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2. LIVER TUMOURS

3. INTRODUCTION

4. INTRODUCTION
• Liver tumours or hepatic tumours are
tumours or growths on or in the liver.
• Medical terms pertaining to the liver often
start in hepato-or hepatic from
the Greek word for liver, hepar.

5. CLASSIFICATION

6. CLASSIFICATION
• Solid Neoplasms
– Solid Benign Neoplasms
– Solid Malignant Neoplasms
• Cystic Neoplasms
– Simple Cyst
– Cystadenoma and Cystadenocarcinoma
– Polycystic Liver Disease
– Bile Duct Cysts

7. CLASSIFICATION
• Solid Benign Neoplasms
1. Hepatic Haemangioma
2. Hepatic adenoma ( Hepatocellular
adenoma/Hepadenoma)
3. Focal nodular hyperplasia
– Other benign tumours
• Solid Malignant Neoplasms
1. Primary Solid Malignant Neoplasms
2. Metastatic Tumors

8. CLASSIFICATION
• Primary Solid Malignant Neoplasms
– Hepatocellular Carcinoma
– Intrahepatic Cholangiocarcinoma
– Other Primary Malignant Neoplasms
• Hepatoblastoma, sarcomas, Non-Hodgkin’s
lymphoma (NHL) Primary hepatic neuroendocrine
tumors or carcinoid tumorsMalignant germ cell
tumors of the liver including teratomas,
choriocarcinomas, and yolk sac tumors are very rare
and are principally described in the pediatric
population. Epithelioid hemangioendothelioma
• Metastatic Tumors

9. CLASSIFICATION
• Metastatic Tumors
– Colorectal Metastases
– Neuroendocrine Metastases
– Noncolorectal,Non-Neuroendocrine
Metastases

10. CLASSIFICATION
• Several distinct types of tumours can
develop in the liver because the liver is
made up of various cell types.
THEY ARE CLASSIFIED INTO:
• BENIGN TUMOURS
• MALIGNANT TUMOURS (Most cases
are metastases from other tumours,
frequently of the GI tract)

11. BENIGN TUMOURS

12. BENIGN TUMOURS
• Benign focal liver masses are present in
approximately 10% to 20% of the
population.

13. BENIGN TUMOURS
• The more common benign tumours of the
liver include:
1. Hepatic Haemangioma
2. Hepatic adenoma ( Hepatocellular
adenoma/Hepadenoma)
3. Focal nodular hyperplasia
• Other benign tumour which are very rare
include fibroma, lipoma, leiomyoma and
cystadenoma.

14. Investigations

15. Investigations
• Laboratory Studies
– Routine
– Special
• Imaging Studies
• Tissue diagnosis
– Cytology
• FNAC
– Histology

16. Diagnostic Studies

17. Diagnostic Studies
Imaging Studies
• X-Ray
• USG
• CT
• Angiography
• MRI
• Endoscopy
• Nuclear scan

18. Diagnostic Studies
• Many benign lesions can be adequately
characterized by modern imaging studies
such as CT, ultrasound, and MRI
• serum tumor markers (e.g., AFP, CEA)
• search for a primary tumor
• A resection might be necessary to make a
definitive diagnosis.
• Laparoscopic techniques for assessment,
biopsy, and/or resection have become an
important diagnostic technique as well.

19. Hepatic Haemangioma
• A liver haemangioma is a tangle of
blood vessels in or on the surface of the
liver.
• The most common benign liver tumour
in adults and children.
• They are more common in the right
lobe of the liver than in the left lobe

20. Hepatic Haemangioma

21. Hepatic Haemangioma
• Liver haemangiomas are noncancerous.
• These growths are usually about 4 cm in
size ( In some cases, they can grow
much larger.)
• Typically, there can occur only one liver
haemangioma, however in few cases in
which several have been found on liver
at once.

22. Hepatic Haemangioma: Causes &
Risk factors-
• Congenital.
• Diagnosed in patients between the
ages of 30 and 50.
• Women more men
• Women who are on hormone therapy
to increase their oestrogen levels are at
an increased risk of developing liver
haemangiomas.

23. Hepatic Haemangioma: Symptoms
and signs
• Asymptomatic
• However, if they have been aggravated
by an injury or fuelled by a change in
oestrogen levels, symptoms can occur.
• Pain in the upper-right side of the
abdomen
• Feeling full after eating a small amount
of food
• Nausea, Vomiting, anorexia

24. Hepatic Haemangioma
• Diagnosis -
• Usually undiagnosed until accidently found in other
circumstances
• Ultrasound, CT scan, MRI scan, or a single photon
emission computerized tomography (SPECT) scan.
• Treatment- Most liver haemangiomas do not require
treatment. However, if the haemangioma is large or
causes symptoms, it can be removed surgically,
hepatic artery ligation, arterial embolization.
• In Extremely rare cases, a liver transplant surgery or
radiation treatments may be required

25. Hepatic adenoma
• Uncommon benign liver tumour.
• Also called as Hepatocellular
adenoma/ Hepadenoma
• Large hepatic adenomas have a tendency
to rupture and bleed massively inside the
abdomen.

26. Hepatic adenoma
Causes & Risk factors-
• 90% hepatic adenomas arise in women aged 20–40.
• Patients taking higher potency hormones, patients of
advanced age, or patients with prolonged duration of
use have a significantly increased risk of developing
hepatocellular adenomas.
• When hepatic adenomas grow to a size of more than
6–8 cm, they are considered cancerous and thus
become a risk of hepatocellular carcinoma.
• Hepatic adenomas transform into the more dangerous
hepatocellular carcinoma in anabolic steroid users.

27. Hepatic adenoma
Symptoms and signs
• Asymptomatic.
1. Pain in abdomen.
2. Palpable mass
3. Large hepatic adenomas have a tendency to
rupture and bleed massively inside the
abdomen.

28. Hepatic adenoma: Diagnosis
• It is important to distinguish hepatic
adenoma from other benign liver
tumours, such as haemangiomas and
focal nodular hyperplasia, because
hepatic adenomas have risk of
progressing into a malignancy.
• MRI is the most useful investigation in
the diagnosis and work-up.
• A poly-phasic CT scan is another useful
test for diagnosing hepatic adenoma

29. Hepatic adenoma
Treatment :
• All hepatocellular adenoma should be resected,
because of the risk of rupture causing bleeding
and because they may contain malignant foci.
• Patients with adenomas should avoid oral
contraceptives or hormonal replacement therapy.
• Pregnancy could cause the adenoma to grow
faster, so patients with hepatic adenomas should
avoid pregnancy.

30. Focal nodular hyperplasia
• Its the second most prevalent tumour of the
liver.
• Non- malignant
• This tumour is the result of a congenital
arteriovenous malformation
• This process is one in which all normal
constituents of the liver are present, but the
pattern by which they are presented is abnormal.
Even though those conditions exist the liver still
seems to perform in the normal range.

31. MALIGNANT TUMOURS

32. MALIGNANT TUMOURS
• Most cases are metastases from other tumours,
frequently of the GI tract.
• The most frequent, malignant, primary liver
cancer is hepatocellular carcinoma
• More rare primary forms of liver cancer includes
• Cholangiocarcinoma,
• Mixed tumours,
• Sarcoma and
• Hepatoblastoma(a rare malignant tumour in
children).

33. Hepatocellular carcinoma HCC
• Also called malignant hepatoma ( also
named hepatoma, which is a misnomer
because adenomas are usually benign).
• Most common type of liver cancer.

34. HCC:Epidemiology
• The geographic distribution of HCC is
clearly related to the incidence of hepatitis
B (HBV) infection
• The highest incidence of disease (>10 to 20
cases/100,000) is found in Southeast Asia
and tropical Africa.
• HCC is two to eight times more common in
males compared with females.
• In general, the incidence of HCC increases
with age,

35. HCC Risk factors
• Alcoholism
• Hepatitis B & Hepatitis C (25% of causes
globally)
• Aflatoxin
• Cirrhosis of the liver
• Non-alcoholic steatohepatitis (if
progression to cirrhosis has occurred)
• Hemochromatosis
• Wilson's disease
• Type 2 diabetes (probably aided by
obesity)
• Haemophilia

36. Risk factors

37. Risk factors
• The risk factors which are most important varies
widely from country to country.
• In countries where Hepatitis B is endemic, such as
China, Hepatitis B will be the predominant cause of
Hepatocellular Carcinoma.
• Whereas in countries, such as the United States,
where Hepatitis B is rare because of high
vaccination rates, the major cause of HCC is
Cirrhosis (often due to alcohol abuse).
• The risk of hepatocellular carcinoma in type 2
diabetics is greater (from 2.5 to 7.1 times the non
diabetic risk) depending on the duration of diabetes
and treatment protocol.

38. HCC :Presentations

39. HCC :Presentations
• 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
• anorexia, nausea, lethargy, and weight loss
• 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

40. HCC :Presentations
• Other rare presentations include hepatic vein
occlusion (Budd-Chiari syndrome), obstructive
jaundice, hemobilia, and fever of unknown origin.
• Less than 1% of cases of HCC present with a
paraneoplastic syndrome, usually hypercalcemia,
hypoglycemia, and erythrocytosis.
• Small incidentally noted tumors have become a
more common presentation because of the
knowledge of specific risk factors, screening
programs for diagnosed HBV or HCV infection,
and increasing use of high-quality abdominal
imaging.

41. HCC :Signs and symptoms
•

42. HCC :Signs and symptoms
• Icterus
• Ascities
• Easy bruising from blood clotting
abnormalities
• Loss of appetite
• Unintentional weight loss
• Abdominal pain especially in the right
upper quadrant, nausea, vomiting or feeling
tired.

43. Diagnosis

44. Diagnosis
• USG
• AFP- alpha-fetoprotein
• CECT/MRI typical features of HCC—
arterially enhancing mass with washout of
contrast in delayed phases.
• Needle Biopsy

45. Pathology

46. Pathology
• Histologically, HCC is graded as well,
moderately, or poorly differentiated. The
grade of HCC, however, has never been
shown to predict outcome accurately.

47. Gross Pathology
Growth patterns-
1. The hanging type
2. The pushing type of HCC is well
demarcated and often contains a fibrous
capsule
3. infiltrative type
4. Small tumors
5. multifocal

48. Distinct Variants of HCC

49. Distinct Variants of HCC
• Fibrolamellar HCC
– Encapslated
– Better prognosis
• mixed hepatocellular-cholangiocellular
• A clear cell variant
• A pleomorphic or giant cell variant
• Childhood HCC

50. Prognosis

51. Prognosis
• The usual outcome is poor, because only
10–20% of hepatocellular carcinomas can
be removed completely using surgery.
• If the cancer cannot be completely
removed, the disease is usually deadly
within 3 to 6 months.
• However, survival can vary, and
occasionally people will survive much
longer than 6 months.

52. Treatment

53. Treatment
• Surgical resection
• Liver transplantation
• Adjuvant chemotherapy
• Hormonal therapy
• Cryosurgery
• Targeted therapy

54. Treatment
• Liver resection is considered the treatment
of choice for HCC.
• Liver transplantation is ideal for HCC with
Cirrhosis.
• Other potentially successful treatments are
available for HCC, such as ablative
techniques, embolization techniques,

55. Decision making in HCC Treatment
55

56. Decision making in HCC Treatment
• The status of the non-tumorous liver:
– Underlying cirrhosis.
– Non-cirrhotic liver (HBV).
• Size and extension of the tumour:
– Is it ≤5 cm in size/≤3 lesions ≤ 3 cm ?
– Vascular involvement.
• General condition of patient, the age and
expected life expectancy.
56

57. Treatment Approach
MANAGEMENT INDICATION PROGNOSIS Recurrence
HEPATIC RESECTION Non Cirrhotic HCC 5 year survival is about
50%
50%
recurrence
rate at 5
years
LIVER
TRANSPLANTATION
Cirrhotic HCC 5 year survival is
about 75%
Unfortunately
Hepatitis B &
C may also
occur in
transplanted
Liver
PERCUTANEOUSABLATI
ON(ETHANOL)
TUMOURS OF 3 cm
or small
80% cure rate 50% at 3
years
CHEMOEMBOLIZATION Cirrhotic Patients with
unresectable HCC and
good Liver Functions
at 2 years
No survival benefit
Beyond 4 years

58. CHILD PUGH SCORING

59. CHILD PUGH SCORING
 This Scoring system is used to assess the
prognosis of Chronic Liver Disease,mainly
Cirrhosis.
 It is now used to determine the prognosis as well
as required strength of treatment and the neccesity of
Liver transplantation.
Scoring is done by following methods:

60. SCORING
MEASURE 1 POINT 2 POINT 3 POINT
TOTAL
BILIRUBIN
(mg/dL)
<2 2 to 3 >3
SERUM
ALBUMIN
(gm/L)
>35 28 to 35 <28
PT/INR <1.7 1.71 to 2.30 >2.3
ASCITES NONE Mild Moderate to
Severe
HEPATIC
ENCEPHALOPAT
HY
NONE Grade I to II Grade III to
IV(or
refractory)

61. Treatment

62. Treatment
Nonsurgical local ablative therapy
• Percutaneous ethanol injection
• Percutaneous injection of acetic acid
• Radiofrequency ablation (RFA)
• Hepatic arterial infusional chemotherapy
using 5-fluorouracil (5-FU-– based
compounds, cisplatin, and doxorubicin
• percutaneous transarterial
embolization(chemoembolization) and
bland embolization

63. Treatment
Nonsurgical local ablative therapy
• Transarterial radiotherapy transarterial
injections of iodine-131 with Ethiodol or
yttrium-90 in glass microspheres.

64. Treatment
• Systemic chemotherapy
• Systemic immunotherapy and hormonal
therapy
• Sorafenib, a molecular targeted therapy

65. Prevention

66. Prevention
• Since hepatitis B or C is one of the main causes of
hepatocellular carcinoma, prevention of this
infection is key to then prevent hepatocellular
carcinoma.
• Thus, childhood vaccination against hepatitis B
may reduce the risk of liver cancer in the future.
• In the case of patients with cirrhosis, alcohol
consumption is to be avoided. Also, screening
for hemochromatosis may be beneficial for some
patients.
• It is unclear if screening those with chronic liver
disease for hepatocellular carcinoma improves
outcomes.

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