Liver TumorsLiver Tumors

Sameer smadi MD, FACSSameer smadi MD, FACS

ObjectiveObjective1.1. Identify the most important features of Identify the most important features of

common benign liver tumorscommon benign liver tumors2.2. Know the risk factors, diagnosis, and Know the risk factors, diagnosis, and

management of hepatocellular management of hepatocellular carcinomacarcinoma

ClassificationClassification

HemangiomaHemangiomaFocal nodular Focal nodular hyperplasiahyperplasiaAdenomaAdenomaLiver cystsLiver cysts

1.1. Primary liver cancersPrimary liver cancersHepatocellular Hepatocellular carcinomacarcinomaFibrolamellar carcinomaFibrolamellar carcinomaHepatoblastomaHepatoblastoma

2. Metastases2. Metastases

Benign Malignant

Benign Liver LesionsBenign Liver Lesions1.1. HemangiomaHemangioma2.2. Focal nodular hyperplasiaFocal nodular hyperplasia3.3. AdenomaAdenoma4.4. CystsCysts

HemangiomaHemangiomaClinical FeaturesClinical Features

The commonest liver tumorThe commonest liver tumor5% of autopsies5% of autopsiesUsually single smallUsually single smallWell demarcated capsuleWell demarcated capsuleUsually asymptomaticUsually asymptomatic

HemangiomaHemangiomaDiagnosis and ManagementDiagnosis and Management

DiagnosisDiagnosisUS: echogenic spot, well demarcatedUS: echogenic spot, well demarcatedCT: venous enhancement from periphery to CT: venous enhancement from periphery to centercenterMRI: high intensity areaMRI: high intensity areaNo need for FNANo need for FNA

TreatmentTreatmentNo need for treatmentNo need for treatment

CT/HemangiomaCT/Hemangioma

Focal Nodular Hyperplasia (FNH)Focal Nodular Hyperplasia (FNH)Clinical FeaturesClinical Features

Benign nodule formation of normal liver Benign nodule formation of normal liver tissuetissueCentral stellate scarCentral stellate scarMore common in young and middle age More common in young and middle age womenwomenNo relation with sex hormonesNo relation with sex hormonesUsually asymptomaticUsually asymptomaticMay cause minimal painMay cause minimal pain

Focal Nodular Hyperplasia (FNH)Focal Nodular Hyperplasia (FNH)Diagnosis and ManagementDiagnosis and Management

DiagnosisDiagnosis::US: Nodule with varying echogenicityUS: Nodule with varying echogenicityCT: Hypervascular mass with central scarCT: Hypervascular mass with central scarMRI: iso or hypo intense MRI: iso or hypo intense FNA: Normal hepatocytes and Kupffer cells with FNA: Normal hepatocytes and Kupffer cells with central core.central core.

TreatmentTreatment::No treatment necessaryNo treatment necessaryPregnancy and hormones OKPregnancy and hormones OK

CT/FNHCT/FNH

Hepatic AdenomaHepatic AdenomaClinical featuresClinical features

Benign neoplasm composed of normal Benign neoplasm composed of normal hepatocytes no portal tract, central veins, hepatocytes no portal tract, central veins, or bile ductsor bile ductsMore common in womenMore common in womenAssociated with contraceptive hormonesAssociated with contraceptive hormonesUsually asymptomatic but may have RUQ Usually asymptomatic but may have RUQ painpainMay presents with rupture, hemorrhage, or May presents with rupture, hemorrhage, or malignant transformation (very rare) malignant transformation (very rare)

Hepatic AdenomaHepatic AdenomaDiagnosis and ManagementDiagnosis and Management

DXDXUS: filling defectUS: filling defectCT: Diffuse arterial enhancementCT: Diffuse arterial enhancementMRI: hypo or hyper intense lesionMRI: hypo or hyper intense lesionFNA : may be neededFNA : may be needed

TxTxStop hormonesStop hormonesObserve every 6m for 2 yObserve every 6m for 2 yIf no regression then surgical excisionIf no regression then surgical excision

AdenomaAdenoma

Liver CystsLiver CystsMay be single or multipleMay be single or multipleMay be part of polycystic kidney diseaseMay be part of polycystic kidney diseasePatients often asymptomaticPatients often asymptomaticNo specific management requiredNo specific management requiredHydated cystHydated cyst

Malignant Liver LesionsMalignant Liver Lesions

Malignant Liver TumorsMalignant Liver Tumors

1.1. Hepatocellular carcinoma (HCC)Hepatocellular carcinoma (HCC)2.2. Fibro-lamellar carcinoma of the liverFibro-lamellar carcinoma of the liver3.3. HepatoblastomaHepatoblastoma4.4. Intrahepatic cholangiocarcinomaIntrahepatic cholangiocarcinoma5.5. OthersOthers

HCC: IncidenceHCC: IncidenceThe most common primary liver cancerThe most common primary liver cancerThe most common tumor The most common tumor Increasing in US and all the worldIncreasing in US and all the world

HCC: Risk FactorsHCC: Risk FactorsThe most important risk factor is The most important risk factor is cirrhosiscirrhosis

from any cause:from any cause:1.1. Hepatitis B (integrates in DNA)Hepatitis B (integrates in DNA)2.2. Hepatitis CHepatitis C3.3. AlcoholAlcohol4.4. AflatoxinAflatoxin5.5. OtherOther

HCC: Clinical FeaturesHCC: Clinical FeaturesWt loss and RUQ pain (most common)Wt loss and RUQ pain (most common)AsymptomaticAsymptomaticWorsening of pre-existing chronic liver disWorsening of pre-existing chronic liver disAcute liver failureAcute liver failure

O/E:O/E:Signs of cirrhosisSigns of cirrhosisHard enlarged RUQ massHard enlarged RUQ massLiver bruit (rare)Liver bruit (rare)

HCC: MetastasesHCC: MetastasesRest of the liverRest of the liverPortal veinPortal veinLymph nodesLymph nodesLungLungBoneBoneBrainBrain

HCC: labsHCC: labsLabs of liver cirrhosisLabs of liver cirrhosis

AFP (Alfa feto protein)AFP (Alfa feto protein)Is an HCC tumor markerIs an HCC tumor markerValues more than 100ng/ml are highly Values more than 100ng/ml are highly suggestive of HCCsuggestive of HCCElevation seen in more than 70% of ptElevation seen in more than 70% of pt

HCC: DiagnosisHCC: DiagnosisClinical presentationClinical presentationElevated AFPElevated AFPUSUSTriphasic CT scan: very early arterial Triphasic CT scan: very early arterial perfusionperfusionMRIMRIBiopsyBiopsy

US: HCCUS: HCC

CT: Venous PhaseCT: Venous Phase

CT: Arterial PhaseCT: Arterial Phase

HCC: PrognosisHCC: PrognosisTumor sizeTumor sizeExtrahepatic spreadExtrahepatic spreadUnderlying liver diseaseUnderlying liver diseasePt performance statusPt performance status

HCC: Liver HCC: Liver TransplantationTransplantation

Best available treatmentBest available treatmentRemoves tumor and liverRemoves tumor and liverOnly if single tumor less than 5cm or less Only if single tumor less than 5cm or less than 3 tumors less than 3 cm eachthan 3 tumors less than 3 cm eachRecurrence rate is lowRecurrence rate is lowNot widely availableNot widely available

HCC: ResectionHCC: ResectionFeasible for small tumors with preserved Feasible for small tumors with preserved liver function (no jaundice or portal HTN)liver function (no jaundice or portal HTN)Recurrence rate is highRecurrence rate is high

HCC: Local AblationHCC: Local AblationFor non resectable ptFor non resectable ptFor pt with advanced liver cirrhosisFor pt with advanced liver cirrhosisAlcohol injectionAlcohol injectionRadiofrequency ablationRadiofrequency ablationTemporary measure onlyTemporary measure only

Radio Frequency AblationRadio Frequency Ablation

Ethanol InjectionEthanol Injection

HCC: ChemoembolizationHCC: ChemoembolizationInject chemotherapy selectively in hepatic Inject chemotherapy selectively in hepatic arteryarteryThen inject an embolic agentThen inject an embolic agentOnly in pt with early cirrhosisOnly in pt with early cirrhosisNo role for systemic chemotherapyNo role for systemic chemotherapy

ChemoembolizationChemoembolization

Fibro-Lamellar CarcinomaFibro-Lamellar CarcinomaPresents in young pt (5-35)Presents in young pt (5-35)Not related to cirrhosisNot related to cirrhosisAFP is normalAFP is normalCT shows typical stellate scar with radial CT shows typical stellate scar with radial septa showing persistant enhancementsepta showing persistant enhancement

Secondary Liver Secondary Liver MetastasesMetastases

The most common site for blood born The most common site for blood born metastasesmetastasesCommon primaries : colon, breast, lung, Common primaries : colon, breast, lung, stomach, pancreases, and melanomastomach, pancreases, and melanomaMild cholestatic picture (ALP, LDH) with Mild cholestatic picture (ALP, LDH) with preserved liver functionpreserved liver functionDx imaging or FNADx imaging or FNATreatment depends on the primary cancerTreatment depends on the primary cancerIn some cases resection or chemoembolization In some cases resection or chemoembolization is possibleis possible

SummarySummary

HemangiomaHemangiomaFocal nodular Focal nodular hyperplasiahyperplasiaAdenomaAdenomaLiver cystsLiver cysts

1.1. Primary liver cancersPrimary liver cancersHepatocellular Hepatocellular carcinomacarcinomaFibrolamellar carcinomaFibrolamellar carcinomaHepatoblastomaHepatoblastoma

2. Metastases2. Metastases

Benign Malignant

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