18-8: Nodules and Tumors

Question 1

what are the benign hepatic masses?

Answer 1

nodular hyperplasias

hemangiomas

adenomas

Question 2

what are the malignant hepatic masses?

Answer 2

hepatoblastoma

hepatocellular carcinoma

cholangiocarcinoma

angiosarcoma

lymphoma

metastatic

Question 3

what is focal nodular hyperplasia?

Answer 3

a single well-demarcated lesion with central scar

incidental finding in otherwise normal liver

map-like pattern of strong cytoplasmic GS staining

Question 4

what conditions are associated with FNH?

Answer 4

hepatic or extra-hepatic hemangioma

vascular malformations

some brain tumors

Question 5

what is nodular regenerative hyperplasia?

Answer 5

multiple nodules that resemble cirrhosis however there is no fibrous septa

risk of portal hypertension

Question 6

what conditions are associated with NRH?

Answer 6

HIV

rheumatologic disease

Question 7

what is the most common benign neoplasm of the liver?

Answer 7

cavernous hemangioma

Question 8

what is the presentation of cavernous hemangioma?

Answer 8

F > M

usually asymptomatic and incidental discovery

risk of hemorrhage due to subcapsular location

Question 9

what is the presentation of hepatocellular adenoma?

Answer 9

F > M

associated with oral contraceptives and anabolic steroids

increased incidence with obesity and metabolic syndrome

usually an incidental finding on imaging but may be found due to rapid growth or hemorrhage

Question 10

what are the adenoma subtypes?

Answer 10

HNF1-a inactivated adenoma

Inflammatory adenoma

B-Catenin activated adenoma

Question 11

HNF1-a inactivated adenoma

Answer 11

strong female predilection

fatty tumor without atypia

minimal risk of malignant transformation

Question 12

Inflammatory adenoma

Answer 12

strongly associated with females and obesity/metabolic syndrome

overexpress CRP and amyloid A

risk for malignant transformation

Question 13

B-Catenin activated adenoma

Answer 13

40% occur in men

associated with oral contraceptives and anabolic steroids

high risk for malignant transformation

Question 14

what is the clinical presentation of hepatoblastoma?

Answer 14

< 3 years old

asymptomatic abdominal swelling

occasionally presents with jaundice and pruritis

Question 15

what are the histological features of the epithelial type hepatoblastoma?

Answer 15

small polygonal fetal cells or smaller embryonal cells forming acini, tubules or papillary structures

Question 16

what are the histological features of the mixed type hepatoblastoma?

Answer 16

contains primitive mesenchyme of osteoid, cartilage or striated muscle along with epithelial tissue

Question 17

where is a hepatoblastoma likely to metastasize?

Answer 17

the lungs

Question 18

what conditions are associated with hepatoblastoma?

Answer 18

FAP

Beckwith-Wiedemann Syndrome

Question 19

what is the most common primary malignancy of hepatocytes?

Answer 19

hepatocellular carcinoma

Question 20

where is HCC most common?

Answer 20

in Asia and sub-Saharan Africa where chronic HBV infection is common

Question 21

what factors are most important in the formation of HCC?

Answer 21

viral infections (HBV and HCV)

toxic injuries (aflatoxins and alcohol)

Question 22

what typically precedes HCC?

Answer 22

chronic liver disease with cirrhosis

*15-20% arise in noncirrhotic livers

Question 23

what are the macroscopic and microscopic features of HCC?

Answer 23

macro: single, large, hard, scirrhous tumor with fibrous bands
micro: large polygonal cells with granular cytoplasm, vesicular nuclei with a prominent nucleolus and parallel lamellae of dense collagen bundles

Question 24

what is the treatment for HCC?

Answer 24

Surgical resection for noncirrhotic livers or cirrhotic livers with adequate function

Transplant for advanced cirrhotic livers

Tumor ablation for unresectable tumors or those that cannot receive a transplant

Question 25

what is the origin of intrahepatic cholangiocarcinoma?

Answer 25

arising from the intrahepatic biliary tree

Question 26

what is the origin of biliary adenocarcinoma?

Answer 26

arising from extrahepatic bile ducts

Question 27

where is intrahepatic cholangiocarcinoma most common?

Answer 27

Southeast Asian countries where liver fluke infestations are endemic

Question 28

what are some risk factors associated with intrahepatic cholangiocarcinoma?

Answer 28

fibropolycystic liver disease primary sclerosing cholangitis liver fluke infestation hepatolithiasis Hep B and C Nonalcoholic fatty liver disease

Question 29

where are the majority of intrahepatic cholangiocarcinoma located within the biliary tree?

Answer 29

at the bifurcation of the biliary system (Klatskin tumors)

Question 30

What features are similar between intrahepatic and extrahepatic tumors?

Answer 30

clearly defined glandular/tubular structures lined by malignant epithelial cells embedded in an abundant fibrous stroma lymphovascular and perineural invasion are common

Question 31

how do the presentations of intrahepatic and extrahepatic tumors differ?

Answer 31

intrahepatic may be asymptomatic or present as a liver mass extrahepatic present with symptoms related to biliary obstruction

Question 32

angiosarcoma is caused by exposure to which substances?

Answer 32

vinyl chloride arsenic Thorotrast

Question 33

what diseases are associated with hepatic lymphoma?

Answer 33

Hep B and C HIV Primary biliary cholangitis

Question 34

which is more common, primary liver cancer or metastatic malignancy?

Answer 34

metastatic malignancy from another primary source ex: colon, breast, lung and pancreas

Question 35

what symptoms are universal to all hepatic malignancies?

Answer 35

anorexia fevers jaundice nausea RUQ pain sweats weight loss