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Y3R6: Surgery I πŸ‘¨β€βš•οΈ > L9: DDx of Hepatic Masses > Flashcards

L9: DDx of Hepatic Masses Flashcards

1
Q

What are Benign Lesions of the Liver?

A
  • Focal Nodular Hyperplasia.
  • Hepatocellular Adenoma.
  • Hemangioma.
  • Nodular Regenerative Hyperplasia.
  • Biliary Cystadenoma.
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2
Q

Def of Focal Nodular Hyperplasia (FNH)

A

Hyperplastic hepatocellular lesions resulting from vascular malformation

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3
Q

Incidence of Focal Nodular Hyperplasia (FNH)

A
  • Second most common benign liver tumor.
  • Clinically relevant in 0.03%.
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4
Q

Age of Focal Nodular Hyperplasia (FNH)

A

Average age at presentation 35–50 years.

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5
Q

Sex of Focal Nodular Hyperplasia (FNH)

A

90% of patients are female.

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6
Q

what is Focal Nodular Hyperplasia (FNH) often associated with?

A

Often associated with other vascular anomalies.

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7
Q

Genetics in Focal Nodular Hyperplasia (FNH)

A

Upregulation of Extracellular matrix (ECM) genes associated with TGF-Ξ² signaling.

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8
Q

CP of Focal Nodular Hyperplasia (FNH)

A
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9
Q

Relation between Focal Nodular Hyperplasia (FNH) & OCP

A

None

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10
Q

Dx of Focal Nodular Hyperplasia (FNH)

A
  • Radiological Imaging
  • Biopsy
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11
Q

Rad Imaging of Focal Nodular Hyperplasia (FNH)

A
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12
Q

Bx in Focal Nodular Hyperplasia (FNH)

A

Biopsy is rarely required because imaging is mostly diagnostic.

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13
Q

Managment of Asymptomatic Focal Nodular Hyperplasia (FNH)

A
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14
Q

Managment of Symptomatic Focal Nodular Hyperplasia (FNH)

A
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15
Q

Def of Hepatocellular Adenoma (HCA)

A

Benign neoplasms with various types of clonal benign hepatocellular proliferations.

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16
Q

Prevelance of Hepatocellular Adenoma (HCA)

A

7-12 per 100,000.

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16
Q

Who is susceptible for Hepatocellular Adenoma (HCA)?

A

Tend to develop in individuals with a hormonal or metabolic abnormality which stimulates hepatocyte proliferation.

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17
Q

Age of Hepatocellular Adenoma (HCA)

A

Average age at presentation 35–40 years.

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18
Q

Sex of Hepatocellular Adenoma (HCA)

A

10:1 female to male.

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19
Q

Risk Factors for Hepatocellular Adenoma (HCA)

A
  • 30–40-fold increase in incidence with long-term OCP use.
  • Increasing incidence in males associated with androgenic steroids.
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20
Q

CP of Hepatocellular Adenoma (HCA)

A
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21
Q

Molecular Classification of Hepatocellular Adenoma (HCA)

A
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22
Q

what gene mutation is most associated with HCC?

A

Ξ²-catenin with inflammatory features

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23
Q

Dx of Hepatocellular Adenoma (HCA)

A
  • MRI
  • Biopsy
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24
Q

Rad Imaging of Hepatocellular Adenoma (HCA)

A
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25
Q

Bx of Hepatocellular Adenoma (HCA)

A
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26
Q

General Precautions in Managment of Hepatocellular Adenoma (HCA)

A
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27
Q

Managment of Asymptomatic Hepatocellular Adenoma (HCA)

A
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28
Q

Managment of Symptomatic Hepatocellular Adenoma (HCA)

A
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29
Q

…….. is recommended in men and in all cases of proven Ξ² catenin mutation

A

Resection irrespective of size

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30
Q

Number in Hepatic Adenomatosis

A

> 3 liver adenomas.

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31
Q

CP of Hepatic Adenomatosis

A

Presentation, genetics, and imaging similar to solitary lesions.

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32
Q

TTT of Hepatic Adenomatosis

A
  • Treatment is based on the size of the largest tumor.
  • Liver resection may be difficult to offer.
  • Followed the same as solitary adenomas.
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33
Q

Def of Nodular Regenerative Hyperplasia

A

Benign hepatic condition.

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34
Q

Incidence of Nodular Regenerative Hyperplasia

A

2.1 to 2.6% in the general population.

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35
Q

Pathology of Nodular Regenerative Hyperplasia

A
  • Normal parenchyma transformed into small regenerative nodules.
  • Result of ischemia either related to thrombosis or phlebitis
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36
Q

CP of Nodular Regenerative Hyperplasia

A
  • Rarely symptomatic.
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37
Q

Similarities between Nodular Regenerative Hyperplasia and micronodular cirrhosis & How to Diffrentiate?

A
  • Shares common features with micronodular cirrhosis:
  • Differentiate based on β†’ Absence of fibrous septa between nodules
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38
Q

INVx in Nodular Regenerative Hyperplasia

A
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39
Q

TTT of Nodular Regenerative Hyperplasia

A

Treatment geared toward management of the underlying etiological condition.

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40
Q

Incidence of Hepatic Hemangioma

A
  • Most common primary liver tumors.
  • Ultrasound studies have placed the frequency at 0.7% to 1.5%.
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41
Q

Age of Hepatic Hemangioma

A

Most common in women aged 30–50 years

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42
Q

Sex in Hepatic Hemangioma

A
  • Female to male ratio ranges from 1.2–6:1.
  • Can occur in all age groups.

No definite relationship to OCP use. .

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43
Q

CP of Hepatic Hemangioma

A
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44
Q

Dx of Hepatic Hemangioma

A
  • US
  • Contrast Enhanced Imaging
  • Biopsy
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45
Q

US in Hepatic Hemangioma

A
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46
Q

Contrast enhanced Imaging in Hepatic Hemangioma

A
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47
Q

Bx in Hepatic Hemangioma

A

Biopsy is rarely needed.

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48
Q

Managment of Hepatic Hemangioma

A
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49
Q

Another name of Hepatobiliary Cystadenoma

A

Hepatobiliary Mucinous Cystic Lesions

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50
Q

What is Hepatobiliary Cystadenoma?

A

Primary cystic neoplasms of the biliary tree

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51
Q

Etiology of Hepatobiliary Cystadenoma

A

Etiology remains unclear

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52
Q

Incidence & Prevelance of Hepatobiliary Cystadenoma

A

Incidence and prevalence are not clear since most current impression in the literature are still based on the earlier criteria of cystadenoma/cystadenocarcinoma.

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53
Q

Age & Sex of Hepatobiliary Cystadenoma

A

Middle-aged females almost exclusively affected.

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54
Q

Site of Hepatobiliary Cystadenoma

A
  • 90% is intrahepatic.
  • 10% arise in the extrahepatic biliary tree.
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55
Q

Size of Hepatobiliary Cystadenoma

A
  • Tumors tend to be large compared with other hepatic lesions.
  • In the largest series, tumor size averaged greater than 10 cm.
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56
Q

Types of Hepatobiliary Cystadenoma

A

Mucinous or serous; mucinous is more common.

57
Q

Histology of Hepatobiliary Cystadenoma

A

Mucinous epithelium characterized by presence of an ovarian-like mesenchymal stroma (maybe focal).

58
Q

Hepatic counterpart of pancreatic mucinous cystic neoplasm (MCN)

A

…

59
Q

CP of Hepatobiliary Cystadenoma

A
60
Q

Complications of Hepatobiliary Cystadenoma

A
61
Q

Labs in Hepatobiliary Cystadenoma

A

Absence of CA19-9 or CEA cannot rule out HB-MCN

62
Q

Rad in Hepatobiliary Cystadenoma

A
63
Q

FNAC in Hepatobiliary Cystadenoma

A

Fine needle aspiration is not sensitive or specific enough.

64
Q

Managment of Hepatobiliary Cystadenoma

A
65
Q

Pathological Classification of liver Malignancies

A
66
Q

Most common of all hepatic neoplasms

A

Hemangioma

67
Q

Most common malignant hepatic tumors

A

Metastatic lesions

68
Q

Most common primary hepatic malignancy

A

Hepatocellular carcinoma

69
Q

Incidence of HCC

A
  • Most common 1ry malignant liver tumor.
  • 4th most common cancer worldwide.
  • 2nd most common cause of cancer related death worldwide.
70
Q

Geographic Distribution of HCC

A
  • High incidence in China and Africa,
  • Lower in Europe and North America.
71
Q

Curability of HCC

A

Only 20-30% are curable.

72
Q

RF for HCC

A
73
Q

Dx of HCC

A
74
Q

Screening in HCC?

A
  • Asian studies confirm benefit.
  • Western studies conflicting
  • Variation in tumor doubling may make more frequent screening necessary but reduce cost effectiveness.
75
Q

Methods of screening for HCC

A

AFP + US or CT every 12 months.

76
Q

Milan Criteria for Liver Transplantation in HCC

A

1) Single tumor diameter less than 5 cm.

2) Not more than three foci of tumor, each one not exceeding 3 cm.

3) No angio invasion.

4) No extrahepatic involvement.

77
Q

Imaging in HCC

A
78
Q

What does Imaging show in HCC?

A
79
Q

Prognostic Factors in HCC

A
80
Q

Managment Lines in HCC

A
  • Resection
  • Locoregional therapy
  • Transplant
  • Medical therapy
81
Q

Indications of resection in HCC

A
82
Q

Locoregional Therapy in HCC

A
83
Q

Indications of Transplantation in HCC

A
84
Q

Medical Therapy of HCC

A
  • Some advances in chemotherapy
  • Sorafenib and other anti-angiogenesis factors
85
Q

Incidence of Fibrolamellar HCC

A

Approximately 1% of all HCC.

86
Q

age of Fibrolamellar HCC

A

Predominately younger Caucasian individuals (80% between age 10- 35).

87
Q

Sex in Fibrolamellar HCC

A

Women slightly more affected.

88
Q

CP of Fibrolamellar HCC

A
89
Q

Def of Cholangicarcinoma

A
  • No history of chronic liver disease.
  • More indolent course (late diagnosis).
  • Present as a large solitary mass (> 10 cm in approximately 70% of patients).
  • Only less than 10% of cases may show increased AFP greater than 200.
90
Q

Histology of Cholangicarcinoma

A

> 90% β†’ adenocarcinoma.

<10% β†’ squamous, sarcoma, small cell, lymphoma

91
Q

Incidence of Cholangicarcinoma

A

2nd most common 1ry hepatic malignancy.

92
Q

Geographic Distrubtion of Cholangicarcinoma

A

Highest incidence in Southeast (SE) Asia (Hep B, parasitic infections),

93
Q

Age in Cholangicarcinoma

A

Uncommon before age 50.

94
Q

Types of Cholangicarcinoma

A
95
Q

Risk Factors for Cholangicarcinoma

A
96
Q

CP of Cholangicarcinoma

A
  • Jaundice
  • Vague RUQ pain
  • Pruritis
  • Anorexia & Wt. loss.
97
Q

Labs in Cholangicarcinoma

A
  • CA 19-9 (>100 has sensitivity of 70-90%, specificity of 85-98%.)
  • Bilirubin.
  • AP, GGT (hilar).
  • ALT, AST.
98
Q

Rads in Cholangicarcinoma

A
99
Q

Findings in Triphasic CT in Cholangicarcinoma

A
100
Q

Managment of Cholangicarcinoma

A
101
Q

Suregry in Cholangicarcinoma

A
102
Q

Liver Transplanation in Cholangicarcinoma

A
103
Q

Def of Hepatic Epitheliod Hemangioendothelioma (HEHE)

A

Rare malignant neoplasm from vascular endothelium.

104
Q

Sex in Hepatic Epitheliod Hemangioendothelioma (HEHE)

A

Predominately females.

105
Q

Prognosis of Hepatic Epitheliod Hemangioendothelioma (HEHE)

A

Unpredictable prognosis

106
Q

CP of Hepatic Epitheliod Hemangioendothelioma (HEHE)

A
  • Usually multifocal tumor (misdiagnosed as metastatic lesions).
  • Appears on the background of normal liver histology.
107
Q

TTT of Hepatic Epitheliod Hemangioendothelioma (HEHE)

A
  • More than 90% of patients are unresectable and transplant is an option.
108
Q

Incidence of Hepatoblastoma

A

Most common liver malignancy in infants and young children.

109
Q

Age of Hepatoblastoma

A

Most present at <3yo β†’ Upper abdominal mass.

110
Q

What is Hepatoblastoma associated with?

A

Associated with:
1) Beckwith-Wiedmann syndrome,
2) Wilm’s tumor,
3) Familial adenomatous polyposis (FAP), 4) Hemihypertrophy,
5) Glycogen storage diseases.

111
Q

CP of Hepatoblastoma

A
  • Usually in right lobe, well circumscribed, 5 – 20 cm diameter.
  • Aggressive tumors β†’ invade locally, spread to regional LN, lungs, adrenals, brain, BM.
112
Q

Dx of Hepatoblastoma

A
  • CT/MRI.
  • Elevated AFP (very high levels, tens of thousands).
  • Liver biopsy.
113
Q

TTT of Hepatoblastoma

A
  • Cure requires gross tumor resection.
  • Can downsize with neoadjuvant chemo.
  • Transplant can be option if remains unresectable after chemo.
114
Q

Types of Sacrcomas in liver

A
  • Angiosarcoma
  • Epithelioid Hemagioendothelioma
  • Embryonal (undifferentiated)
  • Other primary types
115
Q

Incidence of Hepatic Angiosarcoma

A

Most common 1ry sarcoma of liver.

116
Q

Age in Hepatic Angiosarcoma

A

Peak incidence in 60-70 y.

117
Q

Sex in Hepatic Angiosarcoma

A

Male predominance (3:1).

118
Q

Risk Factors in Hepatic Angiosarcoma

A

Thorotrast exposure, vinyl chloride, arsenic.

119
Q

TTT of Epithelioid Hemagioendothelioma

A

Excellent results with transplant.

119
Q

Behaviour of Epithelioid Hemagioendothelioma

A

Low grade angiosarcoma.

120
Q

Behaviour of Embryonal (undifferentiated)

A

Highly malignant childhood cancer.

121
Q

Age in Embryonal (undifferentiated)

A

Peak incidence in 6-10 y.

122
Q

Other Primary Sarcomas of the liver

A
  • Fibrosarcoma.
  • Leiomyosarcoma.
  • Liposarcoma.
  • Hepatobiliary rhabdomyosarcoma.
123
Q

Incidence of 2ry malegnancies of the liver

A
  • Most common hepatic malignancies.
  • 95% of hepatic neoplasms at autopsy.
124
Q

Most Common Sources of 2ry malegnancies of the liver

A

Colon, lung, breast, pancreas.

  • Malignancies arising in organs drained by the portal vein (PV) are more likely to show hepatic metastases and more likely to have metastases confined to the liver.
125
Q

Direct Sources of 2ry malegnancies of the liver

A

From the gallbladder, bowel, or stomach.

126
Q

Venous Sources of 2ry malegnancies of the liver

A

From abdominal or pelvic viscera. (The commonest route)

127
Q

Lymphatic Sources of 2ry malegnancies of the liver

A

From malignant glands in the porta hepatis.

128
Q

Arterial Sources of 2ry malegnancies of the liver

A

From tumors elsewhere.

129
Q

Types of 2ry malegnancies of the liver according to time of occurence

A

Synchronous to 1ry tumor
- Same time with 1ry tumor.

Metachronous to 1ry tumor
- 6-12 months after 1ry.

130
Q

Types of lesion 2ry malegnancies of the liver

A
  • Neuroendocrine.
  • Colorectal.
  • Others (Melanoma, breast, prostate…)
131
Q

Labs in 2ry malegnancies of the liver

A
  • Liver function tests: No abnormalities until tumor involvement is marked.
  • ↑ CEA: Due to metastasis from colorectal carcinoma
  • Urinary excretion of 5-hydroxy-indole-acetic acid (serotonin metabolite) in carcinoid tumor
132
Q

Rads in 2ry malegnancies of the liver

A

Ultrasound & CT & MRI scanning.

133
Q

Laproscopy & LUS in 2ry malegnancies of the liver

A

The best method for detection of metastatic disease.

134
Q

Managment of 2ry malegnancies of the liver

A
  • Surgical Resection
  • Chemotherapy
  • Chemoembolization.
  • Radiofrequency.
135
Q

Indications of surgery in secondary liver Cancers

A

1) Single liver metastases or multiple confined to one segment or surgical lobe.

2) No extrahepatic metastases.

3) Completely resected 1ry tumor with no apparent residual tumor.

136
Q

procedure in secondary liver Cancers

A
  • Anatomical resection of recognized anatomical segments or lobes.
  • Non-anatomical.
137
Q

Chemotherapy in secondary liver Cancers

A
  • Chemotherapy Systemic: Indicated in the presence of other organ
  • Regional Systemic: Involvement. indicated if liver is only organ with metastases.
138
Q

Done

A

..

Y3R6: Surgery I πŸ‘¨β€βš•οΈ (30 decks)

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