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Dr. M. Atiq Popal's Guide to Liver Lesions
- 2. Liver lesion Incidentaloma By: Dr M. Atiq Popal General surgery Fellow Cure international hospital, Kabul 02/07/2017
- 3. Liver lesion Cystic liver lesion Solid liver Lesion Benign liver Mass Malignant liver mass Primary Secondary
- 4. Work up and risk groups history hepatic disease Viral hepatitis Autoimmune hepatitis Primary biliary cirrhosis Hemochromatosis Hemosiderosis Sclerosing cholangitis Long-term OC Wight loss High risk factors Cirrhosis for primary malignancy Metastasize Melanoma Breast malignancies Gastrointestinal malignancies
- 5. Cont. Work up and risk groups Examination hepatomegaly spider nevi a hard liver edge splenomegaly ascites. Jaundice Investigations LFT Hepatitis serology Tumor markers (AFP, CEA and CA19.9) Imaging US, Triphasic CT,MRI Biopsy Needle biopsy Open biopsy
- 6. Common benign liver lesion Hepatic hemangioma Focal nodular hyperplasia Hepatic adenoma Idiopathic noncirrhotic portal hypertension (including nodular regenerative hyperplasia) Regenerative nodule
- 7. Common Malignant solid liver lesion Hepatocellular carcinma Chlagiocarcinoma Metastatic disease Common in male Stomach Lung Colon Common in female Breast Colon Stomach Uterus Less common Pancreas Leukemia Lymphoma Caracinoid tumor
- 8. Hemangioma The most common benign liver tumor Prevalence from autopsy 3% to 20% Middle-aged women, Female-to-male ratio 6:1 Estrogen receptors Size less than 5 cm can reach 20 cm or larger Their blood supply is derived from the hepatic artery. Clinic Asymptomatic Intermittent symptoms may occur when there is necrosis, infarction, or thrombosis of the tumor. Life-threatening hemorrhage Kasabach-Merritt syndrome is a rare coagulopathy Don’t advice Needle biopsy Treatment Observation Hepatic artery embolization
- 10. Focal nodular hyperplasia (FNH) Second-most-common benign hepatic tumor about 8% of cases. Lesions usually are solitary and small and often are located near the edge of the liver. Clinical Epigastric or right-upper-quadrant pain with a palpable mass Diagnostic studies. US,CT, MRI Treatment. Elective resection is not indicated Resection for differentiate from adenoma or malignant lesions. Unresectable Transarterial embolization stop OC
- 12. Hepatic adenoma (HA) HA is the benign proliferation of hepatocytes. HA is found in young women and has a 4:1 female-to-male ratio. Risk OC, anabolic steroids solitary round, well-circumscribed lesions, unencapsulated. Clinic: Abdominal Pain One third spontaneous rupture Diagnostic studies. U/S non specific CT- scan MRI T99 Treatment: Small (<4 cm) Stop oral contraceptives. Radiofrequency ablation Indications for resection : Patients with lesions that are 5 cm or greater in diameter. Tumors that do not shrink after discontinuation of oral contraceptives . Patients who medically cannot stop OCP use. Women who are planning pregnancy.
- 13. Bile duct hamartomas Most common liver lesions seen at laparotomy. They are usually peripherally located and firm, smooth, and white, 1 to 5 mm lesionsin Distinguishing them from miliary metastatic lesions (colorectal cancer or cholangiocarcinoma) Biopsy should be perform the diagnose. Regenerative nodule History of Liver cirrhosis
- 14. Malignant liver solid lesion
- 15. Hepatocellular carcinoma HCC Primary liver malignancy 2.4/ 100000 Male : female 2-3:1 History of Chronic liver disease (cehrrhosis) Major risk HCV, alchol, autoimmune, metabolic Serology Immageng αFP , ECA
- 16. Chlangiocarcinoma Entra / extra hepatic Biliar duct Risk Primary scalrosing chlongitis Choduchal cyst MRI hypointense lesions on T1-weighted images and hyperintense lesions on T2-weighted images MRCP
- 17. Metastasis Common in western countries Cystic or solid Multiple Metastatic disease Common in male Stomach Lung Colon Common in female Breast Colon Stomach Uterus Less common Pancreas Leukemia Lymphoma Caracinoid tumor
- 18. Ultrasound CT MRI hemagioma well-demarcated homogeneous hyperechoic mass well-demarcated hypodense mass smooth, well-demarcated homogeneous mass that has low signal intensity on T1-weighted images and is hyperintense on T2-weighted FNH hyper-, hypo-, or isoechoic on ultrasoun hypo- or isodense on non-contrast imaging with a central scar identified have increased T1-weighted signal On T2-weighted images heterogeneous Hepatic andenoma ultrasonographic features are nonspecific CT features are variable Idiophatic portal hyper tension nodules hypoechoic, often with a hypoechoic rim limited diagnostic high-intensity pattern on T2-weighted images a low-intensity pattern on T1-weighted images HCC poorly-defined margins and coarse, irregular internal echoes increased vascularity compared high-intensity pattern on T2-weighted images a low-intensity pattern on T1-weighted images Cholangio carcenoma homogenous hypoechoic mass hypodense hepatic lesion with peripheral (rim) hypointense lesions on T1-weighted images and hyperintense lesions on T2- weighted images Metastasis multiple and hypoechoic internal heterogeneity lower attenuation MRI metastatic lesions appear as low- signal areas intraoperative ultrasound is still more sensitive
- 19. Approach to a solitary focal liver lesion ©2017 UpToDate, AFP: alpha-fetoprotein; CA: carbohydrate antigen; HBV: hepatitis B virus; HCC: hepatocellular carcinoma; FNH: focal nodular hyperplasia; MDCT: multidector computed tomography; MRI: magnetic resonance imaging. * Patients should be evaluated for HBV and cirrhosis if not already done. ¶ The management of patients with lesions <1 cm in size varies among institutions. Guidelines from the American Association for the Study of Liver Diseases recommend ultrasound rather than MRI. Δ HCC is likely if any of the following are present: The mass is known to be new in a patient being screened for HCC; the AFP has been rising; the AFP is >500 mcg/L; the mass is hypervascular on the arterial phase and radiolucent on the venous phase of a MDCT scan (arterial enhancement with washout); the mass has increased T2 signal intensity on MRI; the mass invades the portal vein. ◊ Other causes of an elevated AFP include pregnancy, tumors of gonadal origin, gastric cancer, and chronic liver disease without HCC. § Surveillance with MDCT or MRI is an alternative. If MDCT is being used, attention should be paid to the patient's cumulative radiation exposure. ¥ If the patient has a history of oral contraceptive use, a reasonable alternative is to stop the oral contraceptive and repeat the imaging in 3 to 4 months. If the lesion persists, it should be resected.
- 20. Guide line of American college of Gastro- entrology Clinical factors may help determine the cause of FLLs, including age, sex, oral contraceptive use, chronic liver disease history, and recent travel. FLL size is crucial in guiding the workup, as those smaller than 1 cm are generally benign incidental findings. Radiologic studies can easily differentiate cystic from solid lesions, and a quality imaging modality alone may precisely diagnose certain solid FLLs such as FNH and hemangiomas. Liver biopsy has a high risk of causing bleeding and often adds no additional value to the radiologic diagnosis of many benign lesions, such as hemangiomas and hepatocellular adenomas. Most FLLs presenting as incidentalomas are benign, requiring only patient reassurance and monitoring. Patients with cirrhosis and ultrasound lesion larger than 1 cm should undergo magnetic resonance imaging or triple-phase computed tomography.
- 21. Guide line of American college of Gastro-entrology Patients with chronic liver disease, especially cirrhosis, and solid FLLs must be considered to have hepatocellular carcinoma until otherwise proven. Patients with hepatocellular adenoma should avoid oral contraceptives, hormone- containing intrauterine devices, and anabolic steroids. Asymptomatic FNH does not require intervention. Management of nodular regenerative hyperplasia involves diagnosis and management of any underlying predisposing disease processes. Asymptomatic simple hepatic cysts should be observed with expectant management. Monotherapy with antihelminthic drugs is not recommended in symptomatic patients with suspected hydatid cysts who are surgical or percutaneous treatment candidates.
- 22. Cystic lesion of liver Cystic lesions of the liver represent a heterogeneous group of disorders, which differ in etiology, prevalence, and clinical manifestations. Small asymptomatic Larger cysts are more likely to be symptomatic and cause complications such as spontaneous hemorrhage , rupture into the peritoneal cavity or bile duct [, infection and compression of the biliary tree .
- 23. Cystic lesion
- 24. SIMPLE CYST Containing clear fluid 1 % of autopsied adults. Commonly in the right lobe Female-to-male ratio 1.5:1 Imaging studies — U/S CT MRI DDX mucinous cystic , hepatic abscess, necrotic malignant tumor, hemangioma, and hamartoma. Histology, Aspiration Treatment Fallow up evry 6-12 months for 2 years. Aspiration high recurency Unroofing Cyst resection Aspiration & sclerosing agent injection
- 26. Noninvasive mucinous cyst (Cystadenoma) Rare Right lob Asyptomatic or nonspesfic symptom DDX by histology Simple cyst, hydatid cyst, cyst adenocarcinoma Content blood or chocolate-colored material Treatment Resection
- 27. mucinous cystic neoplasm (Cystadenocarcinoma) Old age Multilocular Treatment Complete excision Radio/chemo result unknown
- 28. Other cystic lesion of liver Ciliated hepatic foregut cyst More in male More in lift lob Primary squamous cell carcinoma Poor prognoses Liver metastasis Central necrosis Ovarian, pancreas, colon, kidney, neuroendocrain Poly cystic liver disease Choleducla cyst Pain, jaundice, abdominal mass Hydatid cyst, liver pyogenic amoebic abscess,
- 29. Surgical anatomy of live International Hepato-Pancreato- Biliary Association
- 30. Surgery Diagnostic and therapeutic wedge resection Sigmentectomy Pluri-segmentectomy Lobectomy Liver transplantation
- 31. Summery for solid lesion Common lesions include: Hepatic hemangioma Focal nodular hyperplasia Hepatic adenoma Idiopathic noncirrhotic portal hypertension (including nodular regenerative hyperplasia) Regenerative nodules Hepatocellular carcinoma Cholangiocarcinoma Metastatic disease Majority solid liver lesions are asymptomatic, Follow algorithm Metastases to the liver are a likely cause of a solid liver lesion in patients with an extrahepatic malignancy. If the history and physical examination are negative, we typically start the evaluation with laboratory testing and a triphasic CT ,MRI. If imaging tests fail need biopsied or resected
- 32. Cystic Large asymptomatic, noncomplicated simple cysts should be monitored by periodic ultrasonography for the first two to three years Significant growth, progressive symptoms, or any suspicion of neoplastic cyst mandates surgical intervention. In symptomatic patients, the possibility of coexisting pathology must be excluded When symptoms are the only indication for surgery, selection of patients with truly symptomatic cysts Any suspicion regarding underlying malignancy (eg, solid or thickened cyst wall, nodules, etc.) mandates a biopsy for frozen section histopathology. Laparoscopic unroofing is usually curative for simple cysts
- 34. Internal anatomy A. first division Midplane of the liver and runs from the gallbladder fossa to the inferior vena cava The liver is divided into two almost equally sized hemilivers. The plane between the hemilivers is the. Each hemiliver is supplied by one hepatic arterial branch, one bile duct, and one portal vein. B. second division Further divisions of the liver are based on the internal course of the hepatic artery and bile duct. These structures retain a high order of bilateral symmetry, whereas the portal vein does not. Its asymmetry results from retained portions from the fetal circulation. The liver is thus divided into four nearly equal sections: the right anterior and posterior sections and the left medial and lateral sections. A vessel supplying a section is a sectional vessel (e.g., the right anterior sectional artery). C. third division The liver is further subdivided into segments numbered I to VIII. These are the same as originally described by Couinaud. Resection of a segment is termed a segmentectomy.
- 35. Summery and recommendation Solid lesion Benign or malignant A/symptomatic Fallow algorethem Cystic lesion Small simple cyst nedle aspiration not required Large asemptomatic cyst 2-3 year follow up Symptomatic cyst pathology Resection open lapracopic
- 36. Reference Uptodate Medescap Bailey & Love’s Short practice of surgery 26th edition Schwartz’s Principles of surgery 9th edition Washiton manual of surgery 6th edition
- 37. Idiopatic non cirrhotic portal hypertension appear isointense on T2-weighted images and contain foci of high intensity on T1-weighted images.
- 38. Patients with cirrhosis or chronic hepatitis B virus infection Patients with extrahepatic malignancy CT, FNA Patients without cirrhosis, HBV, or extrahepatic malignancy Size > 1cm Fallow up < 1cm
- 39. Clinical manifestation Asymptomatic Pain, pruritus, or a palpable mass Weight loss and early satiety Clinic of Cirrhosis Palmar Erythema, Spider Angiomata Hepatic Encephalopathy, Variceal Bleeding, Or Ascites Elevated Bilirubin, Prolonged Prothrombin Time, Anemia, And Thrombocytopenia Metastatic tumors History Physical exam
- 40. Lab test Α-FP other tumor marker Serology Imaging Triphasic abdominal CT MRI with gadolinium-based contrast histological examination US CEUS FNA Diagnose Risk Surgical resection