Liver TumorsLiver Tumors

Ayman AbdoAyman AbdoMD, AmBIM, FRCPCMD, AmBIM, FRCPC

ObjectiveObjective1.1. Identify the most important features of Identify the most important features of

common benign liver tumorscommon benign liver tumors

2.2. Know the risk factors, diagnosis, and Know the risk factors, diagnosis, and management of hepatocellular management of hepatocellular carcinomacarcinoma

ClassificationClassification

HemangiomaHemangioma

Focal nodular Focal nodular hyperplasiahyperplasia

AdenomaAdenoma

Liver cystsLiver cysts

1.1. Primary liver Primary liver cancerscancersHepatocellular Hepatocellular carcinomacarcinoma

Fibrolamellar carcinomaFibrolamellar carcinoma

HepatoblastomaHepatoblastoma

2. Metastases2. Metastases

Benign Malignant

Benign Liver LesionsBenign Liver Lesions1.1. HemangiomaHemangioma

2.2. Focal nodular hyperplasiaFocal nodular hyperplasia

3.3. AdenomaAdenoma

4.4. CystsCysts

HemangiomaHemangiomaClinical FeaturesClinical Features

The commonest liver tumorThe commonest liver tumor

5% of autopsies5% of autopsies

Usually single smallUsually single small

Well demarcated capsuleWell demarcated capsule

Usually asymptomaticUsually asymptomatic

HemangiomaHemangiomaDiagnosis and ManagementDiagnosis and Management

DiagnosisDiagnosisUS: echogenic spot, well demarcatedUS: echogenic spot, well demarcatedCT: venous enhancement from periphery to CT: venous enhancement from periphery to centercenterMRI: high intensity areaMRI: high intensity areaNo need for FNANo need for FNA

TreatmentTreatmentNo need for treatmentNo need for treatment

CT/HemangiomaCT/Hemangioma

Focal Nodular Hyperplasia (FNH)Focal Nodular Hyperplasia (FNH)Clinical FeaturesClinical Features

Benign nodule formation of normal liver Benign nodule formation of normal liver tissuetissue

Central stellate scarCentral stellate scar

More common in young and middle age More common in young and middle age womenwomen

No relation with sex hormonesNo relation with sex hormones

Usually asymptomaticUsually asymptomatic

May cause minimal painMay cause minimal pain

Focal Nodular Hyperplasia (FNH)Focal Nodular Hyperplasia (FNH)Diagnosis and ManagementDiagnosis and Management

DiagnosisDiagnosis::US: Nodule with varying echogenicityUS: Nodule with varying echogenicityCT: Hypervascular mass with central scarCT: Hypervascular mass with central scarMRI: iso or hypo intense MRI: iso or hypo intense FNA: Normal hepatocytes and Kupffer cells with FNA: Normal hepatocytes and Kupffer cells with central core.central core.

TreatmentTreatment::No treatment necessaryNo treatment necessaryPregnancy and hormones OKPregnancy and hormones OK

CT/FNHCT/FNH

Hepatic AdenomaHepatic AdenomaClinical featuresClinical features

Benign neoplasm composed of normal Benign neoplasm composed of normal hepatocytes no portal tract, central veins, hepatocytes no portal tract, central veins, or bile ductsor bile ductsMore common in womenMore common in womenAssociated with contraceptive hormonesAssociated with contraceptive hormonesUsually asymptomatic but may have RUQ Usually asymptomatic but may have RUQ painpainMat presents with rupture, hemorrhage, or Mat presents with rupture, hemorrhage, or malignant transformation (very rare) malignant transformation (very rare)

Hepatic AdenomaHepatic AdenomaDiagnosis and ManagementDiagnosis and Management

DXDXUS: filling defectUS: filling defectCT: Diffuse arterial enhancementCT: Diffuse arterial enhancementMRI: hypo or hyper intense lesionMRI: hypo or hyper intense lesionFNA : may be neededFNA : may be needed

TxTxStop hormonesStop hormonesObserve every 6m for 2 yObserve every 6m for 2 yIf no regression then surgical excisionIf no regression then surgical excision

AdenomaAdenoma

Liver CystsLiver CystsMay be single or multipleMay be single or multiple

May be part of polycystic kidney diseaseMay be part of polycystic kidney disease

Patients often asymptomaticPatients often asymptomatic

No specific management requiredNo specific management required

Hydated cystHydated cyst

Malignant Liver LesionsMalignant Liver Lesions

Malignant Liver TumorsMalignant Liver Tumors

1.1. Hepatocellular carcinoma (HCC)Hepatocellular carcinoma (HCC)

2.2. Fibro-lamellar carcinoma of the liverFibro-lamellar carcinoma of the liver

3.3. HepatoblastomaHepatoblastoma

4.4. Intrahepatic cholangiocarcinomaIntrahepatic cholangiocarcinoma

5.5. OthersOthers

HCC: IncidenceHCC: IncidenceThe most common primary liver cancerThe most common primary liver cancer

The most common tumor in Saudi menThe most common tumor in Saudi men

Increasing in US and all the worldIncreasing in US and all the world

HCC: Risk FactorsHCC: Risk FactorsThe most important risk factor is The most important risk factor is cirrhosiscirrhosis

from any cause:from any cause:

1.1. Hepatitis B (integrates in DNA)Hepatitis B (integrates in DNA)

2.2. Hepatitis CHepatitis C

3.3. AlcoholAlcohol

4.4. AflatoxinAflatoxin

5.5. OtherOther

HCC: Clinical FeaturesHCC: Clinical FeaturesWt loss and RUQ pain (most common)Wt loss and RUQ pain (most common)AsymptomaticAsymptomaticWorsening of pre-existing chronic liver disWorsening of pre-existing chronic liver disAcute liver failureAcute liver failure

O/E:O/E:Signs of cirrhosisSigns of cirrhosisHard enlarged RUQ massHard enlarged RUQ massLiver bruit (rare)Liver bruit (rare)

HCC: MetastasesHCC: MetastasesRest of the liverRest of the liver

Portal veinPortal vein

Lymph nodesLymph nodes

LungLung

BoneBone

BrainBrain

HCC: Systemic FeaturesHCC: Systemic FeaturesHypercalcemiaHypercalcemia

HypoglycemiaHypoglycemia

HyperlipidemiaHyperlipidemia

HyperthyroidismHyperthyroidism

HCC: labsHCC: labsLabs of liver cirrhosisLabs of liver cirrhosis

AFP (Alfa feto protein)AFP (Alfa feto protein)

Is an HCC tumor markerIs an HCC tumor marker

Values more than 100ng/ml are highly Values more than 100ng/ml are highly suggestive of HCCsuggestive of HCC

Elevation seen in more than 70% of ptElevation seen in more than 70% of pt

HCC: DiagnosisHCC: DiagnosisClinical presentationClinical presentation

Elevated AFPElevated AFP

USUS

Triphasic CT scan: very early arterial Triphasic CT scan: very early arterial perfusionperfusion

MRIMRI

BiopsyBiopsy

US: HCCUS: HCC

CT: Venous PhaseCT: Venous Phase

CT: Arterial PhaseCT: Arterial Phase

HCC: PrognosisHCC: PrognosisTumor sizeTumor size

Extrahepatic spreadExtrahepatic spread

Underlying liver diseaseUnderlying liver disease

Pt performance statusPt performance status

HCC: Liver HCC: Liver TransplantationTransplantation

Best available treatmentBest available treatment

Removes tumor and liverRemoves tumor and liver

Only if single tumor less than 5cm or less Only if single tumor less than 5cm or less than 3 tumors less than 3 cm eachthan 3 tumors less than 3 cm each

Recurrence rate is lowRecurrence rate is low

Not widely availableNot widely available

HCC: ResectionHCC: ResectionFeasible for small tumors with preserved Feasible for small tumors with preserved liver function (no jaundice or portal HTN)liver function (no jaundice or portal HTN)

Recurrence rate is highRecurrence rate is high

HCC: Local AblationHCC: Local AblationFor non resectable ptFor non resectable pt

For pt with advanced liver cirrhosisFor pt with advanced liver cirrhosis

Alcohol injectionAlcohol injection

Radiofrequency ablationRadiofrequency ablation

Temporary measure onlyTemporary measure only

Radio Frequency AblationRadio Frequency Ablation

Ethanol InjectionEthanol Injection

HCC: ChemoembolizationHCC: ChemoembolizationInject chemotherapy selectively in hepatic Inject chemotherapy selectively in hepatic arteryartery

Then inject an embolic agentThen inject an embolic agent

Only in pt with early cirrhosisOnly in pt with early cirrhosis

No role for systemic chemotherapyNo role for systemic chemotherapy

ChemoembolizationChemoembolization

Fibro-Lamellar CarcinomaFibro-Lamellar CarcinomaPresents in young pt (5-35)Presents in young pt (5-35)

Not related to cirrhosisNot related to cirrhosis

AFP is normalAFP is normal

CT shows typical stellate scar with radial CT shows typical stellate scar with radial septa showing persistant enhancementsepta showing persistant enhancement

Secondary Liver Secondary Liver MetastasesMetastases

The most common site for blood born The most common site for blood born metastasesmetastasesCommon primaries : colon, breast, lung, Common primaries : colon, breast, lung, stomach, pancreases, and melanomastomach, pancreases, and melanomaMild cholestatic picture (ALP, LDH) with Mild cholestatic picture (ALP, LDH) with preserved liver functionpreserved liver functionDx imaging or FNADx imaging or FNATreatment depends on the primary cancerTreatment depends on the primary cancerIn some cases resection or chemoembolization In some cases resection or chemoembolization is possibleis possible

SummarySummary

HemangiomaHemangioma

Focal nodular Focal nodular hyperplasiahyperplasia

AdenomaAdenoma

Liver cystsLiver cysts

1.1. Primary liver Primary liver cancerscancersHepatocellular Hepatocellular carcinomacarcinoma

Fibrolamellar carcinomaFibrolamellar carcinoma

HepatoblastomaHepatoblastoma

2. Metastases2. Metastases

Benign Malignant