Chapters 59 & 62 Hepatic and Biliary Neoplasms Lisa Spiguel, MD True or False: The caudate lobe is Couinauds segment IV. True or False: The portal veins divide the right and left lobes into anterior and posterior segments. The Right Lobe is comprised of which segments: 1.IV-VII 2.V -VIII 3.I-IV 4.II-V Couinauds Segmental Anatomy Couinauds Classification system based on the vascular supply to the liver Allows the ability to resect segments without damaging those remaining Hepatic Veins: Right hepatic vein: Anterior and posterior division of right lobe Middle hepatic vein: Divides right and left lobes (Cantlies Line) Left Hepatic vein: Medial and Lateral division of left lobe Portal Veins: Superior and inferior division True or False: Viral hepatitis remains the most common cause of chronic liver disease and cirrhosis worldwide. Which of the below criteria is not included in Child Turcotte-Pugh Score? 1.Ascites 2.Albumin 3.ALT 4.Bilirubin 5.Encephalopathy Which of the below criteria is not included in MELD Score? 1.INR 2.Creatinine 3.ALT 4.Bilirubin Chronic Liver Disease Assessing Liver Function Viral Hepatitis remains the most common cause of chronic liver disease and cirrhosis worldwide World Health Organization estimates more than 500 million people with Hepatitis C ( 180) or B (350) Other Common Causes: Non-alcoholic liver disease Cholestatic Liver Disease: Primary sclerosing cholangitis Symptoms: Early: Fatigue, weight loss, muscle wasting Advanced: Splenomegaly, encephalopathy, ascites, variceal bleeding, jaundice Classification Systems: Child-Turcotte-Pugh Model for End-Stage Liver Disease (MELD) Indications for Transplantation: Meld > 15 Child Class C A 73 yr-old woman presents with complaints of an increase in her abdominal size and early satiety. You perform a physical exam and palpate a mass in the right upper quadrant of the abdomen. Her CT scan is demonstrated below. What is the procedure of choice for her treatment? 1.Right hepatectomy 2.Wedge resection 3.Laparoscopic Unroofing 4.Plan for liver transplant A 73 yr-old woman presents with complaints of an increase in her abdominal size and early satiety. You perform a physical exam and palpate a mass in the right upper quadrant of the abdomen. Her CT scan is demonstrated below. What is her diagnosis? 1.Simple hepatic Cyst 2.Hemangioma 3.Hepatocellular carcinoma 4.Hepatic Cystadenoma A 35 yr-old woman presents with complaints of RUQ pain, fevers and chills. She was hospitalized approximately 2 weeks ago for perforated diverticulitis for which she was discharged three days ago doing better. A CT abdomen/Pelvis was performed and is demonstrated below. What is the treatment of choice for her? 1.Percutaneous drainage and gram negative antibiotic coverage 2.Avoid percutaneous drainage and iv flagyl 3.Avoid percutaneous drainage and Albendazole therapy 4.To OR for Laparoscopic marsupialization A 35 yr-old woman presents with complaints of abdominal discomfort for the past week. A CT abdomen/Pelvis was performed and is demonstrated below. What is her diagnosis? 1.Hydatid Cyst 2.Pyogenic Liver Abscess 3.Simple hepatic cyst 4.Amoebic Abscess True or False: Flagyl is first line treatment for a Hydatid Cyst. Cystic Liver Lesions Simple Cysts Cystadenomas Infectious Cystic Liver Lesions Simple Cysts More common in women Increased in right lobe Symptoms: Pain, infection, bowel compression, rare bleeding Tx: If symptomatic: Laparoscopic un- roofing/marsupialization Cystic Liver Lesions Most common primary cystic neoplasm of the liver Accounts for 5% of all cystic lesions of the liver Arise from biliary epithelium Propensity toward local recurrence and malignant degeneration to Cystadenocarcinoma Imaging: Papillary-like fronds or septa Dx: Elevated CA 19-9 and CEA of cyst fluid/ Mucin Tx: Wedge resection (cystadenomas), formal resection (cystadenocarcinomas) Cystadenoma/ Cystadenocarcinoma Cystic Liver Lesions Infectious Echinococcus Cyst Right Lobe Dx: ELISA for IgG Ab against Echinococcus/ Hemagglutinin CT: Ectocyst (calcified wall) Tx: Do not aspirate Treat Albendazole Pack bowel with hypertonic saline, inject cyst with ETOH, Aspirate contents, remove cyst wall, Albendazole post op Pyogenic Abscess Right Lobe MC type of hepatic abscess MC organism: E. Coli 2 nd to biliary tract disease with ascending infection or biliary manipulation, or any intraabdominal infection drains via portal to liver Tx: Percutaneous drainage + Abx, ERCP to rule out biliary obstruction Amoebic Abscess Recent travel to Mexico or Latin America Entamoeba Histolytica 2 nd to Amoebic colitis Right Lobe Dx: Agglutinin+Immuno- electrophoresis Ab tests Tx: Flagyl, Aspiration is difficult (Anchovy Paste) True or False: Focal Nodular Hyperplasia is recommended for excision due to increased future risk of malignancy A 31 yr-old woman presents to the ED with RUQ Pain and orthostatic symptoms. Her vitals are 37.2/118/100/50/18/99% 2LNC. A CT was performed that is demonstrated. What is the most likely underlying etiology? 1.Hepatic Adenoma 2.Hepatocellular carcinoma 3.Hepatic Cyst 4.Focal Nodular Hyperplasia Which of the following below demonstrates a classic central stellate scar on CT and MRI? 1.Liver Cyst 2.Hepatic Adenoma 3.Focal Nodular Hyperplasia 4.Hepatocellular Carcinoma True or False: Surgical resection is indicated for both symptomatic and asymptomatic hemangiomas due to the increased risk of rupture and hemorrhage. True or False: 99m-Technitium sulfur colloid scans can be used to differentiate hepatic adenomas from Focal Nodular Hyperplasia. Hepatic adenomas demonstrate uptake while FNH does not demonstrate uptake. Which of the below is not a criteria in the Milan Staging for Hepatocellular carcinoma? 1.Absence of macrovascular invasion 2.Single tumor less than or equal to 6 cm 3.Three or less tumors all less than or equal to 3 cm in size 4.All of the above are criteria Which two agents are used for TACE? 1.Sorafenib, Cisplatin 2.Cisplatin, Doxorubicin 3.Sorafenib, Doxorbicin 4.Sorafenib alone True or False: Sorafenib is the only systemic medical therapy with proven efficacy for HCC therapy. Solid Liver Lesions Hepatic Adenoma Focal Nodular Hyperplasia Hemangioma Hepatocellular Carcinoma Solid Liver Lesions Rare tumor of the liver, prevalence is 1% Associated with OCPs: 5-fold increase in risk in women on OCPs for > 5 years Other causes: glycogen storage disease, steroid use Dx: MRI/CT Bright uniform enhancement on arterial phase 99m-Technitium sulfur colloid scan No uptake Tx: Asymptomatic 5 cm: Resect due to rupture and malignant degeneration Hepatic Adenoma Solid Liver Lesions 2 nd Most common benign neoplasm of the liver Typically asymptomatic found incidentally Risk of rupture and bleeding are rare Not premalignant Dx: MRI/CT: Peripheral enhancement with central stellate scar Tx: Observation Focal Nodular Hyperplasia Solid Liver Lesions Most common benign solid neoplasm of the liver Typically in patients yrs of age More common in women Associated with use of OCPs Typically asymptomatic, with incidental finding on imaging Rarely rupture or bleed Dx: MRI/CT: Pathognomic pattern of initial peripheral, nodular enhancement with progressive infilling of the lesion on delayed images Tagged RBC scan to confirm diagnosis, Avoid biopsy Tx: Observation unless symptomatic enucleation or formal hepatic resection Hemangioma True or False: The gallbladder is different from the GI tract in that it lacks a muscularis mucosa and submucosa. True or False: Gallbladder cancer is found incidentally in 5% of patients following an elective cholecystectomy. A cholecystectomy is performed on a 70 yr old woman for biliary colic. On final pathology, the pathologist reports that the gallbladder cancer that invades into the muscular layer of the gallbladder and all margins are free. What T Stage is this? 1.T1 2.T2 3.T3 4.T4 What is the best treatment plan for the prior patient? 1.Take the patient back for a radical resection with at minimum resection of 1-2 cm rim of normal liver around the gallbladder fossa with formal lymphadenectomy 2.Take the patient back for a radical resection with an extend right hepatectomy 3.Tell the patient that this is an unexpected finding however due to the depth you do not need any further surgery. 4.None of the above Gallbladder Cancer Rare malignancy with dismal outlook 5 yr survival < 5% 6-7,000 Cases annually More common in women, 7 th decade of life 70-90% of patients with gallbladder cancer also have stones < 0.5% of patients with stones have gallbladder cancer, 20 yr risk of developing cancer in patients with gallstones is < 0.5% Larger stones > 3cm are associated with 10-fold increase in risk Porcelain gallbladder is not necessarily associated with gallbladder cancer Only 1% of gallbladder cancer is found incidentally following cholecystectomy Clinical presentation: Varies: jaundice, weight loss, anorexia, increase abdominal girth, hepatomegaly, ascites, palpable mass LFTs elevated Dx: US/CT/MRI: Tx:Simple Cholecystectomy for T1 (lamina propria or muscular layer) tumors, without lymphadenectomy (100% 5 yr survival) T2 (Into perimuscular connective tissue) Radical cholecystectomy T3/T4 tumors require radical cholecystectomy with at times formal resection of segments IV/V or extended right hepatectomy segments IV-VIII (50% 5 yr survival) Incidental finding following lap chole: T2 or higher with no evidence of mets: radical resection and excision of port sites Systemic chemo: 5-FU and Mitomycin C A 60 yo man is evaluated for a newly diagnosed cholangiocarcinoma of the distal CBD following a work up for painless jaundice. The surgical treatment of choice is? 1.Liver transplantation 2.Resection of the CBD with primary anastomosis 3.This patient is not a surgical candidate 4.Pancreaticoduodenectomy Bile Duct Carcinoma/Cholangiocarcinoma Incidence of Hilar Cholangiocarcinoma is 1/100,000 per year Increased incidence in male, and average age of Risk Factors: Primary sclerosing cholangitis, ulcerative colitis, choledochal cysts, biliary tract infection, chemicals (nitrosamines, dioxin, asbestos, polychlorinated biphenyls) Classified based on location: Intrahepatic, Extrahepatic (upper third, middle third, lower third of bile duct) Sx: painless jaundice, vs mild RUQ pain, pruritus, anorexia, malaise, weight loss, cholangitis symptoms in 10-30% Tx: Surgical resection: Complete resection of tumor and adequate biliary drainage Hilar tumors: Neoadjuvant chemo 5-Fu followed by transplantation Intrahepatic tumors: Formal liver resection to negative margins Extrahepatic tumors: Distal tumors pancreaticoduodenectomy