Approach to Benign and Malignant lesion of the liver.pptx

Surgical note

1. Approach to Benign and Malignant lesion of the liver Prepared by -Dr . Gezahegn Assefa (GSR-IV) Moderator - Dr. Getachew Desta (Consultant GENERAL SURGEON ,HBPS and Laparoscopic surgeon ) 5/11/2024 Gezahegn 1

2. Outline Benign solid liver tumors Hepatic hemangioma Focal nodular Hyperplasia (FNH) Hepatocellur Adenoma ( HCA) Malignant solid liver tumors Hepatocellur carcinoma (HCC) Intrahepatic cholangioc Carcinoma(IHCC) Colorectal cancer liver metastasis ( CRLM) 5/11/2024 Gezahegn 2

3. BENIGN SOLID TUMORS The most common benign solid tumors of the liver are Hemangioma Focal nodular hyperplasia Hepatocellular adenoma 5/11/2024 Gezahegn 3

4. Hepatic Hemangioma T he most common of all solid liver tumors P revalence ranges from 3% - 20% A 5 : 1 F/M with mean age of 50 yrs E qually in the left and right lobes of the liver The vast majority of hemangiomas are <5 cm in diameter G iant hemangiomas- refered hemangioma > 10 cm 5/11/2024 Gezahegn 4

5. Clinical presentation M ajority of hemangiomas are asymptomatic and found incidentally Pain Associated disorder Compression of the adjacent structure Large hemangiomas can be asymptomatic or may manifest as an abdominal mass Liver function test are normal 5/11/2024 Gezahegn 5

6. Complication ( larger tumor) Alteration of internal architecture Coagulation abnormalities Compression of adjacent structure Kasabach -Merritt syndrome Intratumoral hemorrhage Spontanous rupture 5/11/2024 Gezahegn 6

7. US H omogenous hyperechoic mass with sharp margins A ssociated with acoustic enhancement Sonographic criteria Typical feature Measuring < 3cm No cirrhosis / extrahepatic ca 5/11/2024 Gezahegn 7

8. Cross sectional imaging CT-Scan Low attuention on non contract CT-scan Peripheral / globular enhancement followed by central enhancement of contras CT Contrast enhancement of delayed phase MRI A hypointense lesion on T1-weighted sequences S trongly hyperintense lesion on heavily T2-weighted sequences with a “light bulb” pattern 5/11/2024 Gezahegn 8

9. Imaging atypia Giant and rapidly filling hemangioma Hemangioma developing Fatty liver Cirrhotic liver Others Slowly filling hemangioma Calcified hemangioma Cystic hemangioma 5/11/2024 Gezahegn 9

10. Management Asymptomatic – what ever the size , there is no treatment There is no need To interrupt oral contraceptive To avoid pregnancy and sporting activity to have follow up ( with few exceptions) Indication for treatment Severe symptom Complication Inability to rule out malignancy 5/11/2024 Gezahegn 10

11. Option of treatment Surgical resection –definitive treatment Open vs laparoscopic Enucleation VS Resection –based on size and location Other –less effective option Hepatic artery ligation Radiation therapy Arterial embolization Radio-frequency ablation(RFA) Exceptional situations-liver transplant technically unresectable complicated giant hemangiomas hemangiomatosis with cardiopulmonary complications 5/11/2024 Gezahegn 11

12. Focal Nodular Hyperplasia FNH represents the second most frequent benign lesion Prevalence 1% with F/M ratio of 9 : 1 In women often discovered b/n 30-40, men are usually older Most FNH and their surrounding liver parenchyma express estrogen receptors Usually solitary , 20 % multiple and can be associated with HCAs or hemangioma 5/11/2024 Gezahegn 12

13. Clinical presentation Abdominal pain or discomfort-large tumor Pressure effect on adjacent structure Torsion of pedicle- pediculated lesion Large FNH below the gillenson capsule Other associated disorder Size remain stable over time Liver test is normal (80%) Mild elevation of GGT and ALP in large FNH Malignant transformation not established 5/11/2024 Gezahegn 13

14. Imaging US I soechoic appearance central artery with spoke wheel appearance patteren centerfuagal arterial flow radiating peripheraly CT scan Hypo or iso dense on precontrst images H omogenous hyperdense lesion I sodense during potal and delayed images and central scar become hyperdense as contrast diffue into fibrous scar 5/11/2024 Gezahegn 14

15. Management Asymptomatic-no treatment (size or number) regenerative process rather than a tumor no risk of malignant transformation or complication remains stable, could decrease, and even disappear after the fifth decade 5/11/2024 Gezahegn 15

16. Surgical management –(symptomatic pt ) Resection –open VS laparoscopic Trans artirial embolization- Percutanous RFA 5/11/2024 Gezahegn 16

17. Hepatocellular Adenoma(HCA) Rare benign liver neoplasm F/M: 9/1 It know for its potential complication Hemorrhage Malignant transformation to HCC 5/11/2024 Gezahegn 17

18. OCP VS HCA It has been reported that the hormonal background had a role in the pathogenesis of HCA estrogens have consistently been reported as a predominant factor, significantly and independently correlating with the development of HCA Positive correlation is dose dependent Other risk factor Androgen Obesity NASH 5/11/2024 Gezahegn 18

19. Pathology Macrospic features Large Subcapsular vessels Well- delinated fleshy appearing , ranging white to brown Heterogeneous area of hemorrhage and necrosis Microspic feature Absent normal liver architecture Proliferation of benign hepatocytes Arranged in trabecular fashion Four subtypes HNF1 α- mutated HCAs ( HNF1A) I nflammatory ( also known as telangiectatic ) HCAs ( IHCA) β- catenin–mutated HCAs ( b-HCA) and unclassified subtypes 5/11/2024 Gezahegn 19

20. Clinical presentation Asymptomatic – discovered incidentally on US Symptoms Abdominal pain Fever-1/3 of patient IHCA Abnormal liver test Elevated GGT and ALP Slight elevation on transaminase 5/11/2024 Gezahegn 20

21. Imaging Vary according to the subtype of HCA Imaging should be fat sensitive ( such as MRI) A nd use contrast agents to look for dilated vascular spaces CT-scan overlaps with FNH and HCC Iso dense on unenhanced scan Enhance homogenously arterial phase with sharp marginated hypervascularity fade on portal venous phase images 5/11/2024 Gezahegn 21

22. Complication Hemorrhage The main complication , occurring 25% of the patient Risk of hemorrhage Size > 5cm Visualization of arteries with in the lesion Left lateral liver and exophytic growth Malignant transformation 5-6 % Risk Sex (male 6-10 flod ) Androgen use B-HCA Tumor size > 5cm (independent of the subtypes) 5/11/2024 Gezahegn 22

23. Management Male patient –it should be resected ( despite the size and type) Female patient Size < 5cm Cessation of hormonal therapy Annual or biannual Surveillance with MRI Persistent or size > 5cm -resection Female with multiple HCA- only tumor > 5cm should be resected Options of management Resection-Open VS laprscopic RFA or selective trans arterial embolization- for resudial tumor 5/11/2024 Gezahegn 23

24. Complications Hemorrhage Hemodynamic instability- Open and control of the bleeding Hemodynamic stability Conservative management with transarterial embolization Residual tumor Large sized –resection Lesion < 4cm –RFA or TAE Liver transplant Multiple unresectable lesions in men a large HCA associated with intrahepatic venous shunt, and in patients with glycogen storage disorders unresponsive to medical treatment 5/11/2024 Gezahegn 24

25. Hepatocellular carcinoma (HCC) HCC is the most common primary liver tumor Currently represents the 5 th most common cancer worldwide A nd is the third major cause of cancer death Its incidence presents marked geographic differences ( E ast Asia and S ub- sarah Africa) Cirrhosis has been estimated to present 80-90% of a time 3-4 of pt with cirrhosis will develop HCC annually 5/11/2024 Gezahegn 25

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27. Pathology Hepatitis B increase the rate of oncogene transcription Hepatitis C cause chronic inflammation resulting cirrhosis 90 % of patients with HCC evidence of fibrosis in the liver The risk of liver cancer is generalized to entire organ called field effect HCC occurs after 10 yr of delay HCC greater than 2 cm increased risk of portal invasion and their risk of recurrence 5/11/2024 Gezahegn 27

28. Prevention of risk factors Vaccination for HBV prevention Treatment for viral hepatitis- association with protective effect Statins Observational studies - associated with a lower risk of HCC Meta-analysis - non users vs users had a 37 % decrease in the risk of developing HCC [OD]0.63: 95% CI Aspirin and other NSAID associated with lower risk of HCC and lower liver-related mortality 5/11/2024 Gezahegn 28

29. Life style Coffee- protective factors against liver cancer Diet   -fish , omega-3 fatty acids, or vegetables was associated with a reduced HCC risk Physical activity –improve glucose and lipid metabolism in the liver and improve disease progression in Non-alcoholic liver disease 5/11/2024 Gezahegn 29

30. Surveillance and screening Goal of surveillance- to detect asymptomatic and early stage disease The recommendation for HCC surveillance in high-risk patients is based on a trial that found a 37 % reduction in mortality after surveillance in patients with chronic hepatitis B virus (HBV) infection, with or without cirrhosis Society guidelines on surveillance for HCC vary somewhat in the patient populations specified 5/11/2024 Gezahegn 30

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32. Clinical presentation There is a spectrum of clinical presentations for patients with HCC Many patients have no symptoms related to the tumor ( early stage dx) Among patients with more advanced liver disease, symptoms and physical findings are often due to underlying cirrhosis rather than the tumor itself Patients with advanced lesions may present with mild to moderate upper abdominal pain, weight loss, early satiety, or a palpable mass in the upper abdomen  5/11/2024 Gezahegn 32

33. Paraneoplastic syndromes Patients with HCC may occasionally develop a paraneoplastic syndrome G enerally associated with a poor prognosis Hypoglycemia Erythrocytosis Hypercalcemia  Diarrhea  5/11/2024 Gezahegn 33

34. P/E jaundice, ascites, cachexia, splenomegaly, hepatomegaly, or it may be normal stigmata of liver disease, such as spider angiomata or palmar erythema Extrahepatic metastases: Lung, Intra abdominal LNs, Bone & Adrenals…..Brain. 5/11/2024 Gezahegn 34

35. DIAGNOSIS - laboratory Assess severity of underlying liver illness CBC (anemia, platelet count) ELECTRLYTES ( hyponatremia in advanced CLD) LFTs RFTs ( ? Hepatorenal syndrome) Coagulation studies, Albumin, Bilirubin RBS Serum AFP Etiologic Workup HBV, HCV Iron saturation study α1- antitrypsin levels 5/11/2024 Gezahegn 35

36. Liver function assessment A thorough history and physical examination- clinically significant portal hypertension S erum laboratory tests hepatic synthetic function (albumin and coagulation studies) and total bilirubin should also be evaluated Child-Pugh (CP) class –the most widely used tool to asses liver funcition Classify a patient with cirrhosis Compnested (Class A) Decompnsted (class B and C) 5/11/2024 Gezahegn 36

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38. Serum Markers AFP – A level of 10 to 20 ng/mL showed sensitivity of 60% & Specificity of about 80%. Insensitive for early tumors Elevated in 75% of cases An elevation of greater than 400 ng/mL predicts for HCC with specificity greater than 95 % Not recommended as primary diagnostic or screening tool Response follow up after Loco regional therapy DDx – Hepatitis, Pregnancy, Gonadal tumors, gastric ca… 5/11/2024 Gezahegn 38

39. US Used to screen for HCC in high-risk patients Can detect nodules>1.5 cm D oesn't provide sufficient anatomic details 60% sensitivity & 97% specificity 5/11/2024 Gezahegn 39

40. Contrast Enhanced CT-scan (cirrhotic liver) Triphasic (Late arterial ,Portal venous,Delayed (2-5minute) Small and multi-focal Image characteristics Hypervascular in the arterial phase hypoattenuating to surrounding liver in later phases Enhancing tumor capsule Enhancing tumor in the portal vein Exceptions washout appearance only on delayed imaging or not at all, others are not hypervascular . Larger lesions (>5 cm) tend to be heterogeneous 5/11/2024 Gezahegn 40

41. Contrast Enhanced CT-scan (non-cirrhotic liver) typically presents as large hypervascular solitary or dominant mass with small satellite nodules central necrosis 5/11/2024 Gezahegn 41

42. MRI Sensitivity 81% and specificity of about 85%. Varying features depending on tumor architecture, grade & fat and glycogen content Well differentiated tumors Hypointense on T1-weighted and hyperintense on T2-weighted images, and shows arterial phase hyperenhancement Poorly differentiated / large tumor Heterogeneous enhancement Contrast washout in portal venous or later dynamic phase 5/11/2024 Gezahegn 42

43. Staging and prognostic C rucial tools to stratify patients into different subgroups according to prognosis P rognosis is related mainly to tumor stage at the time of diagnosis P resence of underlying liver disease makes prognostic evaluation HCC more complex Despite several modifications over time, the TNM system is still not valid because it relies predominantly on pathologic findings 5/11/2024 Gezahegn 43

44. Okuda classification Prognostic system based on Rough assessment of tumor burden Liver function- Bil , albumin and asciteis Stage I, II and III Major usefulness identification of end-stage patients with a poor prognosis Does not link to treatment indication BCLC staging system Based on Tumor burden-number ,size, PV invasion Liver function –child score Cancer related symptom –Ps It links staging with treatment indication 5/11/2024 Gezahegn 44

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46. HKLC prognostic classification 5/11/2024 Gezahegn 46

47. The HKLC prognostic classification scheme Based on Performance status Child score Tumor status ( number, size and presence of intrahepatic vascular invasion) Metastasis ( extrahepatic vascular invasion ) 5/11/2024 Gezahegn 47

48. HKLC VS BCLC BCLC is too Conservative in Treatment Recommendation Role of surgical resection can be extended to intermediate or locally advanced HCC with intrahepatic venous invasion Role of ablation can be extended to tumor 3-5 cm, or even slightly > 5 cm Role of transarterial therapy can be extended to locally advanced HCC with intrahepatic venous invasion 5/11/2024 Gezahegn 48

49. The HKLC system has significantly better ability than the BCLC system to distinguish between patients with specific overall survival times (area under the receiver operating characteristic curve values, approximately 0.84 vs 0.80; concordance index, 0.74 vs 0.70) HKLC identifies subsets of BCLC intermediate- and advanced-stage patients for more aggressive treatments than what were recommended by the BCLC system, which improved survival outcomes 5/11/2024 Gezahegn 49

50. Treatment Strategies( based on BCLC) Selection of best treatment in patient with HCC depends on Status of the underlying liver Tumor Stage Non cirrhotic HCC Resection 1 st line of treatment Major lobectomies are well-tolerated 5/11/2024 Gezahegn 50

51. Cirrhotic HCC Liver transplantation (1 st line treatment ) solitary tumors less than 5 cm those with up to three nodules, each less than 3 cm Percutaneous treatment If patients are not candidates for surgery If expected transplant waiting time exceeds 6 months Very early stage and who are not potential candidates for liver transplantation 5/11/2024 Gezahegn 51

52. Principles of Resection and Transplant Patients must be medically fit for a major operation All patients should be evaluated for possible transplant candidacy. Hepatic resection is indicated as a potentially curative option in the following circumstances Adequate liver function (generally Child-Pugh Class A without portal hypertension ,) Solitary mass without major vascular invasion Adequate future liver remnant (at least 20% without cirrhosis and at least 30%–40% with Child-Pugh Class A cirrhosis, adequate vascular and biliary inflow/outflow ) 5/11/2024 Gezahegn 52

53. Advanced disease (large unresctabe , large or multifocal) TACE Preserved liver function, no-portal invasion and cancer related symptom Associated with improve survival Significantly impact the out come Systematic treatment ( sorafenib ) If chemoembolization is not feasible but patients still have preserved liver function (CTP class A or B) without major cancer-related symptoms if the patient presents at advanced stage Terminal stage Severe liver function deterioration Severe cancer related symptoms Offered Best Supportive Care 5/11/2024 Gezahegn 53

54. CRC-liver metastasis (CRLM) For patients with CRC the most common site for metastasis is the liver Challenges Significant number of patient present with metastatic disease (40%) Many newly diagnosed patients eventually develop metastatic disease (50%) 5-year survival -2 % if unresectable / 50% if resectable At diagnosis ¼ present with synchronous tumor ½ eventually develop metachronous tumor only 20 % are candidates for liver resection 5/11/2024 Gezahegn 54

55. Selection criteria Significant comorbidities Non treatable extrahepatic disease Involvement of >70% of the liver or 6 segments Involvement of the hepatic artery , major bile ducts, main portal vein , celiac LN Modern multidisplinary consenus defines resctable CRLM simply as tumor that can be resected completely (R0) while leaving an adequate liver remnant 5/11/2024 Gezahegn 55

56. Pre-Operative evaluation Medical resectablity Comorbidities Acute infectious and thrombotic process Underlying liver impairment Oncologic resectablity to determine that the primary tumor site is either completely treated or amenable to simultaneous or future resection to quantify the number and location of extrahepatic disease To assess the response of pre-operative treatment Technical resectablity Only after confirmation of medical and oncologic resectability It include Liver specific imaging Volumetric assessment clear understanding of the techniques and approaches that can be performed 5/11/2024 Gezahegn 56

57. Workup If pt is candidate for surgical therapy Colonoscopy should be performed Complete abdominal and pelvic cross-sectional imaging must also be performed Chest CT PET Approximately 25% of patients have a change in management based on PET scan 5/11/2024 Gezahegn 57

58. Option of management of potential resectable CRC to liver Regional treatment Surgical resection Local tumor Ablation Regional hepatic intraarterial chemotherapy Chemoemboliztion RT Surgical resection is associated with a survival advantage 5/11/2024 Gezahegn 58

59. Principles of resections R0 resection of both intra-and extrahepatic disease sites must be feasible At least two adjacent liver segment need to spared Vascular inflow-outflow and biliary drainage to the remaining segment must be preserved The volume of the future liver remnant must be adequate 5/11/2024 Gezahegn 59

60. Surgical approach Simultaneous resection  Liver resection-----Colorectal resection Liver resection is extensive ------Staged resection Staged Resection Classic ( colo -rectal first) approach Reverse (liver-first) approach No proof of inferior survival or greater morbidity for simultaneous resection as compared to staged hepatic resection 5/11/2024 Gezahegn 60

61. Neoadjuvant chemotherapy The optimal selection criteria, specific regimen and duration of neoadjuvant chemotherapy, and the best way in which chemotherapy should be integrated with surgery in patients who present with synchronous metastatic disease have not been defined 5/11/2024 Gezahegn 61

62. Adjuvant chemotherapy Conventional 5 FU based chemotherapy Newer agent ( oxaliplatin , irinotecan ) Targeted therapy Bevacizumab( Avastin ) Cetuximab Pantumumab Frist line FOLFOX( oxaliplatin + 5FU & leucovorin ) FOLFIR( Irinotecan + 5FU & leucovorin ) CAPOX( capecitabine + oxaliplatin ) 5/11/2024 Gezahegn 62

63. Management of Metachronous CRLM surgical treatment of these lesions is not different from surgery for any other liver lesions 5/11/2024 Gezahegn 63

64. Conversion therapy for initially unresectable metastases 12-33 % of patients with "initially unresectable" hepatic metastases have a sufficient objective response to conversion therapy to permit a subsequent complete (R0) resection   5/11/2024 Gezahegn 64

65. Intrahepatic Cholangiocarcinoma (IHCC) IHCC is a primary malignancy of the liver tumors arising from biliary epithelium in intrahepatic bile ducts above the level of the left and right main ducts These tumors constitute 10% of primary hepatic malignancies They are biologically aggressive Surgical resection is the only known potentially curative therapy 5/11/2024 Gezahegn 65

66. Risk factors Primary sclerosing cholangitits 1.5 % per year , prevalence 8-40 % develops 2 to 3 decades earlier than in those with sporadic tumors (30-50 vs . 60-70 years of age) Parastitc infection Hepatolithiasis Congenital Biliary Cystic Disease Hepatic cirrhosis 5/11/2024 Gezahegn 66

67. Clinical presentation IHCCs often present as asymptomatic hepatic masses detected during PE or imaging Those who have symptoms Abdominal pain Other none specific symptoms-weigh loss, decreased energy and loss of appetite Jaundice –centrally located tumor compressing/ invading the confluence 5/11/2024 Gezahegn 67

68. Diagnosis and evaluation Detailed history and PE Liver function should be assessed- Platelet count, serum Bil , GGT, AST, ALP, albumin, total protein, and PT or INR Cross sectional imaging – typical finding of hypovascualar mass Pathological conformation – an adenocarcinoma, which typically stains + for CK7 and CK8/18 and - for CK20 staging laparoscopy Used to exclude nodal disease , peritoneal disease and abdominal invision 5/11/2024 Gezahegn 68

69. CT-Scan most effective investigation in diagnosing and staging IHCC tumors present as hypodense lesions with irregular, infiltrative margins and a variable degree of delayed enhancement in the portal venous phase Use to define associated biliary dilation portal and hepatic venous invasion detecting metastatic disease affecting regional lymph nodes, peritoneum , or lung fields accurate assessment of hepatic volumetry , with risk of liver failure 5/11/2024 Gezahegn 69

70. US IHCC has a nonspecific appearance as a hypoechoic hepatic mass With minimal Doppler flow Use to define associated biliary dilation portal venous invasion hepatic venous invasion, and rarely, portal lymphadenopathy MRI IHCCs appear as hypointense lesions on T1-weighted images and hyperintense on T2-weighted images define venous and arterial involvement by tumor 5/11/2024 Gezahegn 70

71. Staging and Classification The 7th-edition AJCC staging Use TNM Validated in multi- instutional study staging classification was associated with significantly varying survival More emphasis on periductal invasion 5/11/2024 Gezahegn 71

72. Treatment Surgical Hepatic resection Transplantation Tumor ablation TACE TARE Systematic Neoadjuvant Adjuvant Advanced 5/11/2024 Gezahegn 72

73. Hepatic Resection Principles of resection R0 resection well-vascularized remnant with adequate venous and biliary drainage Resection 80% of hepatic volume –for pt good liver function up to 60% in patients with compromised liver function Criteria for unresectablity locally advanced solitary tumors involving either in-out flow bilaterally multiple intrahepatic tumors metastatic disease 5/11/2024 Gezahegn 73

74. Lymphadenectomy “regional lymphadenectomy should be considered in patients to provide staging information, But that resection should be carefully considered in patients with bulky nodal disease in the porta hepatis ” NCCN, 2024 Neoadjuvant Retrospective review and phase-ii trail indicate-effective neoadjuvant therapy is a realistic future goal for IHCC Adjuvant with gemcitabine- or fluoropyrimidine -based therapy in patients with positive margins after resection (NCCN 2012) 5/11/2024 Gezahegn 74

75. Blumgart’s : Surgery of the Liver , Biliary tracts , and Pancreas 6 e Shackelford’s : Surgery of the Alimentary tract Schwartz’s : Principle of Surgery 11 e NCCN Guidelines Version 1.2024 Hepatocellular Carcinoma Yau T, Tang VY, Yao TJ, Fan ST, Lo CM, Poon RT. Development of Hong Kong Liver Cancer staging system with treatment stratification for patients with hepatocellular carcinoma. Gastroenterology. 2014 Jun;146(7):1691-700.e3. doi : 10.1053/j.gastro.2014.02.032. Epub 2014 Feb 25. PMID: 24583061. Up To date 5/11/2024 Gezahegn 75