Liver Neoplasms

Question 1

• Tumor-like condition
• Unknown etiology
• MC in women
• Usually asymptomatic
• Small
• Central stellate scar

Answer 1

Focal nodular hyperplasia

Question 2

• MC in young adult women; strongly associated with oral contraceptives
  
  • ​Also with anabolic steroids, glycogen storage diseases
• Benign epithelial tumor (on otherwise healthy liver)
  
  • Small risk of malignant transformation, bleeding; need to excise
• Typically solitary
• Clinical
  
  • Epigastric
  • RUQ pain
• AFP normal

Answer 2

Hepatic adenoma

Question 3

• MC benign hepatic tumor
  
  • Often asymptomatic
  • No malignant potential
• Most diagnosed at 30-50 years of age
• MC in woman

Answer 3

Cavernous hemangioma

Question 4

Rare, high-grade neoplasm of endothelial cells

MC sarcoma arising in the liver

Older patients (>60); M>F

Risk factors:

1. Vinyl chloride
2. Arsenic
3. Anabolic steroids

Clinical:

• Abdominal pain
• Fatigue
• Weight loss
• Liver failure (common cause of death)
• Intra-abdominal bleed (common cause of death)
• Metastasis common (lungs, bone, adrenals)

Answer 4

Angiosarcoma

Question 5

Name the (3) risk factors for angiosarcoma.

Answer 5

1. Vinyl chloride
2. Arsenic
3. Anabolic steroids

Question 6

MC primary hepatic malignancy in early childhood (<5 y/o)

M>F

Associated with Down syndrome, FAP

May grow rapidly; can rupture and bleed

AFP markedly elevated

Sexual precocity may be present (extopic synthesis of gonadotropin)

Answer 6

Hepatoblastoma

Question 7

MC primary malignant tumor of liver

Increasing incident in US due to hepatitis C

M>F

U.S. - 60s; Asians - 20s-40s (HBV at birth)

Commonly develops secondary to chronic liver disease (most have cirrhosis)

Answer 7

Hepatocellular carcinoma (HCC)

Question 8

Risk factors for hepatocellular carcinoma (HCC)

(6)

Answer 8

1. Chronic HBV, HCV
2. Aflatoxin (grains, Aspergillus)
3. Chronic alcohol abuse
4. Fatty liver disease
5. Hereditary hemochromatosis
6. Alpha-1-antitrypsin deficiency

Question 9

HCC frequently diagnosed late because of the absence of pathognomonic symptoms. As a result, many patients have untreatable disease when 1st diagnosed; survival measured in months.

Poor prognostic factors include (3): ___, ___, ___

Answer 9

1. Increasing tumor size
2. Vascular invasion
3. Nodal metastases

Question 10

Well-differenciated HCC cells may produce ___

Answer 10

Bile (creating yellow pigment)

Question 11

Grossly, HCC may present as (3)

Answer 11

1. Single mass
2. Multiple, widely distributed nodules
3. Diffusely infiltrative

Question 12

HCC paraneoplastic syndromes (3)

Answer 12

1. Hypoglycemia
   
   • High metabolic needs of tumor
   • Secretion of insulin-like growth factor
2. Erythrocytosis
   
   • Tumor secretion of EPO
3. Hypercalcemia
   
   • Tumor secretion of PTHrP

Question 13

HCC MC metastasizes to the ___

Other sites include (3)

Answer 13

Lungs (MC)

Other sites:

1. Intra-abdominal LN
2. Bone
3. Adrenal gland

Question 14

___ is a tumor marker for HCC

• Normally produced during gestation (by fetal liver and yolk sac)
• Not specific; not specific (not all tumors secrete; normal levels with fibrolamellar variant of HCC)
• Rise + cirrhosis/chronic hepatitis = worrisome for HCC
• Not used for screening; may be used for example in a known cirrhosis patient

Answer 14

Alpha-fetoprotein (AFP)

Question 15

Other than cirrhosis, a patient can develop portal HTN with HCC growth impacting the ___ or ___, both causing obstruction and portal HTN.

Answer 15

Portal vein

Hepatic vein/IVC

Question 16

• Distinctive liver tumor that differs clinically, histologically, and molecularly from conventional HCC
• Affects younger patients
• F > M (think young females)
• Not associated with cirrhosis or chronic viral hepatitis
• In general, has better prognosis than conventional HCC
• Tumor is slow growing
• Patients present with abdominal mass or pain
• Serum AFP levels usually normal

Answer 16

Fibrolamellar varient of HCC

Question 17

• Adenocarcinoma of the bile ducts (epithelial cells)
• Can involve any portion of the biliary tree
  
  • Intrahepatic - 10%
  • Perihilar (central) - 60%
    
    • Klatskin’s tumor (tumor arises at bifurcation of R and L hepatic ducts)
  • Distal extrahepatic - 30%
• Highly lethal

Answer 17

Cholangiocarcinoma

Question 18

Predisposting factors to cholangiocarcinoma are chronic inflammatory conditions of the biliary tree, including (5)

Answer 18

1. Primary sclerosing cholangitis (MC; longstanding UC)
2. Chinese liver fluke, Opisthorchis (Clonorchis) sinensis
3. Choledochal cyst
4. Caroli disease
5. Choledocholithiasis

Question 19

Jaundice, pruritis, clay-colored stools, dark urine, abdominal pain, fever.

Extrahepatic or intrahepatic cholangiocarcinoma?

Answer 19

Extrahepatic (entire biliary tree will be blocked)

Question 20

Dull RUQ pain, weight loss, less likely to be jaundice

Extrahepatic or intrahepatic cholangiocarcinoma?

Answer 20

Intrahepatic (won’t obstruct then entire biliary tree, thus won’t cause, at least as much, jaundice)

Question 21

Cholangiocarcinoma lab include:

Typically ___ pattern with transaminase levels being ___

Answer 21

• Cholestatic
• Initially normal (may increase if long-term obstruction causes hepatocellular injury)

Question 22

Dianosis of cholangiocarcinoma?

Answer 22

1. US
2. MRI/CT
3. ERCP

Question 23

Tx of cholangiocarcinoma?

Answer 23

Surgery

Biliary stent

Question 24

Prognosis of cholangiocarcinoma?

Answer 24

Poor

Question 25

MC liver tumor is ___; common sites include (4)

Answer 25

Metastasis from another location (multple masses); common sites include:

• Lung
• Colon
• Pancreas
• Breast

Question 26

With liver metastasis, ascites can become present by one or two ways: ___, ___

Answer 26

1. Portal HTN
2. Concomitant peritoneal tumor seeding