Liver Nodules and Tumors

Question 1

What are the main types of benign hepatic nodules/tumors?

Answer 1

Nodular hyperplasias:

• focal nodular hyperplasia
• nodular regenerative hyperplasia

Cavernous hemangioma

Hepatocellular adenoma:

• HNF1-α
• inflammatory
• β-catenin

Question 2

What is the most common benign neoplasm of the liver?

Answer 2

-cavernous hemangioma

Question 3

What is focal nodular hyperplasia?

Answer 3

benign nodular hyperplasia of the liver

• typcially single, well demarcated lesion w/ central scar
• “maplike pattern”

Question 4

What is nodular regenerative hyperplasia?

Answer 4

benign nodular hyperplasia of the liver

• typically multiple nodules
• appears like cirrhosis, but lacks fibrous septa

Question 5

What is cavernous hemangioma of the liver?

Answer 5

benign neoplasm of the liver

• asymptomatic
• has life threatening risk of hemorrhage

Question 6

What are the subtypes of the hepatic adenomas?

Answer 6

HNF1-α:

• fatty change with no atypia
• mostly female
• minimal risk of transformation

β-catenin activated:

• associated with oral contraceptives and anaboic steroids
• males and females
• high risk of transformation

Inflammatory:

• most common hepatic adenoma (40-50%)
• associated with metabolic syndrome
• mimics focal nodular hyperplasia

Question 7

What are the main types of malignant tumors of the liver?

Answer 7

Primary hepatic tumors:

• hepatoblastoma
• hepatocellular carcinoma
• colangiocarcinoma

Metastasis:

• colon
• breast
• lung
• pancreas

Question 8

What is the most common liver tumor of early childhood?

Answer 8

-hepatoblastoma

Question 9

What are the types of malignant liver tumors?

Answer 9

• hepatocellular carcinoma
• cholangiocarcinoma
• angiosarcome
• lymphoma
• metastasis

Question 10

What is the most common primary liver tumor?

Answer 10

-hepatocellular carcinoma

Question 11

What is the most common liver tumor of any origin?

Answer 11

-tumor metastasis to the liver is significanlty more common that primary liver tumors

Question 12

How does hepatoblastoma present?

Answer 12

• typicaly asymptomatic
• jaudice and pruritis if symptomatic
• abdominal swelling typcial presenting sign
• typically not detected until metastasis has already occured

Question 13

What is the most common cause of HCC?

Answer 13

-HBV and HCV

Question 14

What feature is most associated with development of HCC?

What are common causes?

Answer 14

80% of HCC arises in the setting of cirrhosis:

• HBV/HCV
• alcoholic liver disease
• NASH
• hemochromatosis
• Wilson disease
• α-1 anittrypsin deficiency
• hepatic autoimmune disease (PBC/PSC)

With no cirrhosis:

• aflatoxin (Aspergillus toxin)
• transformation of adenomas
• HBV

Question 15

What cause of HCC is odd in that it can cause HCC both w/ and w/o cirrhosis?

Answer 15

-HBV

Question 16

How does HCC present?

Answer 16

typcially asympomatic itself or its symtpoms are masked by underlying liver disease

• weight loss
• anorexia
• hepatomegaly
• RUQ tenderness
• jaundice
• ascites

Question 17

What serum marker is used to screen for HCC?

Answer 17

α-fetoprotein (AFP)

Question 18

How is HCC treated?

Answer 18

• typically resistant to chemotherapy
• non-cirrhotic livers -> resection
• cirrhotic livers -> liver transplant
• ablation in tumors that cannot be resected and do not qualify for transplant

Question 19

How does HCC metastasize?

Where?

Answer 19

hematogenous metastasis

most commonly to the lungs

Question 20

What feature can be useful in differentiating HCC from metastatic tumors of the liver?

Answer 20

• HCC is typically a single mass
• metastasis is typically many mases

Question 21

What is cholangiocarcinoma?

Answer 21

adenocarcinoma of the intrahepatic (intrahepatic CCA) or extrahepatic (biliary CCA) trees

Question 22

Whrere is cholangiocarcinoma most common?

Answer 22

sourtheast Asia (endemic liver fluke)

Question 23

What are risk factors for cholangiocarcinoma?

Answer 23

• liver fluke (**significant especially in Asia)
• fibropolycystic liver disease
• primary sclerosing cholangitis (PSC)
• chronic inflammatory conditions of the bile ducts
• hepatolithasis
• HBV and HCV

Question 24

What are common locations of colangiocarcinoma development within the biliary tree?

Answer 24

• biliary hilum -> Klatskin tumors (most common site)
• extrahepatic (20-30%)
• intrahepatic (5-10%)

Question 25

How does cholangiocarcinoma present?

Answer 25

Varies depending on location

Intrahepatic:

-very likely to be asymptomatic and detected only incidentally

Extrahepatic:

• cholestasis signs
• Courvoisier sign

Question 26

What is Courvoisier sign?

Answer 26

-painlessly enlarged gallbaldder

-painless jaundice

• acholic/pale stools
• dark urine
• pruritis

typically indicates obstruction of biliary tree by a mass:

• most commonly head of pancreas
• also within the biliary tree

Question 27

What factors are associated with angiosarcoma development in the liver?

Answer 27

• vinyl chloride
• arsenic
• Thorotrast

prevalence of exposure to these compounds has decreased significantly and so has the prevalence of hepatic angiosarcoma

Question 28

What subtypes of lymphoma present in the liver?

What risk factors are associated with their development?

Answer 28

• diffuse large B-cell lymphoma (most common)
• MALT

Risk factors:

• HBV and HCV
• HIV
• primary biliary cholangitis (PBC)