Part two - liver

Question 1

Complications of liver cystic lesions

Answer 1

• Spontaneous haemorrhage
  * Rupture into peritoneal cavity
  * Rupture into bile duct
  * Infection
  * Biliary tree compression

Specific types of cysts have unique complications:

  * Malignant transformation of a cyst adenoma
  * Anaphylactic shock due to a hydatid cyst

Question 2

Classify hepatic cysts

Answer 2

Simple cyst & polycystic disease most common
Parasitic - hydatid
Neoplastic - cystadenoma -> adenocarcinoma
Secondary neoplastic - ovary, pancreas, colon
Duct related - Caroli’s, bile duct duplication
False cyst - haemorrhage, infarction, biloma
Ciliated foregut cyst

Question 3

CRC liver metastases - poor prognostic factors for long term survival

Answer 3

Node positive primary
Positive resection margin
More than one live metastases
Extrahepatic metastases
CEA >200
DFS < 12 months
Largest liver met > 5cm

Question 4

Define suitable liver remnant

Answer 4

Adequate remnant liver volume with sufficient inflow/outflow & biliary drainage

  * Theoretically 20% normal liver
  * 30% after chemotherapy
  * 40% with CLD
  * 50% ideally

Question 5

Criteria for CRC liver metastasis resection

Answer 5

Evolving, MDT required, varies between centres, focus from what is being resected to what is left behind

  * Fit for surgery
  * Any extrahepatic disease is potentially resectable
  * R0 resection possible or all disease can be treated            (resection + ablation)
  * Cannot involve CHA, CHV, PV, CBD
  * Adequate remnant liver volume with sufficient inflow/outflow & biliary drainage

Question 6

Role of biopsy in CRC liver metastases

Answer 6

Usually not required except to confirm untreatable disease (omentum for example)

False positive of good CT 1%

Risk of seeding up to 20% is perhaps overstated

Discuss at MDT first

Question 7

Staging for CRC liver metastases

Answer 7

Examination for local recurrence if low cancer (else CT)
Tumour markers, liver function
CT triple phase for liver and extrahepatic mets
MRI for small liver mets <1cm & fatty liver (not always required)
PET good for radiologically occult disease
Staging lap if PET abnormal

Question 8

Disadvantages of PET in CRC liver metastases

Answer 8

Expensive
False +ve
Poor localisation
Poor sensitivity <1cm
Unreliable post chemotherapy

Question 9

What do CRC liver metastases look like on CT?

Answer 9

Triple phase scan using iodine based contrast

PV phase - liver appears white & mets are hypointense
Arterial phase - peripheral rim enhancement
Delayed/washout phase (after 4-5 mins) - can distinguish between benign haemangiomas & malignant lesions

Question 10

What is the microbe of hydatid disease

Answer 10

Echinococcus and most commonly in humans:

• -Echinococcus granulosus
• -Echinococcus multilocularis

Question 11

What is FNH?

Answer 11

Focal nodular hyperplasia (FNH) is the most common non-malignant hepatic tumor that is not of vascular origin. It is a hyperplastic (regenerative) response to hyperperfusion by the characteristic anomalous arteries found in the center of these nodules.