with?
Glycogen storage disease
Risk of adenomas is associted with duration of oral contraceptive use (described with just 6 months use) Does regression occur after discontinuation?
Yes
How is Hepatic adenoma diagnosed?
USS: Filling defect
CT: Diffuse arterial enhancement
MRI: Hypo or hyper intense lesion
Biopsy may be required.
What is the treatment for Hepatic adenoma?
Stop hormone therapy (Pill or anabolic steroids)
Male: surgical excision
Females: Imaging every 6 months. (<5cm or reducing in size => annual MRI. >5cm or increasing in size => surgical excision)
How can you tell the difference between an adenoma and focal nodular hyperplasia using a nuclear sulphur colloid scan?
Adenoma- cold as only hepatocyte tumour
FNH- isointense due to bile duncts and vasculature
What are the 5 types of liver cyst?
Simple, Hydatid, Atypical, Polycystic lesion, Pyogenic or amoebic abscess
How are cystic lesions diagnosed?
UUS- fluid containing
What is a simple cyst?
Liquid collection lined by epithelium with no billary tree communication
Most simple cysts are asymptomatic but if they are symptomatic, what are the symptoms related to?
Intracystic haemorrhage, Infection, rupture, compression (usually small but can grow to 25cm)
How is a simple cyst managed?
No follow up needed. If in doubt reimage in 3-6 months
If symptomatic then consider surgical intervention (open drainage or aspiration)
What is the cause of a Hydatid cyst?
Echinococcus granulosus. (Tape worm)
Endemic in Eastern Europe, central and south americs, middle east and north africa
How do Hydatid cysts present?
Disseminated disease, erosion o cysts into adjacent structures or vessels IVC.
How is a hydatid cyst diagnosed?
History, appearance and serological testing for anti echinocuccus antibodies
How is a hydatid cyst treated?
Surgery: Conservative = open cystectomy, marsupialisation Radical = Pericystectmy or lobectomy Medical: Albendazole Percutanious drainage
What is polycystic liver disease?
Embryonic ductal plate malformation of the intrahepatic biliary tree. Numerous cysts in liver parenchyma. 3 types.
What are the 3 types of polycyctic liver disease?
1) Von Meyenburg Complexes
2) Polycystic liver diease
3) Autosomal dominant polycystic Kidney disease
Describe Von Meyenburg complexes?
Benign cystic nodules throughout the liver
Cystic bile duct malformations originating the peripheral biliary tree.
Remnants develop into small hepatic cysts
What is the treatment for Von Meyenburg complexes?
No treatment, incidental finding, no genetically driven
What are the characteristics of Polycystic liver disease and what are the associated genes?
Liver function preserved and renal failure rare. Symptoms depend of size of cyst. PCLD gene (PRKCSH and SEC63)
What are the characteristics of Autosomal dominant polycystic kidney disease and what are the associated genes?
Renal failure due to polycystic kidneys
Non renal extra hepatic features
Massive hepatic enlargement
ADPKD genes (PKD1 and PKD2)
Most PCLD and ADPKD are managed conservatively to halt cyst growth and allow abdominal decompression. WHen are invasive procedures required and what are these?
Advanced PCLD or ADPKD or liver failure
Aspiration or liver +/- kidney transplant.
What is the effect of therapy with somatostatin for PCLD or ADPKD?
Symptom relief and liver volume reduction
How do liver abscesses present?
Sepsis- high fever, leukocytosis, abdo pain, complex liver lesion with fluid and debris.
What causes liver abscesses?
Abdominal and biliary infection or dental procedures
How is a liver abscess treated?
Empirical broad spectrum antibiotics until aspiration and drainage for culture.
Echocardiogram
Surgery if no clinical improvement and then 4 weeks antibiotics with repeat imaging to check its reducing in size
What is the most common primary liver cancer?
Hepatocellular carcinoma HCC.
More common in men and incidence is increasing across the world
What are the risk factors for HCC?
Cirrhosis from any cause.
1) Hep B
2) Hep C
3) Alcohol
4) Aflatoxin
What are the symptoms of HCC?
Weight loss and RUQ pain. (most common)
Asymptomatic
Worsening of pre-existing chronic liver disease.
Acute liver failure.
What are the signs of HCC?
Signs of cirrhosis
Hard enlarged RUQ mass
Liver bruit- rare
Where does HCC metastatise to?
Rest of liver Portal vein Lymph nodes Lung Bone Brain
How is AFP (Alpha fetoprotein) used in HCC?
AFP is a tumour marker secreted by HCC but not all patients with HCC will have a raised AFP (elevation seen in 60-80% of cases) Not that sensitive but is used alongside USS for surveillance of HCC.
How is HCC diagnosed?
Elevated AFP USS CT scan: early arterial perfusion MRI Biopsy- only required sometimes and not ideal as it may cause seeding of the HCC
What is the prognosis for HCC?
Patient and tumour dependent.
Size, spread, underlying liver disease and patient performance status
How is HCC single lesion <2cm treated?
Surgical resection- high recurrence rate
How is HCC 3 lesions less than 3cm treated or a single lesion <5cm?
Liver transplantation- low recurrence rate
Most HCC are not fit for transplantation or resection. What treatment is available for them?
Palliative rather than curative.
Local ablation: Alcohol injection or radiofrequency ablation
TransArterial ChemoEmbolisation (TACE)
What is TACE?
TransArterial ChemoEmbolisation (TACE) is where chemotherapy is injected selectively into the hepatic artery and then you inject an embolic agent. (Only in early cirrhosis) Can be used while waiting on transplant list.
CAn you use systemic chemotherapy for HCC?
Getting better treatments.
Sorafenib gives a survival advantage of 1-2 months and so many side effects.
In which demographic is Fibro-Lamellar Carcinoma common?
Young patients- 5-35 years.
Not related to cirrhosis and AFP is normal
What are the CT findings in fibro-Lamellar Carcinoma?
Typical stellate scar with radial septa showing persistent enhancement.
What is the treatment for Fibro-Lamella Carcinoma?
Surgical resection or transplantation.
TACE for patients with irresectable tumour
What are the common sites of primary tumours that metastasise to the liver?
Blood
Colon, breast, lung, stomach, pancreas and melanoma
What is the LFT picture for liver mets?
Mild cholestatic picture ALPs with preserved liver function
