Liver lesions benign and malignant and treatment options.pptx

benign and malignant liver lesions and treatment options

1. Liver lesions benign and malignant and treatment options Presented by Abdurahman Maashi

2. Liver lesions benign and malignant Benign Hemangioma Focal nodular hyperplasia Liver cysts Adenoma Malignant 1-Primary liver cancers Hepatocellular carcinoma Fibrolamellar carcinoma Hepatoblastoma 2-Metastasis

3. Benign liver lesions

4. Hemangioma Liver hemangioma is made up of a tangle of blood vessels . Other terms of liver hemangioma are hepatic hemangioma or cavernous hemangioma

5. Clinical features of liver hemangioma The commonest liver tumor 5% of autopsies Usually single , small Well demarcated Capsules Usually asymptomatic but may present with : 1-Pain in the right hypochondrial area 2- Feeling pain after eating only a small amount of food 3-Nausea 4-vomiting

6. Hemangioma Diagnosis: US : echogenic spot , well demarcated CT : Venous enhancement from periphery to center MRI : high intensity area No need for FNA or Biopsy Treatment : No need for treatment

7. CT hemangioma

8. Focal nodular hyperplasia (FNH) Focal nodular hyperplasia(FNH) is a benign liver tumor and is the second most common benign liver lesion after the first benign liver tumor known as hemangioma FNH doesn't grow in size or turn into liver cancer , spread or bleed Central stellate scar More common in young and middle age woman No relation with sex hormones Usually Asymptomatic May cause minimal pain

9. Causes: It is thought that FNH is due vascular accident such as hemorrhage or clots in tiny blood vessels in the liver . Because FNH is more common in women it is thought that estrogen promote its development . Inflammation may also promote its development in the liver

10. CT FNH

11. Hepatic adenoma Rare benign hepatic neoplasm that develop in a normal liver Occurs mostly in woman of child-bearing age( 20-40) Associated with contraceptive hormones Usually asymptomatic but may cause RUQ pain May presents with rupture , hemorrhage or malignant transformation to well differentiated HCC (vary rare)

12. Hepatic adenoma Diagnosis : US : filing defect CT: diffuse arterial enhancement MRI : hypo or hyper intense lesion Biopsy : may be needed for conformation and characterization of nature of the lesion Treatment : Stop hormones Observe every 6 month for 2 years If no regression surgical excision

13. US finding of hepatic adenoma

14. MRI of hepatic adenoma

15. Liver cysts May be single ( simple cyst disease ) or multiple ( polycystic liver disease ) Can be congenital (containing thin serous fluid ) , secondary from trauma ( seroma or biloma ) , infectious ( pyogenic or parasitic ) OR neoplastic 5-14% of population can occur with higher prevalence in women Patients often asymptomatic No specific management required DDX: FNH , hemangioma , adenoma , bile duct hamartoma

16. Liver cyst Diagnosis : Ultrasound round or ovoid liver anechoic lesion (may be lobulated ) well marginated with a thin wall may show anterior acoustic enhancement , if large enough

17. Malignant liver lesions

18. Hepatocellular carcinoma Primary liver cancer (HCC) is one of the world’s most common cancers , and its incidence it is expected to rise rapidly over the next decade due to association with chronic liver disease . Many patients known to have chronic liver disease are now being screened for the development of HCC

19. Epidemiology Most common primarily malignancy of the liver The highest incidence in – south Africa and Tropical Africa The lowest incidence in – Australia , North America and Europe Epidemiologic evidence strongly suggest that HCC is largely related to environmental factors

20. Etiology and risk factors HCC is two to eight times more common in males compared with females in low and high-incidence areas The higher incidence in males is probably related to higher rated of associated risk factor Hep B virus infection Hep C virus infection Cirrhosis Infection Alcohol abuse Higher hepatic DNA synthesis in cirrhosis

21. Agents known to be associated with development of HCC 1-Infection : HBV HCV 2-Cirrhosis Alcohol abuse Autoimmune hepatitis Primary biliary cirrhosis 3-Environmental factors Aflatoxins Pyrrolizidine alkaloid Thorotrast N- nitrosylated compounds 4-Metabolic disease Hemochromatosis Alpha1- antitrypsin deficiency Wilson’s disease Porphyria cutanea tarda Type 1 and 3 glycogen storage disease Galactosemia Citrullinemia Hereditary tyrosinemia Familial cholestatic cirrhosis

22. Pathogenesis : Involves chronic inflammatory process or ongoing hepatocellular damage with high cellular regeneration , which leads to increase genetic mutation in the cells and accumulation of these mutations leading to carcinoma formation . Two histologic subtypes: 1- Nonfibrolamellar Associated with HCV and cirrhosis 2- Fibrolamellar Associated in younger patients , more common in females , no association with HBV or cirrhosis-good prognosis Metastasis to bone , lymph nodes , lungs and adernals

23. Pathogenesis of HCC

24. Presentations 1-Asymptomatic During screening of chronic HBV carrier Investigation for liver cirrhosis Incidentally found on imaging of abdomen 2- Local symptoms Upper abdominal pain Hepatomegaly found on examination Obstructive Jaundice due to invasion of Intrahepatic biliary tree , compression of a Major duct 3- Liver decompensation ( on top of underlying Cirrhosis ) Worsening liver infection Ascites Variceal bleeding Encephalopathy 4- Tumor rupture Pretonitis Shock 5- Metastasis Bone pain Dyspnea 6- Other manifestation Budd- chiari syndrome Pyrexia Paraneoplastic syndrome

25. Differential diagnosis Other causes of liver failure : Acute liver failure hepatitis , drug overdose or other causes Chronic liver failure due to cirrhosis , which may be compensated or decompensated A mass in the liver could be due to : Generalized hepatomegaly Liver abscesses Liver cysts Primary liver tumors Primary liver malignancy Secondary liver metastasis Other causes or right upper quadrant pain

26. Diagnosis For patients suspected to have HCC , the aim of diagnostic investigation are : Verification of diagnosis Determine extent of the disease Determine liver functional reserve Assess biologic determinants that are predictors of long term prognosis Biopsy is usually not performed due to risk or tumor seeding along needle track Diagnosis is based on clinical , biochemical, radiological tests WHO criteria for HCC : Risk factors of HCC Characteristic CT finding Raised AFP ( < 400)

27. Investigations Alpha fetoprotein Elevated in 80% of hepatocellular cancer Triphasic CT is the gold standard investigation Involves scanning of liver at three different times after intravenous contrast : 1-Aertial phase : aorta lights as contrast fills up the aorta , IVC and portal veins are dark 2-Portovenous phase : contrast enter portal vein so portal vein is bright as aorta 3-Delay phase: contrast drains out , so none of the vessels in the liver lights up

28. Characteristic features of HCC Enhancement in the arterial phase (as HCC are rich by blood supply from hepatic arterial system ) with rapid wash out of contrast at Porto venous phase system (hypodense) In patients with HBV/HCV and raised AFP , a liver lesion is not a hemangioma on imaging should be considered HCC until proven otherwise CT can show nodal involvement and metastasis to adrenals

29. CT scan of HCC

30. Grading There are several grading systems for the histopathologic grading of HCC but most used is the degree of differentiation of cell cancers : Grade I – well differentiated Grade II – moderately differentiated Grade III – poorly differentiated Grade IV – undifferentiated Studies have shown that grading of HCC is only a weak prognostic indicator , indicating that it is not predicting likelihood of survival or useful in dictating treatment

31. Staging

32. The severity of liver cirrhosis is graded using Child- pugh score which combines measurement of liver’s synthetic and detoxification

33. BCLC System

34. Treatment The only curative treatment of HCC is surgical resection of tumor About 10-20% of HCC patients have disease amenable to surgery 2 surgical possibilities: 1- Partial hepatectomy 2- Liver transplantation Factors affecting resection: 1- Stage of disease 2- General fitness for procedure 3- Liver function preoperatively 4- Residual liver function post-operatively 5- Degree of portal hypertension 6- Location of tumor

35. Hepatectomy Problem in hepatectomy there is “field change” effect in patient with cirrhosis in the liver , that new tumor can develop in the remnant of the liver Requires fine balance between adequate resection of liver margins and preservation of sufficient functional liver to prevent live failure Good immediate and short term result post-resection ,but no long term results ( > 30 % 5 year survival ) due to occurrence of new primaries in cirrhotic liver

36. Transplantation Milan criteria for transplantation ( < 75 % 5 year survival if followed ) 1- Single tumor 5 cm or smaller or 3 cm or less tumors none larger 3 cm tumors 2- No evidence in gross vascular invasion 3- No regional lymph node or distant metastasis

37. Palliative care Locoregional ablation 1- Radiofrequency ablation – best results for locoregional ablation 2- Percutaneous ethanol injection 3- Cryotherpay Intra-arterial therapy 1- Transarterial chemoembolization 2- Transarterial embolization 3- Radioactive isotope – Yttrium-90 Systematic therapy

38. Malignant liver disease from CRC origin Colon rectal cancer (CRC) is the 3 rd most common cancer worldwide , ranking as high as the 2 nd leading cause of cancer-related deaths in developed countries The liver is recognized as the most common site of CRC metastasis because the majority of the intestinal mesenteric drainage enter the hepatic portal system More than 50% of patient with CRC will develop metastatic disease to the liver (CRLM) over the course of their life , which ultimately results in death for more than two thirds of these patients

39. Currently , hepatic resection of colorectal cancer liver metastasis in patients with isolated liver metastasis remains the only option for potential cure . However , even when resection is combined with modern adjuvant systematic regimens , it is curative in only 20% of patient with 70 % developing recurrence , primarily in the liver Detecting primarily CRC and CRLM at an early stage results in better prognosis

40. Clinical manifestation A persistent change in your bowel habits, including diarrhea or constipation or a change in the consistency of your stool Rectal bleeding or blood in your stool Persistent abdominal discomfort, such as cramps, gas or pain A feeling that your bowel doesn't empty completely Weakness or fatigue Unexplained weight loss

41. Liver manifestation Weight loss Loss of appetite High temperature Nausea Lethargy (extreme tiredness) Enlarged spleen. Secondary liver cancer may also cause or trigger: Discomfort in the upper, right part of the abdomen because of an enlarged liver. Jaundice which is a yellowish tinge to the skin and the whites of the eyes. Ascites, which is a swollen abdominal cavity caused by a buildup of fluid.

42. Diagnosis Colonoscopy.   Biopsy.  Biomarker testing of the tumor. Blood tests.  Computed tomography (CT or CAT) scan: whether the cancer spread to lungs , liver or other organs Ultrasound : whether the cancer spread inside abdomen or in the liver   MRI: whether the cancer spread inside abdomen or pelvi s   Chest x-ray: whether the cancer spread to lungs or not Positron emission tomography (PET) or PET-CT scan

43. Management Surgical Hepatectomy remains the standard of care for CLM . In the past , post-operative mortality was high but nowadays it has decreased to around 1% , allowing more extended hepatic resections by more advanced surgical techniques . Liver failure after hepatectomy remains the major concern for the hepatobiliary surgeon .Resection , even partial can result in small postoperative remanent liver function , hence increasing the risk of postoperative liver failure and subsequent very high mortality

44. Chemotherapy For patients with resectable disease , “ perioperative chemotherapy “ Has become an attractive option , in order to reduce the incidence of cancer relapse , occurring in up to 50-70% of them after resection Through the eradication of occult disease Targeted biological therapy Monoclonal antibody targeting two different mechanisms : 1- Angiogenesis (bevacizumab) 2- Epidermal growth factor receptors (EGFRs) (cetuximab and pantumumab )

45. Thank you