This is about liver tumor

1. LIVER TUMORS: PRIMARY AND
METASTATIC TUMORS

2. Table of Content:
 Anatomy
 Classification
 Primary Liver tumor
 Metastatic Tumor
 Grading of Tumor
 Staging of Tumor
 Prognosis

3. ANATOMY
 Site: in the upper part of the abdominal cavity occupying the right
hypochondrium, epigastrium and extending to the left hypochondrium.
 Size: It is the largest organ in the body with weight of ~1.5kg
 Shape: Wedge-shaped with it's base directed to the right

4. DIVISION OF LOBES
 Surgical (Structural) lobes: On the basis of intrahepatic distribution of
hepatic artery, portal vein and biliary duct, the liver is divided into 2 nearly
equal lobes
• Right Lobe
• Left Lobe
 Segmental Lobes: Divided into 8 segments based on hepatic and portal
venous segments (Couinaud System)
• Caudate lobe : segment I
• Left lobe : segment Il – IV
• Right lobe : segment V - VIll

5. HEPATIC PORTAL SYSTEM
 The hepatic portal system is the venous system that returns blood from
the digestive tract and spleen to the liver
 The main vessel of the hepatic portal system is the hepatic portal vein.
 The hepatic portal vein is formed by the confluence of 3 main vessels, the
gastric, pancreaticomesenteric and lienomesenteric veins.
 They unite to form the hepatic portal vein near the anterior tip of the
dorsal lobe of the pancreas.
 The celiac artery splits into its branches very near this point as well.
Occasionally, the gastric and lienomesenteric veins join to form a very
short vessel that then unites with the pancreaticomesenteric to form the
hepatic portal vein.

6. ANATOMY

7. ANATOMY
Blood Supply
 75% from portal vein and 25% from hepatic artery
 Blood of both vessels is mixed in the liver sinusoids
Nerve supply
 Liver receives nerve supply from the hepatic plexus containing:
• Sympathetic fibers: derived from celiac plexus
• Parasympathetic fibers: from the anterior and posterior vagal trunks
Lymphatic Drainage
 Mainly into hepatic lymph nodes in porta hepatitis.
 Efferent vessels pass to celiac lymph nodes

8. LIVER TUMOR
 Liver tumors also known as hepatic
tumors are abnormal growth of liver cells
on or in the liver.
 Several distinct types of tumors can
develop in the liver because the liver is
made up of various cell types.

9. CLASSIFICATION
They can be divided into 2 groups:
 Benign tumors:-
• Mostly associated with chronic liver diseases with hepatitis B
and C (originating in the liver itself)
• They include Hemangiomas, Focal nodular hyperplasia,
Adenoma and Liver cysts
 Malignant tumors are again divided into Primary liver tumors
and Metastatic Tumors
• Primary tumors – Hepatocellular carcinoma, Fibrolamellar
carcinoma and Hepatoblastoma
• Metastatic tumors
• Metastasis from other primary sites particularly the digestive
system, breast and lungs through the portal system.

10. HEPATOCELLULAR CARCINOMA
 HCC is the most common type of primary liver
cancer in adults and is currently the most
common cause of death in people with
cirrhosis and the third leading cause of
cancer-related deaths worldwide.
 Causes include Hepatitis B and C, Cirrhosis,
Smoking, Alcohol abuse and Aflatoxin
 Symptoms include RUQ pain, weight loss,
acute liver failure, worsening of pre-existing
chronic liver disease

11.  Lab test include Alfa feto protein (>100ng/mL)
which is a HCC tumor marker
 Diagnosis
• Biopsy
• Triphasic CT scan
• MRI scan

12.  Treatment:
• Liver transplantation- Removes both the tumor and the liver. Done
only if a single tumor is less than 5cm or less than 3 tumors having
Here the recurrence rate is low
• Resection- Feasible for small tumors with preserves liver function
(no jaundice or portal HTN). Here the recurrence rate is high
• Local Ablation- For non resectable patients and for patients with
advanced liver cirrhosis. This is a temporary measure only. Alcohol
Radiofrequency is used here
• Chemoembolization- Inject chemotherapy selectively in hepatic
artery and then injecting an embolic agent. This is only done in

13. RADIO FREQUENCY ABLATION ETHANOL INJECTION CHEMOEMBOLIZATION

14. FIBROLAMELLAR CARCINOMA
Mainly presented in young patients (5-35 yrs)
Not related to cirrhosis
Due to lack of symptoms, until the tumor is sizable,
this form of cancer is often advanced when
diagnosed.
Symptoms include vague abdominal pain, nausea,
abdominal fullness, malaise and weight loss. They
may also include a palpable liver mass.
AFP is normal

15.  Diagnosis - ultrasound, CT, MRI and biopsy.
CT shows typical stellate scar with radial
persistent enhancement
 Treatment- surgical removal is preferred.
Liver resection is the optimal treatment and
performed more than once, since this
high recurrence rate. Due to such
follow-up medical imaging (CT or MRI) is
heterogeneous
echogenic lesion
Echogenic
strands

16. HEPATOBLASTOMA
Hepatoblastoma is a malignant liver cancer occurring in
infants and children (0-3 yrs) and composed of tissue
resembling fetal liver cells, mature liver cells, or bile duct
cells.
They usually present with an abdominal mass.
Lab test- AFP is elevated. The normal level for AFP in
children has been reported as lower than 50 nanograms
per milliliter (ng/ml) and 10 ng/ml in adults. An AFP level
greater than 500 ng/ml is a significant indicator of
hepatoblastoma

17.  Treatment-
• Surgical removal of the tumor,
chemotherapy prior to tumor removal,
transplantation have been used to treat
• Primary liver transplantation provides
disease-free survival rate in the range of
of complete tumor removal and adjuvant
survival rates approach 100%.

18. SECONDARY LIVER METASTASES
 The common primaries include colon, breast, lung, stomach and pancreas
 Mild cholestatic picture (ALP,LDH) with preserved liver function
 Diagnosis: Imaging or Fine needle aspiration(FNA)
 Treatment depends on the primary cancer

19. COLORECTAL CANCER
 Colorectal cancer is the 3rd most common cancer worldwide
 The liver is recognized as the most common site foe CRC metastasis because of the
intestinal mesenteric drainage enters the hepatic portal venous system
 More than 50% of the patients with CRC will develop metastatic disease to their liver over
the course of their life.

20.  Currently, hepatic resection of colorectal cancer liver metastasis
in patients with isolated liver metastasis remains the only options
for potential care.
 However, even when resection is combined with modern
adjuvant systemic regimens, it is curative in only 20% of patients
with 70% developing recurrence, primarily in the liver
 Detecting 1ry CRC and CRLM at an early stage results in better
prognosis

21. GRADING OF LIVER TUMOR
There are 4 grades
• Grade I- well differentiated
• Grade II- moderately differentiated
• Grade III- poorly differentiated
• Grade IV- undifferentiated
 The grade of a hepatocellular carcinoma is only a weak prognostic
indicator, meaning it is not particularly useful in dictating treatment or
predicting the likelihood of survival

22. STAGING OF LIVER TUMOR
 In staging we not only check the stage of the cancer but also the severity
of the underlying cirrhosis and the patient’s overall health status
 Here we use TNM system
• STAGE 1- T1N0MO • STAGE 2-TNM

23. • STAGE 3A-T3aN0M0 • STAGE3B-T3bN0M0 • STAGE3C-T4N0M0

24. • STAGE 4A-AnyT N1M0 • STAGE4B-AnyT, AnyNM1

25.  The severity of liver cirrhosis is graded using the Child-Pugh system also known as Child-
Pugh-Turcotte score which combines several measures of the liver’s synthetic and
detoxification functions:

26. PROGNOSIS
The survival rates for liver cancer vary based on several factors. These include the stage of
cancer, a person’s age and general health, and how well the treatment plan works.
For the 43% of people who are diagnosed with liver cancer at an early stage, the 5-year
relative survival rate is 36%.
If the cancer has spread to surrounding tissues or organs and/or to the regional lymph
nodes, the 5-year relative survival rate is 13%.
If the cancer has spread to a distant part of the body, the 5-year relative survival rate is 3%.