Liver Tumors - Benign and Malignant - UG Surgery

Classification, Etiopathogenesis, Clinical features, Management of types of liver tumors

1. Liver TumorsLiver Tumors

2. ObjectiveObjective
1.1.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
carcinoma (Primary Liver cancer)carcinoma (Primary Liver cancer)

3. ClassificationClassification
HemangiomaHemangioma
Focal nodular Focal nodular
hyperplasiahyperplasia
AdenomaAdenoma
Liver cystsLiver cysts
1.1.Primary liver cancersPrimary liver cancers
Hepatocellular Hepatocellular
carcinomacarcinoma
Fibrolamellar carcinomaFibrolamellar carcinoma
HepatoblastomaHepatoblastoma
2. 2. MetastasesMetastases
Benign Malignant

4. Benign Liver LesionsBenign Liver Lesions
1.1.HemangiomaHemangioma
2.2.Focal nodular hyperplasiaFocal nodular hyperplasia
3.3.AdenomaAdenoma
4.4.CystsCysts

5. HemangiomaHemangioma
Clinical 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 asymptomatic Usually asymptomatic

6. HemangiomaHemangioma
Diagnosis and ManagementDiagnosis and Management
DiagnosisDiagnosis
US: echogenic spot, well demarcatedUS: echogenic spot, well demarcated
CT: venous enhancement from CT: venous enhancement from periphery to centerperiphery to center
MRI: high intensity areaMRI: high intensity area
No need for FNACNo need for FNAC
TreatmentTreatment
No need for treatmentNo need for treatment
No risk of malignant transformationNo risk of malignant transformation
Resection – Rupture, KM syndromeResection – Rupture, KM syndrome

7. CT/HemangiomaCT/Hemangioma
Peripheral nodular enhancement

8. 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 relationNo relation with sex hormones with sex hormones
Usually asymptomaticUsually asymptomatic
May cause minimal painMay cause minimal pain

9. Focal Nodular Hyperplasia (FNH)Focal Nodular Hyperplasia (FNH)
Diagnosis and ManagementDiagnosis and Management
DiagnosisDiagnosis::
US: US: NoduleNodule with varying echogenicity with varying echogenicity
CT: CT: Hypervascular mass with central scar / Hypervascular mass with central scar /
homogenous masshomogenous mass
MRI: iso or hypo intense MRI: iso or hypo intense
FNA: FNA: NormalNormal hepatocytes and hepatocytes and Kupffer cellsKupffer cells with with
central core.central core.
TreatmentTreatment::
No treatment necessaryNo treatment necessary

10. CT/FNHCT/FNH

11. Hepatic AdenomaHepatic Adenoma
Clinical featuresClinical features
BenignBenign neoplasm composed of normal neoplasm composed of normal
hepatocytes hepatocytes no portal tract, central veins, no portal tract, central veins,
or bile ductsor bile ducts
More common in More common in womenwomen
Associated with Associated with contraceptive hormonescontraceptive hormones
Usually asymptomatic but may have RUQ Usually asymptomatic but may have RUQ
painpain
Mat presents with rupture, hemorrhage, or Mat presents with rupture, hemorrhage, or
malignant transformation (very rare) malignant transformation (very rare)

12. Hepatic AdenomaHepatic Adenoma
Diagnosis and ManagementDiagnosis and Management
DXDX
US: filling defectUS: filling defect
CT: Diffuse arterial enhancement / CT: Diffuse arterial enhancement / heterogenous heterogenous
massmass
MRI: hypo or hyper intense lesionMRI: hypo or hyper intense lesion
FNA : may be neededFNA : may be needed
TxTx
Stop hormonesStop hormones
Observe every 6m for 2 yObserve every 6m for 2 y
If no regression then surgical excisionIf no regression then surgical excision

13. AdenomaAdenoma

14. Liver CystsLiver Cysts
May be May be single or multiplesingle or multiple
May be part of May be part of polycystic kidney diseasepolycystic kidney disease
Patients often asymptomaticPatients often asymptomatic
No specificNo specific management required management required
Hydatid cystHydatid cyst

15. Malignant Liver LesionsMalignant Liver Lesions

16. 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

17. HCC: IncidenceHCC: Incidence
The 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

18. HCC: Risk FactorsHCC: Risk Factors
The 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

19. HCC: Clinical FeaturesHCC: Clinical Features
Wt loss and RUQ pain (most common)Wt loss and RUQ pain (most common)
AsymptomaticAsymptomatic
Worsening of pre-existing chronic liver disWorsening of pre-existing chronic liver dis
Acute liver failureAcute liver failure
O/E:O/E:
Signs of cirrhosisSigns of cirrhosis
Hard enlarged massHard enlarged mass

20. HCC: MetastasesHCC: Metastases
Rest of the liverRest of the liver
Portal veinPortal vein
Lymph nodesLymph nodes
LungLung
BoneBone
BrainBrain

21. HCC: Systemic FeaturesHCC: Systemic Features
HypercalcemiaHypercalcemia
HypoglycemiaHypoglycemia
HyperlipidemiaHyperlipidemia
HyperthyroidismHyperthyroidism
ErythrocytosisErythrocytosis

22. HCC: labsHCC: labs
Labs 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

23. HCC: DiagnosisHCC: Diagnosis
Clinical presentationClinical presentation
Elevated AFPElevated AFP
USUS
Triphasic CT scan: very early arterial Triphasic CT scan: very early arterial
perfusionperfusion
MRIMRI
BiopsyBiopsy

24. US: HCCUS: HCC

25. CT: Venous PhaseCT: Venous Phase

26. CT: Arterial PhaseCT: Arterial Phase

27. HCC: PrognosisHCC: Prognosis
Tumor sizeTumor size
Extrahepatic spreadExtrahepatic spread
Underlying liver diseaseUnderlying liver disease
Pt performance statusPt performance status

28. Staging SystemsStaging Systems
OKUDA:OKUDA:
BB – Bilirubin >3g/dl – Bilirubin >3g/dl
AA – Ascites – Ascites
AA – Albumin <3g/dl – Albumin <3g/dl
TT – TUMOR >50% of liver – TUMOR >50% of liver
CLIP – Ca of liver Italian parametersCLIP – Ca of liver Italian parameters
CUPI – Chinese Universal Program ICUPI – Chinese Universal Program I

29. HCC: Liver HCC: Liver
TransplantationTransplantation
Best available treatmentBest available treatment
Removes tumor and liverRemoves tumor and liver
Only maximum 3 tumors with largest less Only maximum 3 tumors with largest less
than 6 cm of total size less than 8than 6 cm of total size less than 8
Recurrence rate is lowRecurrence rate is low
Not widely availableNot widely available

30. HCC: ResectionHCC: Resection
Feasible 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

31. HCC: Local AblationHCC: Local Ablation
For 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

32. Radio Frequency AblationRadio Frequency Ablation

33. Ethanol InjectionEthanol Injection

34. HCC: ChemoembolizationHCC: Chemoembolization
Inject 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

35. ChemoembolizationChemoembolization

36. Fibro-Lamellar CarcinomaFibro-Lamellar Carcinoma
Presents in Presents in young ptyoung pt (5-35) (5-35)
Variety of HCCVariety of HCC
Well circumscribedWell circumscribed
Not relatedNot related to cirrhosis to cirrhosis
AFP is normal [AFP is normal [Neurotensin elevatedNeurotensin elevated]]
CT shows typical stellate scar with radial CT shows typical stellate scar with radial
septa showing persistent enhancementsepta showing persistent enhancement
Resectable – Resectable – 50-75%50-75%

37. Secondary Liver Secondary Liver
MetastasesMetastases
The most common site for blood born metastasesThe most common site for blood born metastases
Common primaries : colon, breast, lung, stomach, Common primaries : colon, breast, lung, stomach,
pancreases, and melanomapancreases, and melanoma
Mild cholestatic picture (ALP, LDH) with Mild cholestatic picture (ALP, LDH) with
preserved liver functionpreserved liver function
Dx imaging or FNADx imaging or FNA
Treatment depends on the primary cancerTreatment depends on the primary cancer
Incase of metastasis from intestinal cancer or Incase of metastasis from intestinal cancer or
neuroendocrine cancer. Surgery can offer cure.neuroendocrine cancer. Surgery can offer cure.
Resection or chemoradiation possible for someResection or chemoradiation possible for some

38. HepatoblastomaHepatoblastoma
Hepatoblastoma only affects children of Hepatoblastoma only affects children of 3 years or 3 years or
youngeryounger
MC primaryMC primary hepatic tumor of childhood hepatic tumor of childhood
Hepatoblastoma is a tumor that originates in the Hepatoblastoma is a tumor that originates in the
liver and has a potential to spread to any other liver and has a potential to spread to any other
organsorgans
There are about There are about 100 cases100 cases reported of this reported of this
disorder each yeardisorder each year
The main two genetic disorders associated with The main two genetic disorders associated with
this are this are Beckwith-Wiedemann syndromeBeckwith-Wiedemann syndrome and and
familial adenomatous polyposisfamilial adenomatous polyposis

39. IHCIHC
CholangiocarcinomaCholangiocarcinoma – uncommon tumor – uncommon tumor
TypesTypes 1] MC – hilar / klatskin 1] MC – hilar / klatskin
2] Distal2] Distal
3] IHC – 10% - 23] IHC – 10% - 2
ndnd
MC primary liver MC primary liver
malignancy, also a/w malignancy, also a/w peripheral cholangioCaperipheral cholangioCa
Risk factorsRisk factors – PSC, Choledochal cyst, RPC, – PSC, Choledochal cyst, RPC,
HIV, HCV, DiabetesHIV, HCV, Diabetes
Same as HCC but Same as HCC but AFP and CEA raisedAFP and CEA raised
T/t – Complete resectionT/t – Complete resection

40. SummarySummary
HemangiomaHemangioma
Focal nodular Focal nodular
hyperplasiahyperplasia
AdenomaAdenoma
Liver cystsLiver cysts
1.1.Primary liver cancersPrimary liver cancers
Hepatocellular Hepatocellular
carcinomacarcinoma
Fibrolamellar carcinomaFibrolamellar carcinoma
HepatoblastomaHepatoblastoma
2. Metastases2. Metastases
Benign Malignant