1) The document discusses the classification, diagnosis, and management of various benign and malignant liver lesions. It covers lesions originating from hepatocytes, cholangiocytes, mesenchymal tissues, and other rare etiologies. 2) For most benign liver lesions such as hemangiomas and focal nodular hyperplasia, conservative follow up is sufficient if they are asymptomatic and small (<5cm). Larger lesions may require resection if symptomatic. 3) Malignant liver lesions usually require resection or liver transplantation. Some specific malignant entities like hepatocellular carcinoma and cholangiocarcinoma can also be treated with locoregional therapies like transarterial chemoembolization.

1. 蘇建維1,2,3 侯明志2,4 吳肇卿3,5
1台北榮民總醫院內科部胃腸科
2陽明大學醫學院醫學系
3陽明大學醫學院臨床醫學研究所
4台北榮民總醫院內視鏡診斷暨治療中心
5台北榮民總醫院教學研究部

2. 肝臟結節之分類
來源 良性 惡性
肝細胞 (hepatocellular) 腺瘤 (adenoma) 肝細胞癌 (hepatocellular
carcinoma)
再生結節 (regeneration nodules) 纖維板層肝細胞癌
(fibrolamellar
carcinoma)
結節性再生性增生 (nodular regenerative hyperplasia) 肝母細胞瘤
(hepatoblastoma)
局部結節性增生 (focal nodular hyperplasia)
膽管細胞
(cholangiocellular)
膽管腺瘤 (bile duct adenoma) 膽管癌
(cholangiocarcinoma)
膽管囊腺瘤 (biliary cystadenoma) 囊腺癌
(cystadenocarcinoma)
單純囊腫 (simple hepatic cyst)
多囊性肝疾病 (polycystic liver disease)
間質細胞(mesenchymal) 血管瘤 (hemangioma) 血管肉瘤
(angiosarcoma)
血管脂肪瘤 (angiolipoma) 淋巴瘤 (lymphoma)
異位性(heterotopic) 腎上腺/胰/脾(adrenal/pancreatic/splenic) 轉移癌 (metastases)
感染性(infectious) 膿瘍(abscess)
結核 (tuberculosis)
血吸蟲 (schistosomiasis)

3. 血管瘤 (hemangioma) 局部結節性增生
(FNH)
腺瘤 (adenoma)
發生率 (%) 0.4-20 0.3-3 1x10-6 至1.2 x 10-4
好發年齡 30-50歲 30-50歲 各種年齡層
性別 (男:女) 1:2-6 1:5-17 1: 8-15
超音波所見回音性 高回音 (hyerechoic) 不一定 不一定
電腦斷層 靜脈性影像增強 中央疤
(central scar)
動脈相廣泛性影像增
強
磁振造影 腦脊髓液質地 肝臟質地 肝臟質地
T1時相影像為高訊號
(hyperintense)病灶
血管攝影 高血管性 高血管性 高血管性
核醫檢查 (Tc99m
sulfur colloid scan)
紅血球吸收 吸收 因缺乏Kupffer 細胞，
減少吸收
鈣化 會 不會 不會
結節破裂機會 極少 無 可能

4. Hemangioma: management
• Most hepatic hemangiomas remain stable over time and
require no treatment
• Treatment or follow-up is not indicated for asymptomatic
lesions that are < 5cm in diameter
• Rupture
– Large, peripheral-located
– Trauma
– Liver biopsy or fine needle aspiration
• Resection surgery:
– Symptomatic
– Rapidly enlarging
– > 15 cm in diameter at initial presentation
• Other treatment: radiofrequency ablation; cryoablation;
liver transplantation (for Kasabach-Merritt syndrome)

5. Adenoma: management (I)
• Depends on
– Symptoms
– Size
– Number of lesions
– Risk of bleeding, rupture, and malignant
transformation
• Risk of malignant transformation
– Around 10%
– Increase in size
– Rise in serum AFP levels
– β-catenin gene mutations

6. Adenoma: management (I)
• Small lesions (< 5cm):
– Periodic imaging
– OCP and steroid should be discontinued
– Therapy when symptomatic or increase in size despite
discontinuation of estrogen
• Resection surgery or liver transplantation
(glycogen storage disease or multiple adenomas)
• Mortality rate: < 1% in selection; 5-8% in
emergency resection of bleeding or ruptured
lesions
• Avoid pregnancy prior to resection

7. Liver adenomatosis
• Presence of 10 or more adenomas not associated
with steroid use, but with underlying glycogen
storage diseases
• Pathogenesis: thought to be secondary to
congenital or acquired abnormalities of hepatic
vasculature
• Hemorrhage appears to be common, particularly
in lesions > 4 cm
• Liver transplantation should be considered due to
high risk of bleeding, rupture and malignant
transformation

8. Management of suspected liver
benign lesions
Follow-up OCP use Pregnancy Treatment
Hemangioma Classic features:
no follow-up
Not absolutely
contraindicated
Not
contraindicated
Frequent follow-
up; resect if
symptomatic
(rarely needed)
FNH Classic features:
no follow-up
Not absolutely
contraindicated
Not
contraindicated
Frequent follow-
up; resect if
symptomatic
(rarely needed)
Adenoma Variable Stop No Stop OCP; resect if
solitary and large
(> 5cm)
Brhirwani R, Reddy KR. Aliment Pharmacol Ther 2008; 28:953-65

9. Algorithm for the diagnosis and treatment of FNH and adenoma
Nault JC, et al. Gastroenterology
2013; 144:888-902

10. 奧地利 多瑙河

11. Hepatic angiomyolipoma (AML):
management
• Hepatic AML was considered as a benign disease in the
past.
• Nevertheless, tumor rupture, metastasis, recurrence after
resection surgery of primary tumor, as well as concurrent
hepatic AML and HCC were reported recently.
• Conservative management with close follow-up is
reserved in asymptomatic patients with good
compliance, no chronic hepatitis, as well as small AML
which is less than 5 cm in size and is proved through fine
needle aspiration biopsy.
• Surgical intervention might be considered if the
progression of the tumor or the emergence of symptoms
occurs during the follow-up, especially for those with a
high risk for HCC.

12. Hepatic epithelioid
hemangioendothelioma: treatment
HEHE
Hemi-liver
involvement
Extra-hepatic
involvement
(+)
Liver resection ±
chemotherapy
TACE, chemotherapy, radioth
erapy
Extra-hepatic
involvement
(-)
Liver resection
Diffuse involvement
Extra-hepatic
involvement
(+)
Liver transplantation ±
chemotherapy
TACE, chemotherapy,
radiotherapy
Extra-hepatic
involvement
(-)
Liver transplantation
Mehrabi A, et al. Cancer 2006; 107:2108-21

13. Prognosis of HEHE
Mehrabi A, et al. Cancer 2006; 107:2108-21

14. Long –term prognosis of HEHE and
angiosarcoma after liver transplantation
Orlando G, et al. Transplantation 2013; 95:872-7

15. Management of hepatic angiosarcoma
Kim HR, et al. Ann Oncol 20:780-7

16. Hepatic TB management and
prognosis
• Hepatic TB is treated like any other extra-pulmonary
tuberculosis lesion.
• Chemotherapy with standard anti-TB drugs remains the
corner stone of treatment.
• Most authors have used four drugs (INH, Rifampicin,
Streptomycin and Pyrazinamide) during the initial two
months, followed by INH and Rifampicin for the next seven
months.
• Cumulative mortality for hepatic tuberculosis ranges
between 15% and 42%. The factors associated with adverse
prognosis are: age < 20 years, miliary tuberculosis,
concurrent steroid therapy, AIDS, cachexia, associated
cirrhosis and liver failure.

17. Cystadenoma: treatment
• Resection surgery is preferred due to
malignant transformation occurring in 15% of
patients
• Aspiration and partial resection are associated
with worse prognosis compared with
complete resection and an increased risk of
recurrence

18. Polycystic liver disease: treatment
• Asymptomatic: require no treatment
• Large cysts with symptom: hepatic resection
• Obstructive jaundice caused by extrinic
compression of the biliary tree: unroofing of large
cysts
• Portocaval shunting may be attempted for
patients with portal hypertension
• Percutaneous TAE: decrease intrahepatic cyst
volume
• Mammalian target of rapamycin (mTOR)
inhibitors decrease polycystic liver volume by
inhibiting the proliferation of biliary epithelium

19. 捷克 布拉格