This document discusses the classification and treatment of liver tumors. It outlines four main categories of liver tumors: primary solid benign tumors, primary solid malignant neoplasms, cystic neoplasms, and metastatic tumors. Hepatocellular carcinoma and focal nodular hyperplasia are described as two of the most common primary benign and malignant liver tumors respectively. Surgical resection or liver transplantation are identified as the primary treatments for hepatocellular carcinoma when the liver function and extent of disease are suitable.

2. LIVER TUMORS
Dr. Mohammad Zarin
MBBS, FCPS, MRCS, FMAS
Associate Professor,
Surgical “E” ward,
Khyber Teaching Hospital, Peshawar.

9. CLASSIFICATION OF LIVER TUMMORS
1.PRIMARY SOLID BENIGN TUMORS
2.Primary Solid Malignant Neoplasms
3.CYSTIC NEOPLASMS
4.METASTATIC TUMORS

10. 1.PRIMARY SOLID BENIGN TUMORS
 LIVER CELL ADENOMA
 FOCAL NODULAR HYPERPLASIA
 HEMANGIOMA
 ADENOMATOUS HYPERPLASIA
 NODULAR REGENERATIVE HYPERPLASIA
 MESENCHYMAL HAMARTOMAS
 FATTY TUMORS
 BENIGN FIBROUS TUMORS
 BILE DUCT ADENOMAS

11. 2.Primary Solid Malignant Neoplasms
 HEPATOCELLULAR CARCINOMA
 INTRAHEPATIC CHOLANGIOCARCINOMA
 ANGIOSARCOMA
 NON-HODGKINS LYMPHOMA
 CARCINOID TUMORS
 MALIGNANT GERM CELL TUMORS
 EPITHELIOD HEMANGIOENDOTHELIOMA.

12. 3.CYSTIC NEOPLASMS
 SIMPLE CYST
 CYSTADENOMA & CYSTADENOCARCINOMA
 POLYCYSTIC LIVER DISEASE
 BILE DUCT CYSTS.

13. 4.METASTATIC TUMORS.
 COLORECTAL METASTASES
 NEUROENDOCRINE METASTASES
 NON- COLORECTAL NON- NEUROENDOCRINE METASTASES.

14. In Detail….

15. Liver Cell Adenoma

16. Liver Cell Adenoma
 a relatively rare
 young women (aged 20-40 years)
 female-to-male ratio 11:1
 associated with steroid hormone use such as oral
contraceptive pills
 usually single
 The presence of 10 or more adenomas is termed
adenomatosis.

17. CLINICAL PRESENTATION
 50% to 75% patients are symptomatic
 Upper abdominal pain is common
 tumor markers are normal
 CT usually demonstrates a well-circumscribed heterogenous
mass that shows early enhancement during the arterial
phase.
 MRI scans of LCA have specific imaging characteristics,
including a well-demarcated heterogenous mass containing
fat or hemorrhage.
 resection may be necessary to secure a diagnosis in difficult
cases.

18. MANAGEMENT
 Emergency Hepatic Artery embolization for Patients with acute
hemorrhage
 Once stabilized and resuscitated, RESECTION of the mass is required
 Asymptomatic patients are watched for regression after stopping
the OCPs

19. Focal Nodular Hyperplasia

20. Focal Nodular Hyperplasia
 Second most common benign tumor of the liver
 Mostly in young women.
 Usually a small (<5 cm) nodular mass
 Characterized by a central fibrous scar with radiating
septa

21. CLINICAL PRESENTATION
 Incidental finding at laparotomy or on imaging studies
 If symptomatic, most often vague abdominal pain
 Slightly deranged LFTs may be found
 Serum AFP levels are normal
 Diagnosed accurately by Contrast-enhanced CT and MRI
 a homogeneous mass with a central scar that rapidly enhances
during the arterial phase of contrast administration
 Rupture, bleeding, and infarction are exceedingly rare, and
malignant degeneration of FNH has never been reported.

22. MANAGEMENT
 Asymptomatic patients with typical radiologic features do not require
treatment
 If diagnostic uncertainty exists, resection may be necessary for histologic
confirmation
 Persistent symptomatic FNH or an enlarging mass need to be considered for
resection.

23. Hemangioma

24. Hemangioma
 Commonest benign tumor of the liver.
 Male to female (3:1 ratio) ,at a mean age of about 45 years
 Cavernous hemangiomas have been associated with FNH.
 Enlargement of hemangiomas are by ectasia rather than neoplasia.
 Lesions >5 cm are arbitrarily called giant hemangiomas
 Involution or thrombosis result in dense fibrotic masses which are
symptomatic & difficult to differentiate from malignancy

25. CLINICAL PRESENTATION
 Mostly asymptomatic and incidentally found on imaging
studies
 Large compressive masses may cause vague upper
abdominal symptoms
 An associated syndrome of thrombocytopenia and
consumptive coagulopathy known as Kasabach-Merritt
syndrome

26. INVESTIGATIONS
 LFTs and tumor markers are usually normal
 CT and MRI show a typical peripheral nodular enhancement pattern
 Labeled red blood cell scans
 Percutaneous biopsy of a suspected hemangioma is potentially dangerous
and inaccurate and is therefore not recommended

27. MANAGEMENT
Asymptomatic patients are simply observed
In Symptomatic patients resection is done
 Rupture, change in size, and development of the
Kasabach-Merritt syndrome are indications for
resection
The preferred approach to resection is enucleation
with inflow control

28. Liver hemangiomas in children
 Account for about 12% of all childhood hepatic tumors
 Usually multifocal and can involve other organs
 Can result in congestive heart failure secondary to arteriovenous
shunting, which are treated with Therapeutic Embolisation
 Untreated symptomatic have a 70% mortality rate, but small
capillary hemangiomas almost all resolve
 Resection may be necessary for symptomatic lesions or for rupture

29. Macroregenerative nodules
 previously known as adenomatous hyperplasia
 may be single or multiple
 Result from the hyperplastic response to chronic liver
injury
 Well-circumscribed, bile-stained, bulging surface
nodules that occur primarily in cirrhotic patients
 Have malignant potential and can be very difficult to
distinguish from hepatocellular carcinoma

30. Nodular regenerative hyperplasia
(NRH)
Benign, diffuse, micronodular (usually <2 cm)
Associated with lymphoproliferative disorders,
collagen vascular diseases, and the use of
steroids or chemotherapy.
 No malignant potential
 Not associated with cirrhosis.
Biopsy may be necessary to distinguish from
malignancy

31. Mesenchymal Hamartoma

32. Mesenchymal Hamartoma
 75% are age 1 year or less (rarely adults), 60-70% male
 8% of pediatric liver tumors
 Usually asymptomatic
 Serum AFP is usually normal or mildly elevated
 Rarely associated with undifferentiated sarcoma
 Adult cases are usually women with abdominal pain, more prominent
fibrosis and a lesser myxoid component than childhood cases, usually no
extramedullary hematopoiesis
 Treatment
 Excision
 liver transplantation

33. Cystic Tumors

34. Cystic Tumors
 May be single or multiple
 May be part of polycystic kidney disease
 Often asymptomatic
 No specific management required

35. Cystic Tumors
Simple cysts:
• Asymptomatic
• Pathogenesis:
• Embryonal development of
intrahepatic biliary duct
• Single layer
columnar/cuboidal
epitheliuam, straw-colored
serous fluid
• Diagnosis: imaging
• Treatment: Injection or
enucleation if
symptomatic

36. Cystic Tumors
 Multiple Cysts:
• Asymptomatic
• Polycystic liver disease – autosomal
dominant
• Hepatic parenchyma and function
preserved
• Pathogenesis:
• histo same as simple cysts
• Diagnosis: Imaging
• Treatment: resection or transplant if
symptomatic

37. Cystic Tumors
Cystadenomas
• Presentation:
• Benign w malignant
potential
• Slow growing,
• Pathogenesis
• Multilocular, single layer
cuboidal/columnar
epithelium
• Dx: Imaging
• Treatment: Resection

38. Cystic Tumors
Echinococcal/Hydatid Cysts
• Presentation:
• Travel SW US, Scotland,
Greece, Europe
• Asymptomatic, +/- fever,
abdominal pain
• Pathogenesis
• Echinococcus – humans
intermediary hosts
• Diagnosis: Imaging
• Treatment: Albendezole,
enucleation

39. Primary Solid Malignant
Neoplasms

40. Hepatocellular Carcinoma

41. AETIOLOGY
 Chronic alcohol abuse synergistic with HBV and HCV
infection
 Cigarette
 Aflatoxin, produced by Aspergillus
 Nitrites, hydrocarbons, solvents, pesticides, and vinyl
chloride & Thorotrast (colloidal thorium dioxide)

42. CLINICAL PRESENTATION
 Most commonly, men 50 to 60 years of age
 right upper quadrant abdominal pain and weight loss
and have a palpable mass
 anorexia, nausea, lethargy, and weight loss are
common
 Another common presentation of HCC is hepatic
decompensation in a patient with known mild cirrhosis
or even in patients without previously recognized
cirrhosis.
 HCC can present as a rupture, hepatic vein occlusion
(Budd-Chiari syndrome), obstructive jaundice,
hemobilia, or fever of unknown origin.

43. DIAGNOSIS
 Ultrasound plays a significant role in screening and early
detection of HCC
 definitive diagnosis and treatment planning rely on CT
and MRI
 An AFP level greater than 20ng/mL is noted in about
three fourths of documented cases of HCC
 a hypervascular mass consistent with HCC combined
with an AFP higher than 400ng/mL is diagnostic
 AFP levels are particularly useful in monitoring treated
patients for recurrence after normalization of levels

44. CONTD…..
 Percutaneous needle biopsies of liver lesions suspected of being HCC are
only necessary in patients who are being considered for nonoperative
therapies
 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 adequately assess the extent of disease
 CT and MRI also evaluate the extent of disease in terms of peritoneal
metastases, nodal metastases, and extent of vascular and biliary
involvement

45. STAGING
A. assessing the extent of disease
 Extent of disease in the liver, including macrovascular invasion and the
presence of multiple liver masses
 the common sites of metastases must be considered
 A preoperative chest x-ray is mandatory
 Routine bone scans are not performed unless there are suggestive
symptoms or signs.

46. B. Assessment of liver function
 absolutely critical in considering treatment options for a patient with HCC
 the risk for postoperative liver failure and death must be considered.
 clinical assessment schemes most commonly, Child's status (as modified by
Pugh) is used.
 significant portal hypertension regardless of biochemical assessments is
highly predictive of postoperative liver failure and death

47. Chronic liver disease is classified into
Child-Pugh class A to C, employing the
added score from above.

48. ROLE OF STAGING LAPAROSCOPY
 Staging laparoscopy has recently been employed as a staging tool in HCC
 spares about one in five patients a nontherapeutic laparotomy
 Laparoscopy yields additional information about extent of disease in the
liver, extrahepatic disease, and cirrhosis

49. STAGING SYSTEMS
 probably depend on the specific population being staged and the etiology
of HCC in that particular population
 The TNM staging system is not routinely used for HCC; it does not accurately
predict survival because it does not take liver function into account
 The Okuda staging system is an older but simple and effective system that
takes into account liver function and tumor-related factors
 The most well-validated staging system is the Cancer of the Liver Italian
Program (CLIP).

50. T1 Single tumour without vascular invasion
T2 Single tumour with vascular invasion or multiple nodules, none more than 5 cm in
greatest dimension
T3a Multiple tumours >5 cm
T3b Single tumour or multiple tumours of any size involving a major branch of the portal or
hepatic vein
T4 Tumour(s) with direct invasion of adjacent organ other than gallbladder or perforation of
visceral peritoneum
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastases
N1 Regional lymph node metastases

51. Survival Rate of Liver Cancer
 Stage I-III five year survival rate is 50%
 Stage IV five year survival rate is 10%

52. The Cancer of the Liver Italian Group
Score (CLIP)
CLINICAL PARAMETERS CUTOFF VALUES POINTS
Child-Pugh stage A 0
B 1
C 2
Tumor morphology Uninodular, <50% extension 0
Multinodular, <50% extension 1
Massive or extension >50% 2
AFP (ng/dL) <400 0
>400 1
Portal vein thrombosis No 0
Score ranges from 0 to 6;
scores of 4 to 6 are generally
considered advanced disease,
whereas scores of 0 to 3 have
the potential for long-term
survival.
Yes 1

53. PATHOLOGY
 Histologically, HCC is graded as well, moderately, or poorly differentiated
 The grade of HCC, however, has never been shown to accurately predict
outcome
 A.HANGING TYPE
 B.PUSHING TYPE
 C.INFILTRTIVE TYPE.
 Small tumors less than 5 cm in size usually do not fall into any of these
groups and are often discussed as a separate entity

55. Treatment Options for Hepatocellular Carcinoma
Surgical
Surgical
Resection
Orthotopic liver transplantation
Ablative
EtOH injection
Acetic acid injection
Thermal ablation (cryotherapy, radiofrequency ablation, microwave)
Transarterial
Embolization
Chemoembolization
Radiotherapy
Combination Transarterial and Ablative
External-beam Radiation Therapy
Systemic
Chemotherapy
Hormonal
Immunotherapy

56.  Complete excision of HCC either by partial hepatectomy or by total hepatectomy and
transplantation is the treatment of choice when possible because it has the highest
chance of long-term survival.
 only 10% to 20% of patients are considered to have resectable disease.
 mortality rate less than 5% for partial hepatectomy
 Patients with Child's B or C cirrhosis or portal hypertension do not tolerate resection.
 The volume of the future liver remnant (FLR) is also an important consideration
 Preoperative portal vein embolization is an effective strategy to increase the volume and
function of the FLR
Optimal Criteria
Solitary tumor < 5 cm
No vascular invasion
No portal hypertension
Well-preserved hepatic function (Child-
Pugh Class A

57. Negative prognostic factors
 tumor size,
 cirrhosis
 infiltrative growth pattern
 vascular invasion
 intrahepatic metastases,
 multifocal tumors
 lymph node metastases
 margin less than 1 cm
 lack of a capsule.
ResectionLiver
Transplantation
83, 57, 50 %84, 74, 62 %1, 3, 5-year Survival
70, 44, 31 %83, 72, 60 %1, 3, 5-year Disease
free

58. ROLE OF LIVER TRANSPLANTATION
 liver transplantation is the ideal treatment for HCC because it addresses
both the liver dysfunction and the HCC
 The limitations of transplantation are the need for chronic
immunosuppression as well as the lack of organ donors
 patients with single tumors less than 5 cm or multiple tumors no more than
three in number and 3 cm in size have resulted in improved outcomes
 Patients with advanced cirrhosis (Child's B and C) and early-stage HCC are
considered for transplantation, whereas those with Child's A cirrhosis have
similar results with transplantation and resection and should probably
undergo resection
Optimal Criteria
Solitary tumor < 5 cm
Up to three nodules <3 cm
No vascular invasion
No regional nodal or distant metasteses

59. Percutaneous ethanol injection (PEI)
 useful technique for ablating small tumors
 The tumor is killed by a combination of cellular dehydration, coagulative
necrosis, and vascular thrombosis.
 Most tumors less than 2 cm in size can be ablated with a single application
of PEI, but larger tumors may require multiple injections.
 Long-term survival after PEI for tumors less than 5 cm has been reported to
range from 24% to 40.
Optimal Criteria
Early stage HCC
Not resectable
Solitary tumors <3cm

60. Thermal ablative techniques
 Thermal ablative techniques that freeze or heat tumors to destroy them
have become very popular in recent years.
 Cryotherapy uses a specialized cryoprobe to freeze and thaw tumor and
surrounding liver tissue with resulting necrosis.
 Cryotherapy is usually performed at laparotomy or laparoscopically but
has recently been performed with percutaneous techniques
 Radiofrequency ablation (RFA) uses high-frequency alternating current to
create heat around an inserted probe, resulting in temperatures greater
than 60°C and immediate cell death.
 RFA can easily be performed percutaneously with low complication rates.

61. Transarterial therapy
 based on the fact that most of the tumor's blood supply is from the hepatic
artery
 Hepatic arterial infusion (HAI) chemotherapy using 5-fluorouracil (5-FU)-
based compounds, cisplatin, and doxorubicin has been studied
 requirement of a laparotomy to place the pump and associated hepatic
toxicity limits the applicability of this approach
 patients with preserved liver function and asymptomatic multinodular
tumors without vascular invasion ARE appropriate candidates .
Indications
Large unresectable HCC
Prior to resection or RFA
Palliative purposes

62. Radiofrequency Ablation
Optimal Criteria
Child-Pugh Class A/B
Solitary tumors <4cm

63. Radio Frequency Ablation

64. Ethanol Injection

65. HCC: Chemoembolization
 Inject chemotherapy selectively in hepatic artery
 Then inject an embolic agent
 Only in pt with early cirrhosis
 No role for systemic chemotherapy

66. Chemoembolization

67. OTHER MODALITIES
 Systemic chemotherapy with a variety of agents has been ineffective for
the treatment of HCC and has a minimal role in the treatment of HCC
 External-beam radiation therapy (EBRT) has a limited role in the treatment of
HCC, although occasional dramatic responses are seen
Indications
Large unresectable HCC
Symptomatic portal vein thrombosis
Symptomatic jaundice
Part of combined modality treatment

68. Fibrolamellar HCC
 This tumor generally occurs in younger patients without a history of cirrhosis.
 The tumor is usually well demarcated and encapsulated and may have a
central fibrotic area.
 The central scar can make distinguishing this tumor from FNH difficult.
 FHCC does not produce AFP, but is associated with elevated neurotensin levels.
 In general, FHCC has a better prognosis than HCC.
 This is likely related to high resectability rates, lack of chronic liver disease, and
a more indolent course.
 Long-term survival can be expected in about 50% to 75% of patients after
complete resection,
 but recurrence is common and occurs in at least 80% of patients.

69. Comparison of Standard Hepatocellular
Carcinoma (HCC) and Fibrolamellar
Hepatocellular Carcinoma (FHCC)
CHARACTERISTIC HCC FHCC
Male-to-female ratio 2:1-8:1 1 : 1
Median age (yr) 55 25
Tumor Invasive Well circumscribed
Resectability <25% 50%-75%
Cirrhosis 90% 5%
α-fetoprotein positive 80% 5%
Hepatitis B positive 65% 5%

70. Fibrolamellar Variant of Hepatocellular
Carcinoma
 Young adults 20-40 years, but 30-40% in patients are less than 20 years
old, no gender preference
 1-5% of all hepatocellular carcinoma
 Not associated with hepatitis B virus, cirrhosis or metabolic
abnormalities; pathogenesis unknown
 Better prognosis than classic HCC; 5 years survival is 60%
 Metastasizes to abdominal lymph nodes, peritoneum, lung
 Xray: central scar (similar to focal nodular hyperplasia); often calcified
(uncommon with FNH)
 Laboratory: serum alpha fetoprotein elevated in only 10% vs. 60% of
classic HCC
 Gross: single (75%), large (mean 13 cm), hard, scirrhous, well-
circumscribed, bulging, white-brown tumor with fibrous bands
throughout and central stellate scar; most cases involve left lobe, but
may involve both lobes; variable bile staining, hemorrhage and
necrosis

71. Hepatoblastoma
 Most common primary liver tumor in children (50% of liver
malignancies in children)
 90% occur by age 5 years, 70% by age 2 years
 2/3 male
 Associated with hemihypertrophy (Beckwith-Wiedemann
syndrome), Wilm’s tumor, glycogen storage disease, familial
colonic polyposis); not associated with cirrhosis
 Symptoms: variable virilization due to hCG production by
multinucleated giant cells
 Laboratory: elevated serum AFP in 75%
 Metastases to regional lymph nodes, lung, brain, adrenal glands,
bone marrow
 Treatment: preoperative chemotherapy and surgery; resect lung
metastases; liver transplant if unresectable
 Long term survival now 60-70%
 Prognostic factors: stage, age, sex; increase mitotic activity may
confer poorer prognosis; presence of osteoid may confer
favorable prognosis

72. Hepatoblastoma
Gross: tan-green, 70% solitary, well circumscribed, variable
hemorrhage and cysts; mean 10 cm (range 3-20 cm), often
partially encapsulated; may be calcified in prominent
mesenchymal component

73. Angiosarcoma
 Rare (10-30 annual cases in US), but most common hepatic
primary sarcoma in adults (2% of all primary liver tumors)
 75% men, usually age 50+ years; rare in children
 Causes: 25-42% associated with exposure to vinyl chloride,
arsenic, Thorotrast (thorium dioxide) or androgen steroids;
rarely associated with copper sulfate, estrogenic steroids,
phenelzine, radiotherapy, chemotherapy, hereditary
hemochromatosis
 Patients with exposure to vinyl chloride or Thorotrast may
have synchronous cholangiocarcinoma or hepatocellular
carcinoma
 Most patients die within 6 months from hepatic failure,
intraabdominal bleeding; metastasizes widely, often to lung

74. Undifferentiated Sarcoma
 Also called embryonal sarcoma, malignant mesenchymoma,
mesenchymal sarcoma
 Usually ages 6-10 years, rare in adults, 10% of pediatric
hepatic tumors (#3 after hepatoblastoma and hepatocellular
carcinoma)
 Often aneuploid
 Appears to be a primitive mesenchymal neoplasm with
possible foci of differentiated sarcoma
 Presents with abdominal mass, fever, pain, normal serum AFP
 Most patients die within 2 years due to direct extension; often
metastasizes to lung, pleura, peritoneum
 Treatment: complete resection

75. Undifferentiated sarcoma
 Gross: 10-30 cm, solitary, well-demarcated, soft tumor with
cystic, gelatinous, hemorrhagic and necrotic foci
 Micro: variably cellular tumor with anaplastic, spindled / oval
cells with hyaline globules and ill-defined borders within
pseudocapsule; nuclei have stippled chromatin,
inconspicuous nucleoli; variably myxoid stroma with
numerous thin-walled veins

76. Cholangiocarcinoma (intrahepatic)
 Also called bile duct carcinoma
 10% of primary liver cancers
 High prevalence in southeast and eastern Asia
 10-20% are associated with cholangitis due to autosomal dominant
polycystic disease, congenitally dilated hepatic ducts (Caroli’s
disease), congenital hepatic fibrosis, infection by liver flukes,
Thorotrast, anabolic steroids, intrahepatic lithiasis (5-10% of these
patients), primary sclerosing cholangitis (7-42% of these patients)
 Diagnosis of exclusion (must rule out metastatic adenocarcinoma)
 Usually age 60+ years; no gender preference
 Laboratory: normal AFP
 Poor prognosis; death usually within 6 months
 50-75% metastasize to regional lymph nodes, lungs, vertebrae,
adrenals, brain, elsewhere at autopsy

77. Intra Hepatic Cholangiocarcinoma
 15%of primary liver cancers
 Primary sclerosing cholangitis a predisposing condition
 Widespread infection with liver flukes
(Clonorchissinensis) is at least partly responsible for the
higher incidence of these tumors in some parts of Asia
 There is evidence to suggest that chronic hepatitis C
infection is associated with the rising worldwide
incidence of intrahepatic cholangiocarcinoma

78. Cholangiocarcinoma (intrahepatic)
Gross: solitary, 7-10 cm,
multinodular or diffuse
small nodules < 1 cm;
gray-white and firm;
often hepatomegaly and
satellite nodules; rarely
cirrhosis; rarely bile
stained; may invade
portal vein

79. Cholangiocarcinoma (intrahepatic)
Patterns
 signet ring
 adenosquamous
 osteoclast giant cell
 sarcomatous
 colloid, mucoepidermoid, rhabdoid, clear cell, lymphoepithelioma-like

80. The appearance of intrahepatic CCA is
suggestive of a secondary tumor
Diagnosis of intrahepatic CCA usually
requires a biopsy
which reveals an adenocarcinoma that
is indistinguishable from a hepatic
metastasis arising from a primary
adenocarcinoma
An elevated CA 19-9 concentration is
strongly suggestive of this diagnosis

81. Epithelioid Hemangioendothelioma
 Malignant endothelium derived neoplasm with
intermediate clinical course between hemangioma
and angiosarcoma
 Hepatic EH is considered a neoplasm of
unpredictable malignant potential: the metastatic
rate of hepatic EH was 27%, and 43% of the patients
ultimately died of their disease.
 Mean age 47 years, but occurs at any age, 60%
women
 No predisposing factors
 FNA not recommended as even small biopsies can
be misleading

82. Secondary Liver Tumors (Metastatic)

83. Secondary Liver Metastases
The most common site for blood born
metastases
Common primaries : colon, breast, lung,
stomach, pancreases, and melanoma
Mild cholestatic picture (ALP, LDH) with
preserved liver function
Dx imaging or FNA
Treatment depends on the primary cancer
In some cases resection or
chemoembolization is possible

84. Thanks