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Focal liver lesion


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Focal liver lesion

  1. 1. Focal liver lesionFaculty of surgerySongkhla hospital
  2. 2. WORKUP ALGORYHM FOR LIVERMASSMass on scanHistory of priormalignancyNo history of priormalignancy
  3. 3. HistoryO Symptoms - abdominal pain/ pressureeffect,fever,anoraxia,weight lossO Patient characteristics (age, gender, use ofOCP, risk factors for chronic liver disease )O History or findings of extrahepatic malignancy
  4. 4. Physical examination andinvestigationO Sign of chronic liver stigmata or portalhypertentionO LymphadenopathyO CBC with PLT , coagulogram , LFT, hepatitis profile , tumor markerO Ultrasound , CT scan , MRI
  5. 5. O Study show accurate preoperativeevaluation of liver mass lesions withoutfine-needle biopsy about 98% by historyand lab (including tumor markers) and avariety of imaging studies
  6. 6. Find needle biopsyO commonly used to assist in the diagnosisof a variety of liver lesionsO DisadventageO Increase risk of bleeding and seeding ofneoplastic cellsO Some type liver lesion cannot diagnosissuch as hepatic adenomas and focalnodular hyperplasia
  7. 7. MalignancyO Metastatic liver tumorsO HCCO CholangiocarcinomaO Rare tumor hepatoblastoma , Germ celltumor , Angiosarcoma , non-Hodgkinlymphoma
  8. 8. Metastatic liver tumorsO Most common metastasis malignanthepatic neoplasmO The most common primaries :breast, lung, colonO History or findings of extrahepaticmalignancy menifestation
  9. 9. O U/SO multiple and hypoechoic lesion withHypoechoic rims and internal heterogeneityO CTO Hypovascular or hypervascular mass dependon metastasis originO MRIO metastatic lesions appear as low signal areason T1-weighted images and moderately highsignal on T2-weighted images
  10. 10. HCCO Most common primary malignancy liver tumorO Risk factors for chronic liver disease , viralhepatitis expect Hepatitis A ,metabolic liverdiseases , expose hepatotoxinO Male : female > 4 : 1O Clinical : vary such as asymptomatic, abdominal pain , weight loss , paraneoplasticsyndromeO Diagnosis : elevate AFP , CT scan
  11. 11. InvestigationO U/SO round or oval mass with sharp, smoothboundaries ,vary echogenicityO CT scanO Vascular enhancement hepaticarteryO Liver cirrhotic change , ascites , splenomegalyO Non contrast phase : hypodense massO Contrast phase : arterial phase rapid vascularenhancement then venous phasehypodense
  12. 12. Hepatocellular carcinoma, CT of the liver before (a) and 15 sec (b), 45 sec (c)and 90 sec (d), respectively, following intravenous contrast medium administration
  13. 13. Fibrolamellar hepatocellularcarcinoma (FCHC)O FHCC is a rare form of hepatocellularO Approximately 200 new cases are diagnosedworldwide each year.O FHCC often does not produce AFPO However, FHCC is elevated neurotensin levels.O FHCC generally occurs in young adults (~27yr.)without underlying cirrhosis.O FHCC grows slowly and has better prognosis,
  14. 14. Fibrolamellar hepatocellularcarcinoma (FCHC)O The histopathology of FHCC ischaracterized by laminated fibrouslayers, interspersed between the tumorcells.O FHCC has a high resectability rate
  15. 15. HepatoblastomaO most common liver cancer in childrenO most commonly diagnosed during achilds first three years of lifeO usually present with an abdominal massO Patients with familial adenomatouspolyposis (FAP) are risk factorO Often elevated AFPO Treatment : Surgical resection, adjuvantCMT, and liver transplantation
  16. 16. Germ cell tumorO Germ cell tumor is a neoplasm derivedfrom germ cells.O can be cancerous or non-cancerousO ClassificationO Germinomatous or seminomatousO Non-germinomatous or non-seminomatous
  17. 17. Classification ofGerm cell tumorO Germinomatous - 10% have elevated hCGO DisgerminomaO SeminomaO Non-germinomatousO Embryonal carcinomaO yolk sac tumor - 100% secrete AFPO Choriocarcinoma - 100% secrete hCGO TeratomaO PolyembryomaO GonadoblastomaO Mixed
  18. 18. Germ cell tumorO Compared to germinomatoustumors, nongerminomatous tumors tendtoO grow fasterO earlier mean age at time of diagnosis(~25 vs 35 years)O lower 5 year survival rateO The survival rate for germinomatoustumors is higher because these tumorsare very sensitive to radiation and CMT
  19. 19. Treatment of GCTO Women with benign germ cell tumors suchas dermoid cysts are cured by ovariancystectomy or oophorectomyO In general, all patients with malignant germcell tumors will have the same staging surgerythat is done for epithelial ovarian cancer.O If the patient is still interested in havingchildren, an alternative is unilateralsalpingoophorectomy, while the uterus, theovary, and the fallopian tube on the oppositeside can be left behind.
  20. 20. Treatment of GCTO Most patients with germ cell cancer willneed to be treated with combination CMTfor at least 3 cycles.O The CMT regimen most commonly usedin germ cell tumors is called PEB (or BEP)and consistsof bleomycin, etoposide, a platinum-basedantineoplastic (cisplatin)
  21. 21. CholangiocarcinomaO It has an annual incidence rate of 1–2cases per 100,000 in the Western worldO rates of cholangiocarcinoma have beenrising worldwide over the past severaldecades.
  22. 22. CholangiocarcinomaO It may be suspected in a patientwith obstructive jaundice.O CT scanning is an important role in thediagnosis of cholangiocarcinoma.O may be challenging in patients with primarysclerosing cholangitis (PSC)O ERCP advantages include the ability toobtain biopsies and to place stents orperform other interventions to relieve biliaryobstruction.
  23. 23. Benign
  24. 24. BenignO HemangiomasO Focal nodular hyperplasiaO hepatic adenomasO Simple cysts
  25. 25. HemangiomasO Most common benign liver tumorsO Female : male > 3 : 1O Most are asymptomatic and no malignanttransformationO Large hemangiomas can cause symptoms asa result of compression of adjacent organs orintermittent thrombosisO Surgery may be considered an option if thepatient is symptomaticO Gross : round pink or red capsule
  26. 26. HemangiomasO U/SO echogenic spot, well demarcatedO CT scanO Early phase hypodense peripheralenhancementO Delay phase contrast fillling massO MRIO High sens and spec , high acurracyO Hyperdense in T2 and blood fill space
  27. 27. Peripheral nodular enhancement followby gradual centripetal enhancement
  28. 28. Focal nodular hyperplasiaO Most commonly in women andasymptomaticO No malignant transformationO Gross : subcapsular lesion and centralscarO Surgery indicate in symptomatic patient
  29. 29. Focal nodular hyperplasiaO U/SO Nodule with varying echogenicityO CT scanO Non contrast phase low density massO contrast phase rapid enhance andwash out with central scarO MRIO Hyperdense and central scar
  30. 30. HomogeneousIsoattenuationImmediateIntense enhancementCentral scar 2/3
  31. 31. FNH & HemangiomaSymptomatic : Surgery****
  32. 32. Hepatic AdenomasO Benign epithelial liver tumor that usuallyoccurs in non-cirrhotic liverO most commonly seen in premenopausalwomen older than 30 years of age and relatewith oral contraceptives useO About 50 % abdominal pain and 30 %bleedingO Risk of malignant transformation 10%O Surgery indicate in mass > 4 cm , nodecrease size when stop pill
  33. 33. hepatic adenomasO U/SO often large and in the right lobe of the liverand hyperechoic lesionO CT scanO Non-contrast scanO well-demarcated low density massO Contrast-enhanced scansO Rapid enhance and wash out same FNHO No central scar difference from FNH
  34. 34. HA
  35. 35. Thank you