liver tumors.types symptoms management ppt.pptx

Tumor

1. LIVER TUMORS Dr.purushotham.g Associate professor Department of general surgery Ggh,gmc ongole

2. INTRODUCTION Liver tumors (also known as hepatic tumors) are abnormal growth of liver cells on or in the liver. Several distinct types of tumors can develop in the liver because the liver is made up of various cell types.

3. CLASSIFICATION Liver tumors can be classified as benign (non-cancerous) or malignant (cancerous) growths. BENIGN LESIONS : Benign liver lesions can be solid or cystic lesions Solid benign lesions include: 1. Hemangioma 2. Adenoma 3. Focal nodular hyperplasia. 4. Bile duct hamartoma.

4. Some other benign tumors which are rare include: a. Macroregenerative nodules previously known as adenomatous hyperplasia. b. Nodular regenerative hyperplasia c. Mesenchymal hamartomas d. Fatty tumors of the liver which include lipomas,myelolipomas,angiolipomas . e. Inflammatory pseudotumors Other extremely rare benign hepatic tumors include leiomyomas,myxomas,schwannomas,lyphangiomas and teratomas .

5. Cystic benign lesions include: 1. Congenital or simple cyst 2. Biliary Cystadenoma 3. Polycystic Liver disease 4. Bile duct cysts.

6. Malignant lesions of the liver include: 1. HEPATOCELLULAR CARCINOMA 2. Cholangiocarcinoma 3. Gallbladder cancer 4. Metastatic colorectal cancer 5. Metastatic neuroendocrine cancer 6. Other metastatic cancers

7. EVALUATION OF AN INCIDENTAL LIVER MASS It is estimated that benign focal liver masses are present in approximately 10%-20% of the population in developed countries. A liver mass is often identified incidentally during a radiologic imaging procedure performed for another indication. Many benign lesions can be adequately characterised by modern imaging studies such as CT,ultrasound and MRI. An orderly approach should be taken to the work up of an incidental liver lesion to minimise unnecessary testing.

8. The evaluation of an incidental liver mass begins with a history and physical examination. This should be followed up by the necessary blood work like CBP,platlet count,BUN,creatinine,LFT etc. Imaging studies like USG,CT or MRI etc. Liver biopsy is indicated when biochemical analysis and diagnostic imaging fails to lead to a definitive diagnosis. Absolute contraindications to liver biopsy: . 1.Significant coagulopathy 2.Biliary dilatation 3.Suspicion of hemangioma or echinococcal cyst.

9. HEMANGIOMA: Hemangiomas are the most common solid benign masses that occur in liver. They are congenital vascular lesions that contain fibrous tissue and small blood vessels that eventually grow. It occurs in women more than men (3:1) and at a mean age of 45 years. They range from small(<1cm) to giant cavernous hemangiomas(10-25cm).

10. SYMPTOMS: They are usually asymptomatic and found incidentally on imaging studies with little clinical significance. However large lesions can cause bague abdominal symptoms due to compression of adjacent organs. Spontaneous rupture is rare. The combination of giant hemangioma, thrombocytopenia, and consumption coagulopathy is termed Kasabach -Merritt syndrome (KMS). KMS is an infrequent but potentially fatal complication of rapidly growing vascular lesions in infants

11. If diagnostic uncertainty exists in USG,Ct scanning with delayed contrast enhancement is diagnostic. Biopsy is not recommended An asymptomatic patient with a secure diagnosis can simply be observed. Rupture,significant change in size,and development of the Kasabach-merritt syndrome are indications for resection. Approach to resection is enucleation but anatomic resection may be necessary in some cases.

12. HEPATIC ADENOMA: Hepatic adenoma is a relatively rare benign proliferation of hepatocytes in the context of a normal liver. Female to male ratio is 11:1 with predominance in you g women(aged 20-40). It is often associated with steroid hormone use,such as long term oral contraceptive pill(OCP) use. They are usually singular but multiple lesions have also been reported. Liver adenomatosis is defined by the presence of more than 10 adenomas in the liver.

13. On basis of molecular pathology adenomas are classified as 1. Bet-catenin mutated, HNF1A mutated, inflammatory adenoma,and not otherwise specific adenoma SYMTPOMS: Patients present with symptoms approximately 50-70% of the time.Upper abdominal pain is common and may be related to hemorrhage into the tumor or local compressive symptoms. The two major risks of adenomas are rupture ,with potentially life threatening intraperitoneal hemorrhage,and malignant transformation. Patients presenting with acute hemorrhage are managed with hepatic artery embolization as a temporary maneuver followed by laparotomy and resection of mass.

14. Resection is usually recommended because of low mortality in experienced hands,margin status is not important and limited resections can be performed. The management of adenamatosis is controversial but large lesions should be respected because of the risk of rupture. On ocassion liver transplantation is necessary for aggressive forms of adenamatosis .

15. FOCAL NODULAR HYPERPLASIA(FNH) FNH is the second most common benign tumor of the liver after hemangioma. It is predominantly seen in young women of child bearing age. The cause of FNH is not known,but the most common theory is that FNH is related to a developmental vascular malformation and is believed to be a hyperplastic response to an anamalous artery. It is usually asymptomatic and incidentally found on imaging.

16. Contrast enhanced CT or MRI is diagnostic in which lesions appear well circumscribed with a typical central scar. Rupture,bleeding and infarction are exceedingly rare,and malignant transformation of FNH has never been reported. Therefore the management of FNH is usually reassurance and prospective observation irrespective of size. Patients with persistent symptomatic FNH or an enlarging mass should be considered for resection.

17. HEPATIC CYST: The most common benign lesion found in the liver is the congenital or simple cyst. Simole cysts are the result of excluded hyperplastic bile duct rests. Female to male ratio is approximately(4:1). With the exception of large cysts,simple cysts are asymptomatic and are identified incidentally. Large cysts may cause abdominal pain,epigastric fullness and early satiety.

18. Asymptomatic cysts are best managed conservatively.Preferred treatment for symptomatic cysts is USG or CT guided percutaneous cyst aspiration followed by sclerotherapy . If percutaneous treatment is unavailable or ineffective,treatment may include either laproscopic or open surgical cyst fenestration.

19. BILIARY CYSTADENOMA: Biliary cystadenomas are slow- growing,unusual,benign lesions that most commonly present as large lesions in the right lobe of the liver. They are often multilocular,septated,non calcified. And surrounded by compressed liver tissue. They are usually asymptomatic but can cause upper abdominal pain.An abdominal mass can occassionally be identified on physical examination. Cystadenomas are slow growing but have malignant potential and must be distinguished from other diseases.

20. Diagnosis is suspected by a combination of cross-sectional CT or MRI and USG. Serum and cyst fluid CA 19-9 levels may be elevated on cases of cystadenoma with mesenchymal stroma. CEA is unhelpful and cyst fluid cytology is unreliable. The risk of recurrence and the potential for malignant transformation mandates complete anatomical resection . If the lesion is technically irresectable or cannot be separated from major structures then liver transplantation may be required.

21. POLYCYSTIC LIVER DISEASE Adult polycystic liver disease(PCLD) occurs as an autosomal dominant disease and usually presents in the third decade of life. Approximately 44% to 76% of affected families have mutation in PKD1 and approximately 75% have mutations of PKD2 . The cysts are histologically similar to simple cysts with the only difference being the number of cysts. Liver cysts are always preceded by kidney cysts,and their prevelance in adult polycystic kidney disease increases with age.

22. SYMPTOMS : Patients with small number of cysts usually remain asymptomatic,whereas patient with larger cysts develop symptoms like abdominal pain, distension,SOB,And early satiety. Despite the large number of cysts,hepatic parenchyma and function are usually preserved. LFT results are almost always normal.

23. COMPLICATIONS : The most common liver specific complications associated with PCLD are intracystic hemorrhage , infection ,and post traumatic rupture . Hepatic decompensation,variceal hemorrhage,ascites,and encephalopathy develop rarely in patients with PCLD and in only those with massive cysts.

24. INVESTIGATIONS : Most useful imaging tests are CT or MRI of the abdomen ,which will demonstrate the characteristic polycystic apperance . Modestly elevated gamma- glytamyltransferase level. Other conditions that may be associated with PCLD include cerebral aneurysm,diverticulosis,mitral valve prolapse and inguinal hernia.

25. TREATMENT : The principal aim of the treatment is to ameliorate symptoms by decreasing liver volume. MEDICAL : Somatostatin analogues like octreotide and lanreoride mTOR ( mammalian target of rapamycin inhibitors used to reduce liver volume and decrease the proliferation. SURGICAL : > Cyst aspiration and sclerotherapy >Cyst fenestration,or surgical unroofing of the cyst. >Hepatic resection >OLT(orthotropic liver transplantation) In context of renal failure,a combined kidney and liver transplantation may be appropriate.

26. BILE DUCT CYSTS: Bile duct cysts or choledochal cysts are congenital dilatations of the biliary tree that are usually diagnosed in childhood but can present in adulthood Type IV cysts and Caroli’s disease(type V) is characterized by multiple intrahepatic cysts. Approximately 50% of cases of Caroli’s disease are associated with congenital hepatic fibrosis,the cysts are diffusely located throughout the liver. Because of risk of malignancy and recurrent cholangitis, treatment is excision with re-establishment of biliary-enteric continuity. Treatment for diffuse hepatic involvement is poor and may require transplantation.

27. HEPATOCELLULAR CARCINOMA Liver cancer is the fifth most common cancer and the second most frequent cause of cancer-related death globally. HCC is a malignant tumor arising from hepatocytes and is the most common primary liver cancer. RISK FACTORS : It is two to eight times more common in men. Hepatic viral infections like HBV and HCV Cirrhosis,smoking,alcohol abuse,genetic metabolic diseases like hereditary hemochromatosis and wilsons disease.

28. Other chemicals such as nitrates,hydrocarbons,vinyl chloride,thorotrast etc. Obesity and diabetis mellitus are additional independent risk factors. CLINICAL PRESENTATION : Most commonly men 50-60 years of age with complaints if right upper quadrant pain and weigh loss and have a palpable mass. Non specific symptoms of advanced malignant disease such as anorexia,nausea,lethargy and weight loss are also common. Other rare presentations include hepatic vein occlusion(Budd-Chiari syndrome), obstructive jaundice,hemobilia and fever of unknown origin

29. STAGING OF HCC : Clinical staging systems for HCC are designed to guide management.The Barcelona Clinic Liver Group (BCLC) staging system is the most commonly used. It was designed to reflect underlying liver function and performance status together with tumor characteristics. PREOPERATIVE EVALUATION OF PATIENTS WITH HCC : Achieving good outcomes for patients undergoing surgical resection requires accurate assesment of tumor stage,comorbidities and liver functions. A number of tests and clinical assesment schemes are available out of which Child-Pugh status is most commonly used.

30. DIAGNOSIS : USG,CT and MRI aid in the diagnosis of HCC USG plays a significant role in screening and early detection. Contrast enhanced CT and MRI are investigation of choice Typical inahing criteria for HCC include rapid arterial enhancement followed by washout in the delayed phase.

31. Treatment: Surgical : Resection Orthotopic liver transplantation Ablative : Ethanol injection
Acetic acid injection
Thermal ablation (cryotherapy, radiofrequency ablation, microwave)

32. Transarterial : Embolization Chemoembolization Radiotherapy : Combination transarterial and ablative: external beam radiation Systemic :
Chemotherapy
Hormonal
Immunotherapy

33. TRANSPLANTATION : Theoretically,orthotropic liver transplantation is thenideal treatment for HCC because it adresses the liver dysfunction and cirrhosis. MILAN CRITERIA : The Milan criteria are used to assess suitability in patients for liver transplantation with cirrhosis and hepatocellular carcinoma (HCC) Under the Milan criteria, eligibility for liver transplantation is based on the following:
single tumor with a diameter of ≤5 cm, or up to 3 tumors each with a diameter of ≤3 cm
no extra-hepatic metastases.
no major vessel involvement

34. COLORECTAL LIVER METASTASES Worldwide colorectal cancer is the third most common solid organ malignancy. Upto 70% of patients develop synchronous( i.e.,at thetime of diagnosis of primary disease) or metachronously (arbitrarily defined as >1year after the diagnosis of primary) liver metastases. Despite recent advances in chemotherapeutic agents,resection remains the only potentially curative option.

35. DEFINING RESECTABILITY OF COLORECTAL LIVER METS : Previously,patients with synchronous metastases, a rectal primary,multiple diffuse mets,metastases larger than 5cm,disease free interval <12months,CEA levels >200 were considered irresectable and suitable only for palliative treatment. But improved chemotherapy regimens and surgical techniques have produced aggressive strategies for the management of the disease An R0 resection with negative surgical margins of 1cm is the gold standard. An FLR(future liver remnant) of 25% of preop volume is considered sufficient to prevent hepatic failure.

36. STAGING AND SELECTION OF PATIENTS FOR LIVER SURGERY : Routine staging involves triple phase CT chest/abdomen/ pelvis,contrast MRI scan of liver,whole body PET-CT to identify metastatic disease. CHEMOTHERAPY : Chemotherapy with 5- fluorouracil and folinic acid in combination with oxaliplatin produces a response rate of 50-60% Combination chemo with monoclonal antibodies that recognise vascular endothelial growth factor receptors( VEGFR ) or epidermal growth factor receptor( EGFR ) provide additional benefit .

37. SYNCHRONOUS COLON AND LIVER RESECTION : Resection of the colonic primary followed by chemotherapy restaging and resection of the liver disease,if appropriate is the standard procedure. LIVER-FIRST APPROACH : The traditional strategy is colonic resection followed by chemo and delayed liver resection. But this may allow progression of the liver disease and render the CRLM unresectable . The liver first approach or reverse strategy is a downstaging regimen consisting of systemic chemotherapy,chemoradiotherspy and/or biological agents,followed by resection of the CRLM prior to removal of colonic primary.

38. NEUROENDOCRINE METASTASES: Liver metastases from neuroendocrine tumors are common but vary according to the primary type. Examples are gastrinomas,glucagonomas,somatostatinomas,and non-functional neuroendocrine tumors.Insulinomas and carcinoid tumors metastasize to the liver less commonly. Neuroendocrine tumors often secrete functional neuropeptide that can create debilitating syndromes of hormonal excess.

39. Non surgical therapies include the use of long acting somatostatin analogues for alleviating hormonal symptoms and may also have cytostatic role as well,hepatic arterial embolization or thermoablative approach can also be used. Surgical approach is liver resection which can play a role in patients whose tumor can be completely Encompassed. Five-year survival rates in excess of 50% to 75% can be expected if a complete resection is accomplished. Formal resections with wide margins are not necessary for neuroendocrine tumors,and techniques such as enucleation and wedge resection are reasonable options

40. OTHER METASTATIC TUMORS Other tumors can be manifested as isolated liver metastases such as,breast,ling,melanoma,soft tissue sarcoma,wilms tumor,GIT,urological and gynaecological . General principles that should be considered in dealing with these tumors as isolated liver metastases are similar to those for colorectal metastases. In general,liver resection for metastatic noncolorectal,no neuroendocrine tumors has to be considered cytoreductive and should be used only in the most favourable situations.

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