liver mass - how to investigate?

transcript

Dr Harshal Rajekar MS MRCS DNBHPB, GI and Transplant Surgeon

Dr Harshal Rajekar MS MRCS DNB

HISTOLOGICAL CLASSIFICATION OF TUMOR-LIKE PRIMARY HEPATIC SPACE-OCCUPYING LESIONS

Hepatocellular lesions:1. Focal nodular hyperplasia2. Nodular regenerative

hyperplasia3. Partial nodular transformation 4. Adenomatoid hyperplasia5. Compensatory lobar hyperplasia6.Focal fatty change7. Accessory lobe

Bile duct lesions:1. Biliary microhamartoma2. Cyst and polycystic liver3. Ciliated foregut cyst4. Epidermoid cyst5. Intrahepatic peribiliary gland

cyst6. Mesothelial cyst7. Cystic echinococcosis8.Biloma

Miscellaneous lesions:

1. Mesenchymal hamartoma

2. Inflammatory pseudotumor

3. Pseudolymphoma

4. Solitary necrotic nodule

5. Peliosis hepatis

6. Hereditary hem. Telangiectasia

7. Sarcoidosis

8. Nodular extramed. Hematopoiesis

9. Abscess

10. Tuberculoma

11. Botryomycosis

12. Malacoplakia/ adrenal rest tumor

13. Granulomas

History Clinical examination Lab – Hemogram, LFT, Albumin,INR Serology – ALA , Hydatid Tumor markers – AFP,CEA, CA 19-9

Asymptomatic Nodule on screening in cirrhotic patients Presenting with pain and fever SOL in a known patient of extrahepatic

malignancy

Algorithm for Solitary SOL of Liver on USG

Algorithm for Solid lesions on USG

Algorithm for Multiple Liver SOLs on USG

Symptomatic lesions – no response to treatment

Alterations in LFT

Underlying liver disease

When to do MRI ----- HCC vs regenerating nodule vs dysplastic nodule atypical lesions

Usually not required

Diagnostic uncertainty

Screening strategy

27 year old male vague abdominl discomfort. significant loss of apetite. no history of liver disease. ?W eight loss over the past 4 months.

Went to local doctor, had an abdominal ultrasound.

USG found a liver mass occupying most of right lobe.

What next?

Imaging? CT scan.

Bloods: Normal liver function tests, apart from a rai

sed Alkaline Phosphotase. Alpha Feto protein - >1,600,000 ng/dL

30 female. unmarried, no other medical or

surgical disease. No jaundice. Vague abdominal pain. Post-prandial discomfort.

went to GP, had an US scan. Large 15 cm cystic lesion in the

central part of the liver, reaching the hilum, with +/- septations.

what next? Imaging? Blood tests? FNA?

patients GP did all three. Blood tests:

- Alk Phosp.- >800, rest normal.- CECT - .....

Did a US guided FNA of cyst fluid. Cytology showed dysplastic cells,

degenrate hepatocytes.

63 male. moderate alcohol intake. no co-morbidities. vague symptoms, weakness and abdominal

discomfort. episode of diarrhoeal illness.

Investigated: - HBsAg +ve- USG abdomen deteccted a 4.5cm lesion in liver , seg 5/8, altered liver architechtexture.

What next?

CECT - 4.5cm lesion in right lobe occupying seg 5/8, with another satellite ?8mm lesion in segment 8.

The liver had a nodular outline, no ascites, spleen size normal.

AFP -181 ng/mL

Childs A status.- No jaundice.- No ascites.- INR 1.1- Noencephalopathy.- Albumin 3.6 g/dL

What next?

Patient was offered TACE (chemo-embolization).

HBV treatment was commenced with tenofovir. Patient continued to do well, performance

status remained well. Repeat CT scan 8 months later showed an

increase in the size of the sae lesion to 10.5cm in diameter and the satellite lesion was around the same size at 1.2cm.

There were no new lesions. Liver function – Childs A. No PHT. What next?

Offered repeat TACE. Tolerated procedure well. 1 month post TACE – patient himself got

a CT scan, showed a slight increase in size to 13.1 cm.

No new lesions.

What does this mean?

3 months later. Repeat CT scan – multiple liver and lung

54 yrs gentleman, no comorbidities Change in bowel habit incomplete evacuation No other GI symptoms

USG abdomen – hypo echoic liver lesions

Lab - normal

Ulcero proliferative lesion in sigmoid colon

No synchronous lesions/polyps

Biopsy - adenocarcinoma

FOLFOX + bevaxizumab – 7 cycles

FOLFOX – 5 cycles

PET CT

Sigmoid colectomy + left lateral segmentectomy

+ metastectomy (seg 4b, seg 5, seg 7)

THANK YOU

liver mass - how to investigate?

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