2. Learning objectives
At the end of the session; students should be
able to;
• Describe the surgical anatomy of the liver.
• Classify the types of hepatic cancer.
• Describe the risks factors.
• Describe the symptoms and signs of hepatic
tumors.
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3. Surgical anatomy
Diaphragmatic or upper surface of the liver
• Diaphragmatic or upper
surface-anterior,
superior and right
surfaces.
• Left and right lobes of
the liver are divided by
the falciform ligament.
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4. Posteroinferior or visceral surface
H-shaped arrangement of structures in
visceral surface
–Porta hepatis (the crossbar of the ‘H’)
–Ligamentum teres,
–Inferior vena cava (IVC),
–Gallbladder
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7. • The functional anatomy of the liver is
composed of eight segments, each supplied
by a single portal triad. composed of a portal
vein, hepatic artery, and bile duct.
• These segments are further organized into
four sectors separated by scissurae containing
the three main hepatic veins
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8. Anatomy of the liver
• Receives 1500 ml blood/minute
• 70% of this is from the portal vein(deoxygenated
blood).
• 30% of this is from the coeliac artery via the
hepatic artery(oxygenated blood).
• The lymph vessels leave the liver via the porta
hepatis.
• Anterior vagal trunk gives rise to a large hepatic
branch which passes directly to the liver.
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9. Classification of Hepatic tumours
A. Benign hepatic tumours
i. Cavernous hemangiomas
ii. Focal nodular hyperplasia
iii. Hepatic adenoma
iv. Bile duct hamartomas.
B. Malignant hepatic tumour
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10. Classification of hepatic cancer
A.PRIMARY LIVER CANCER
i. Hepatocellular carcinoma (HCC)/Hepatoma.
ii. Cholangiocarcinoma
iii. Fibrolamellar hepatocellular carcinoma.
B.METASTATIC CANCER
i. Metastasis from gastrointestinal (GI)
cancers(Colorectal-50%)
ii. Other Metastatic Disease to the Liver
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11. Hepatocellular carcinoma
(HCC)/Hepatoma.
Risk factors
• Hepatitis B or hepatitis C virus chronic carrier
state:
• Male gender
• Race africa-america
• Age above 50yrs
• Alcoholic cirrhosis: 60% to 90% of HCC occurs in
cirrhotic livers
• Exposure to foods contaminated with aflatoxins
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12. Risk factors for HCC…
• Metabolic disorders( hemochromatosis , α1-
antitrypsin deficiency, , type I glycogen
storage disease, citrullinemia, porphyria ,
tyrosinemia, and Wilson disease)
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13. Clinical features HCC
Symptoms
• Abdominal pain,
• Weight loss,
• Loss of appetite
• Yellowish
discoloration
• Abdominal
distension
Signs-stigmata of liver diseases
• Asterixis, Ascites, Ankle
oedema, Atrophy of testicles
• Bruising
• Clubbing/ Colour change of nails
(leuconychia)
• Dupuytren’s contracture
• Encephalopathy / palmar Erythema
• Foetor hepaticus
• Gynaecomastia
• Hepatomegaly
• Increase size of parotids
• Jaundice
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14. (2) Cholangiocarcinoma
• Much less common than HCC.
• Cholangiocarcinoma is an adenocarcinoma
arising from the biliary tree.
• May be intrahepatic or extrahepatic.
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16. CHOLANGIOCARCINOMA
Intrahepatic cholangiocarcinoma
• Occurs in normal livers.
• Asymptomatic.
Extrahepatic cholangiocarcinoma
• Arises from the
extrahepatic biliary tree.
• Divided into proximal
(Hilar, perihilar or Klatskin
tumor ) and Distal
cholangiocarcinoma.
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18. CHOLANGIOCARCINOMA
Symptoms
• Patients with
intrahepatic
cholangiocarcinoma
often are asymptomatic.
• But may present with
– Dull abdominal pain,
– Weight loss,
– Weakness
Signs
• Extrahepatic
cholangiocarcinoma:
– Jaundice,
– Cachexia,
– Hepatomegaly,
– Palpable gallbladder.
• Intrahepatic
cholangiocarcinoma:
– Cachexia in patients with
advanced disease,
– Right upper abdominal
mass.
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19. FIBROLAMELLAR HEPATOCELLULAR
CARCINOMA.
• A rare histologic variant of HCC.
• Males and females are equally affected
• Commonly at a younger age (20 to 40 years
old.
• It is uncommon for FLC to be associated with
underlying liver disease such as cirrhosis.
• The histology of FLC strongly resembles that
of FNH.
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20. Metastatic disease of the liver
• Metastasis from gastrointestinal (GI) cancers
because it is the first organ drainage site of
venous blood from the GI tract.
a. Colorectal cancer metastases to the liver
Accounts for the 50% of all patients with colorectal
cancer.
b. Other Metastatic Disease to the Liver
i. GI neuroendocrine tumors.
ii. Noncolorectal and nonneuroendocrine
metastasis.
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21. SUMMARY
• Most hepatic tumors are due to metastases.
• Classifications of hepatic tumors will assist in
their treatment.
• HCC is the most liver primary tumor.
• It is good to understand risk factors for
hepatic tumors.
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22. References
• The washing Manual of Surgery, Mary E.
Klingensmith,7th Ed.
• Schwartz's Principles of Surgery, 11th Ed.
• Greenfield's surgery : scientific principles and
practice 6th edition
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Metabolic disorders( hemochromatosis , α1-antitrypsin deficiency..etc , type I glycogen storage disease, citrullinemia, porphyria , tyrosinemia, and Wilson disease)
Reasons to resect neuroendocrine hepatic metastases include their relatively long tumor doubling time, a lack of effective chemotherapy, and the ability of metastasectomy to provide symptom palliation and long-term survival.
