Score - Liver Flashcards

1
Q

During an intraoperative ultrasound in a patient with a preoperative diagnosis of a solitary colorectal liver metastasis in segment 8, an additional 1-cm solid lesion is identified in segment 7. What should be the next step in operative management?

A

Compare the sonographic features of both tumors.

Intraoperative liver ultrasound has the ability to accurately characterize solid and cystic liver lesions. Solid tumors with similar sonographic features have the same nature. When unsuspected tumors are discovered during intraoperative ultrasound, the surgeon should compare the sonographic features of all identified tumors and alter the operative plan accordingly. In addition, the lesions should be carefully compared with the respective findings of previous imaging such as computed tomography or magnetic resonance imaging.

Aborting the operation would not be the correct next step in this case, especially not until a full evaluation of the nature of the newly found mass has been performed.

A right hepatectomy could be the further management plan, if the lesion is noted to be similar and metastatic in nature and the patient is a good candidate to undergo this operation; however, it is not the best next step.

Disregarding a new tumor in a patient with known metastatic disease is never correct without first evaluating it.

Consulting transplant surgery is very premature at this point.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

A 33-year-old woman is referred to surgery for resection of a 2-cm mass on the right side of the liver, which was incidentally found on cross-sectional imaging after she had been involved in a motor vehicle crash 2 weeks ago. She is otherwise healthy and has been taking oral contraceptive pills since the age of 17. She denies any abdominal pain. On triphasic contrast-enhanced CT, this lesion will most likely display which of the following?

A

Peripheral nodular enhancement in the arterial phase with central filling in the delayed phase

Oral contraceptive (OCP) use is associated with the development of a hepatic adenoma, and discontinuation of the OCP would be the first-line therapy for this lesion.

The most common benign solid liver lesion in an otherwise healthy woman is a hemangioma. Peripheral nodular enhancement describes a hemangioma.

Arterial enhancement and washout describes hepatocellular carcinoma.

Strong arterial enhancement with a persistent central scar describes focal nodular hyperplasia.

A rim-enhancing lesion describes an abscess.

The peripheral enhancing lesion in the arterial phase is compatible with intrahepatic cholangiocarcinoma.

Peripheral nodular enhancement describes a hemangioma.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

The most common benign solid liver lesion in an otherwise healthy woman is a hemangioma. Peripheral nodular enhancement describes a hemangioma.

Arterial enhancement and washout describes hepatocellular carcinoma.

Strong arterial enhancement with a persistent central scar describes focal nodular hyperplasia.

A rim-enhancing lesion describes an abscess.

The peripheral enhancing lesion in the arterial phase is compatible with intrahepatic cholangiocarcinoma.

Peripheral nodular enhancement describes a hemangioma.

A

The most common benign solid liver lesion in an otherwise healthy woman is a hemangioma. Peripheral nodular enhancement describes a hemangioma.

Arterial enhancement and washout describes hepatocellular carcinoma.

Strong arterial enhancement with a persistent central scar describes focal nodular hyperplasia.

A rim-enhancing lesion describes an abscess.

The peripheral enhancing lesion in the arterial phase is compatible with intrahepatic cholangiocarcinoma.

Peripheral nodular enhancement describes a hemangioma.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

A 25-year-old male who recently traveled to Africa presents with a 2 week history of RUQ pain, intermittent fever, malaise, and weight loss. US of the liver is done, and amebic liver abscess measuring 4.5 cm is seen in the right liver. Serology confirms amebic infection. What is the treatment for this patient?

A

Metronidazole

With a cure rate of more than 90%, metronidazole orally 500 to 750 mg three times a day for 7–10 days is the treatment of choice. Metronidazole reaches high concentration in the liver and intestines and, thus, is very efficacious for amebic liver abscesses. The symptom response should be anticipated in 72 to 96 hours.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

A healthy 55-year-old woman presents with an isolated liver lesion in segment VI. She has a history of left nephrectomy for renal cell carcinoma (4 years ago). Biopsy confirms metastatic renal cell carcinoma. A PET/CT scan reveals no additional disease. She is reluctant to proceed with surgery. What other treatment option may be appropriate?

A

Percutaneous radiofrequency or microwave ablation

Renal cell carcinoma is primarily treated with surgery because it is poorly responsive to chemotherapy or radiation. Newer agents such as immune checkpoint inhibitors have shown promising results, but prognosis remains poor for patients with metastatic disease. In patients with oligometastatic disease (minimal metastatic sites), surgical excision or ablation have shown better prognosis when compared with nonoperative treatments. In patients who refuse surgery or are considered high risk, percutaneous ablation offers alternative treatment option. Such patients should be encouraged to enroll in clinical trials. In case of debilitating symptoms, palliative treatment may be attempted with arterial embolization or external beam radiation.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

A 56-year-old healthy man has a 2-cm distal pancreatic mass. He has three hepatic lesions—in segments V, VII, and VIII. His cancer antigen (CA) 19-9 is 25 U/mL. Endoscopic ultrasound with pancreatic mass biopsy is consistent with a low-grade neuroendocrine tumor. Which of the following is an appropriate next step in clinical management?

A

Distal pancreatectomy with splenectomy and right hepatectomy

Unlike pancreatic adenocarcinoma, low-grade pancreatic neuroendocrine tumors have a slow progression and a good 5-year prognosis. Even with metastases to distant sites such as lymph nodes and liver, the prognosis remains good especially if complete resection of all disease is possible, as is the case here. In addition, studies have shown that more than 90% cytoreduction can provide improved symptom control in patients with functional tumors or those that are symptomatic. Because the disease is confined to the right side of the liver, distal pancreatectomy with splenectomy and right hepatectomy is appropriate, provided the future liver remnant is adequate.

FOLFIRINOX is used in patients with pancreatic adenocarcinoma, and hospice may not be preferred if the patient is healthy and has a good 5-year prognosis.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

A 70-year-old man with chronic hepatitis C and Child-Pugh B cirrhosis is diagnosed with hepatocellular carcinoma. You are evaluating him for an extended left hepatectomy. Which of the following tests would be most useful in assessing the functional liver remnant in this man?

A

Computed tomography (CT) with three-dimensional reconstruction

Given the regenerative ability of the liver, patients with normal liver function can tolerate as little as 20% to 25% of remnant liver, whereas those with underlying cirrhosis may require as much as 40% when undergoing resection. Computed tomography or magnetic resonance imaging with three-dimensional reconstruction is the test of choice when evaluating the degree of functional liver remnant (FLR). FLR% is the proportion of functional liver volume made up by the FLR and is calculated by the formula FLR% = FLR ÷ (total liver volume – tumor volume).

Laboratory studies are useful in determining hepatic synthetic function and Child-Pugh classification but cannot determine volume.

Ultrasound may be a useful initial test for hepatic pathology, and positron emission tomography–computed tomography is useful for evaluating distant disease, but neither of these choices is optimal for volumetric calculations.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

A 48-year-old man presents for further evaluation of a new 17-cm right liver mass diagnosed on CT imaging that was performed for dull right upper quadrant pain. The mass exhibits peripheral nodular enhancement on arterial phase followed by progressive centripetal fill-in on portal venous phase. What does the lesion most likely represent?

A

Hepatic hemangioma

A hepatic hemangioma is the most common benign liver lesion, followed by a focal nodular hyperplasia (FNH) lesion. A hemangioma is typically discovered incidentally or during workup for abdominal pain, especially if it is of a considerable size. It has a pathognomonic enhancement pattern on computed tomography (CT)/magnetic resonance imaging (MRI; peripheral puddling of contrast on arterial phase followed by centripetal filling on subsequent phases), which can reliably lead to diagnosis without the need for biopsy. It is also bright on T2 sequences on MRI.

A hepatic adenoma demonstrates early arterial enhancement followed by isoattenuation during a portal phase.

An FNH lesion is benign and usually does not require surgical resection unless it is symptomatic. It is known for a central scar that remains hypoattenuating on a portal venous phase of the CT.

A hepatic hamartoma can have a wide spectrum of radiographic findings, including both solid and cystic characteristics, but it often can be a cystic mass with septations.

A benign liver cyst demonstrates homogenous hypoattenuation and does not enhance with intravenous contrast on imaging.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Hepatic hemangioma: It has a pathognomonic enhancement pattern on computed tomography (CT)/magnetic resonance imaging (MRI; peripheral puddling of contrast on arterial phase followed by centripetal filling on subsequent phases), which can reliably lead to diagnosis without the need for biopsy. It is also bright on T2 sequences on MRI.

A hepatic adenoma demonstrates early arterial enhancement followed by isoattenuation during a portal phase.

An FNH lesion is benign and usually does not require surgical resection unless it is symptomatic. It is known for a central scar that remains hypoattenuating on a portal venous phase of the CT.

A hepatic hamartoma can have a wide spectrum of radiographic findings, including both solid and cystic characteristics, but it often can be a cystic mass with septations.

A benign liver cyst demonstrates homogenous hypoattenuation and does not enhance with intravenous contrast on imaging.

A

Hepatic hemangioma: It has a pathognomonic enhancement pattern on computed tomography (CT)/magnetic resonance imaging (MRI; peripheral puddling of contrast on arterial phase followed by centripetal filling on subsequent phases), which can reliably lead to diagnosis without the need for biopsy. It is also bright on T2 sequences on MRI.

A hepatic adenoma demonstrates early arterial enhancement followed by isoattenuation during a portal phase.

An FNH lesion is benign and usually does not require surgical resection unless it is symptomatic. It is known for a central scar that remains hypoattenuating on a portal venous phase of the CT.

A hepatic hamartoma can have a wide spectrum of radiographic findings, including both solid and cystic characteristics, but it often can be a cystic mass with septations.

A benign liver cyst demonstrates homogenous hypoattenuation and does not enhance with intravenous contrast on imaging.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

A 65-year-old woman is scheduled for a left trisectionectomy for hepatocellular carcinoma. Based on the Brisbane nomenclature, her resection will involve which of the following liver segments?

A

Segments II, III, IV, V, and VIII

A left trisectionectomy involves segments II, III, IV, V, and VIII. Synonyms for this resection include “extended left hepatectomy” as described by Couinaud and “extended left lobectomy” as described by Goldsmith and Woodburne.

Other anatomic liver resections include right hemihepatectomy (segments V-VIII), right trisectionectomy (segments IV-VIII), left hemihepatectomy (II-IV), and left lateral sectionectomy (segments II and III).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

A 53-year-old woman presents with synchronous sigmoid colon cancer and hepatic oligometastasis. A multidisciplinary gastrointestinal oncology team recommends that she begin systemic chemotherapy using 5-fluorouracil and oxaliplatin (FOLFOX). You review the images of the liver and note that only one of the lesions would be amenable to percutaneous biopsy. You communicate with the team about your recommendations for a percutaneous biopsy of a 2-cm lesion at which of the following locations?

A

Within the parenchyma of segment 6
This question reviews the anatomic considerations that help determine when biopsy of the liver should be performed using a percutaneous or surgical approach. This question also requires an understanding of the Couinaud segmental anatomy. Within the parenchyma of segment 6, there are typically no major vascular or biliary structures. The medium to small branches of the right hepatic vein are the only exception.

A lesion near the dome of segment 7 is incorrect because biopsy of lesions high on the liver can result in iatrogenic lung puncture and pneumothorax.

Also, a lesion at the tip of segment 3 is incorrect because lesions adjacent to the stomach can lead to inadvertent visceral injury.

Finally, lesions in the caudate lobe or in the posterior aspect of segment 5 are incorrect because both lesions lie close to the inferior vena cava, which increases the risk of venous laceration during a percutaneous approach.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

A 58-year-old man with cirrhosis previously had a transjugular intrahepatic portosystemic shunt (TIPS) placed, but the TIPS has stenosed and is no longer functional. He develops hypotension and melena. Esophagogastroduodenoscopy demonstrates esophageal variceal bleeding, which cannot be controlled endoscopically. Interventional vascular radiology is unable to embolize because of multiple points of bleeding. What is the best method to prevent recurrent variceal bleeding?

A

Liver transplant

A patient who has failed management with a transjugular intrahepatic portosystemic shunt procedure and has recurrent persistent esophageal variceal bleeding may benefit from definitive management of decompensated cirrhosis and portal hypertension in the form of a liver transplant.

Surgical portosystemic shunts can be used for select patients with portal hypertension, especially those with non-cirrhotic portal hypertension.

At this point, he is beyond medical therapy, an octreotide drip and beta-blockers, which are more useful for prevention.

A partial esophagectomy does not resolve the underlying portal hypertension.

Balloon tamponade would be helpful in the short term as a temporizing method in an emergent situation if he were unstable.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

A 65-year-old man presents with intermittent colicky abdominal pain. During workup, he is found to have cecal adenocarcinoma with a synchronous 2cm metastatic liver lesion in segment II. What is the most appropriate treatment approach?

A

Right hemicolectomy and left lateral segmentectomy

Cecal adenocarcinoma is treated with right hemicolectomy.

A limited cecal resection is not appropriate for oncologic lymphadenectomy and resection.

Because the patient is young and no comorbidities have been reported, in conjunction with the fact that he has a synchronous 2-cm lesion involving segment II; left lateral segmentectomy at the time of original surgery is appropriate as well.

Some patients may be treated with chemotherapy first, but given his symptoms, which are exhibiting signs of early obstruction, early surgical intervention may be preferred.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

A 58-year-old man with a history of chronic obstructive pulmonary disease, atrial fibrillation, hypertension, hyperlipidemia, and alcoholic cirrhosis presents to the hospital with an umbilical hernia that is unable to be reduced. He has missed a couple days of medications. On examination, he has normal vital signs and an incarcerated umbilical hernia with a protuberant abdomen. His white blood count and lactic acid level are normal. Computed tomography of his abdomen demonstrates incarcerated small bowel in his umbilical hernia, without evidence of ischemia, and moderate to severe ascites. What is the best management for this man?

A

Admission, medical management of ascites, and urgent open umbilical hernia repair with drain placement

The best management for this man involves medical management of his ascites and urgent hernia repair; his medical comorbidities need to be optimized and repair of the incarcerated hernia is crucial. Placing a drain is beneficial in a patient with cirrhosis for intermittent ascites drainage to allow the hernia repair to heal.

At this point, this man is stable without evidence of strangulation; therefore, emergent umbilical hernia without medical optimization would be less correct.

Transjugular intrahepatic portosystemic shunt (TIPS) would be beneficial, but the hernia repair should occur in the same admission at the very least, not electively, because it is incarcerated.

The comorbidities of this man would make laparoscopic surgery more challenging and risky.

Again, the surgery should not be elective because he has threatened small bowel incarcerated within the hernia.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly