BENIGN AND MALIGNANT LIVER CANCERS :Hepatic Hemangioma ,FNH, Hepatic adenoma, HCC, cholangiocarcinoma

1. LIVER CANCER
PRANAV THAZHE VEETTIL KARKKDAYIL
GROUP NO.4
DEPT OF SURGERY
TSMU

2. • Liver cancers are of 2 types
BENIGN
MALIGNANT
Benign Tumor Include
1) Hepatic Hemangioma
2) Focus Nodular Hyperplasia (F.N.H)
3) Hepatic Adenoma

3. HEPATIC HEMANGIOMA
• Most common benign tumor
• Womens are effected
• Clinical features:
Mostly asymptomatic
Symptomatic (abdominal discomfort)
• Kassabach Meritt Syndrome: Associated with consumptive
coagulopathy with low platelet count
Both FNAC and biopsy– contra indication due to bleeding
• IOC- MRI

4. • Treatment – Growth of hemangioma occurs by
ectasia not neoplasia
• Treatment of choice ENUCLETION

5. Focus Nodular Hyperplasia (F.N.H)
• Females due to oral contraceptive pills
• Second most common benign tumor of liver
• CECT – Central stellate scar
• Angiogram –CART WHEEL /SPOKE WHEEL
• Treatment – not required

6. Hepatic Adenoma
• Benign proliferation of hepatocytes
• Strongly associated with oral contraceptive pills
• Associated with increased risk of hemorrhage
and tumor

7. MALIGNANT TUMORS OF LIVER
• HEPATOCELLULAR CARCINOMA
• CHOLANGIOCARCINOMA
• HEPATOBLASTOMA
• HEPTIC ANGIOSARCOMA

8. HEPATOCELLULAR CARCINOMA
• Hepatocellular carcinoma (HCC) is the most common
type of primary liver cancer.
• Hepatocellular carcinoma occurs most often in people
with chronic liver diseases, such as cirrhosis caused by
hepatitis B or hepatitis C infection

9. • Most common primary malignancy of the liver.
Geographical distribution is clearly related to the
incidence of Hepatitis B infection.
• The highest incidence in - Southeast Asia and Tropical
Africa. The lowest incidence in - Australia, North
America and Europe. Epidemiologic evidence strongly
suggests that HCC is largely related to environmental
factors

10. • HCC is two to eight times more common in
males compared with females in low- and high-
incidence areas.

11. • The higher incidence in males is probably
related to higher rates of associated risk factors.
HBV infection,
• Cirrhosis,
• Smoking, Alcohol abuse, and
• Higher hepatic DNA synthesis in cirrhosis

12. Infections
• Hepatitis B virus
• Hepatitis C virus
• Cirrhosis Alcohol induced
• Autoimmune hepatitis
• Primary biliary cirrhosis
Environmental
• Aflatoxins
• Pyrrolizidine

13. Metabolicdiseases
• Hemochromatosis
• Alpha1-antitrypsin deficiency
• Wilson's disease Porphyria cutanea tarda
• Type 1 and 3 glycogen storage disease
• Galactosemia Citrullinemia Hereditary
tyrosinemia
• Familial cholestatic cirrhosis

14. CLINICAL FEATURES
• Most commonly, patients presenting with HCC
are men 50 to 60 years of age who complain of
right upper quadrant abdominal pain and weight
loss, and have a palpable mass.
• In countries endemic for HBV, presentation at a
younger age is common and probably related to
childhood infection

15. • Unfortunately, in unscreened populations, HCC
tends to present at a later stage because of the
lack of symptoms in early stages.
• Presentation at an advanced stage is often with
vague right upper quadrant abdominal pain that
sometimes radiates to the right shoulder.
• Nonspecific symptoms of advanced malignancy
such as anorexia, nausea, lethargy, and weight
loss are also common

16. • Another common presentation of HCC is hepatic
decompensation in a patient with known mild
cirrhosis or even in patients with unrecognized
cirrhosis.
• HCC can rarely present as a rupture, with the
sudden onset of abdominal pain followed by
hypovolemic shock secondary to intraperitoneal
bleeding

17. diagnosis
• Diagnosis is often confirmed with a biopsy
Diagnosis can sometimes be confirmed with blood or
imaging tests
• Physical examination
• Blood test for alpha-fetoprotein (AFP); 50%-70% of
people with primary liver cancer have elevated levels
• Ultrasound of the abdomen Computed tomography
(CT or CAT) scan
• Magnetic resonance imaging (MRI)

18. • AFP measurements can be helpful in the
diagnosis of HCC. An AFP level higher than
20 ng/mL is noted in approximately 75% of
documented cases of HCC.

19. • Radiologic investigation is a critical part of the diagnosis
of HCC. Ultrasound plays a significant role in screening
and early detection of HCC, but definitive diagnosis and
treatment planning rely on CT and/or MRI.
• Contrast-enhanced CT and MRI protocols aimed at
diagnosing HCC take advantage of the hypervascularity
of these tumors, and arterial phase images are critical to
assess the extent of disease adequately

20. • CT and MRI also evaluate the extent of disease
in terms of peritoneal metastases, nodal
metastases, and extent of vascular and biliary
involvement.
• Detection of bland or tumor thrombus in the
portal or hepatic venous system is also
important and can be diagnosed with any of
these modalities.

21. • If atypical features appear on imaging, a biopsy should
be obtained for histologic diagnosis.
• For hepatic nodules larger than 2 cm, a triplephase CT or
MRI scan is required if typical features of HCC are
identified in combination with an AFP level higher than
200 ng/mL.
• If typical features appear on imaging, the diagnosis of
HCC is confirmed.
• If atypical features are seen, then biopsy is required to
confirm the histologic diagnosis.

22. TNM GRADING
• T1 :solitory tumour 2cm without vascular
invasion
T1a : Solitary tumor <2 cm
T1b :Solitary tumor >2 cm without vascular invasion
T2 :Solitary tumor >2 cm with vascular invasion; or multiple
tumors, none <5 cm
• T3: Multiple tumors, at least one of which is >5 cm
• T4 :Single tumor or tumors of any size involving a major
branch of the portal vein or hepatic vein, or tumor(s) with
direct invasion of adjacent organs other than the gallbladder
or with perforation of visceral peritoneum

23. Regional lymph nodes (N)
NX:Regional lymph nodes cannot be assessed
• N0: No regional lymph node metastasis
• N1: Regional lymph node metastasiS
• METASTASIS
• Mo :NO distant metastasis
• M1:Distant Metastasis

24. treatment
• 1.Resection of right and left lobe
:Hemipectotomy
• 2.Trans arterial embolization
• 3.Partiation of liver
• 4.liver transplantation: we follow Millams
criteria
a)size of tumor <5cm
b) multiple tumor size <3cm and no. 2-3
c) no extrahepatic or vascular spread

25. CHOLANGIOCARCINOMA
• Malignancy of bile duct epithelium
• Usually in older patients

26. TYPES OF CHOLANGIOCARCINOMA
• INTRA HEPATIC - those starting within the
liver
• PRE HEPATIC – Bile duct cancer starting in the
hilum
• DISTSAL BILE DUCT CANCER – those satrting
from down.

27. RISK FACTOR
• Primary cholangitis
• Ulcerative colitis
• Cirrohsis
• HBV,HCV,HIV toxins
• Diabetes Mellitus
MOST COMMON SITE- HILUM- KLASTIN
TUMOR
• TUMOR MARKERS- CAG-G, CEA

28. HISTOLOGICAL
• Diffuse,infiltrate/sclerosinng (worst prognosis)
• Nodular/mass forming
• Papillary( Best prognosis)

29. CLINICAL FEATURES
• Painless progressive jaundice
• Fatigue
• Anorexia
• Clay coloured stools

30. INVESTIGATION
• Lab investigation
• Tumor markers- CEAX,CA19-9
• USG
• CT
• MRI + MRCP (ioc)

31. MRI IMAGE OF
INTRAHEPATIC
CHOLANGIOCARCINOMA
• MRI IMAGE OF HILAR
CHOLANGIOCARCINOMA

32. BISMUTH-CORELELLE CLASSIFICATION

33. BISMUTH-CORELELLE CLASSIFICATION

35. TREATMENT
• Hilar cholangiocarcinoma:
CBD Resection +lymphadenctomy+caudate lobectomy
Distal cholangiocarcinoma
:Pyrolous sparing Whipples Procedure