L9: DDx of Hepatic Masses Flashcards
(140 cards)
1
Q
What are Benign Lesions of the Liver?
A
- Focal Nodular Hyperplasia.
- Hepatocellular Adenoma.
- Hemangioma.
- Nodular Regenerative Hyperplasia.
- Biliary Cystadenoma.
2
Q
Def of Focal Nodular Hyperplasia (FNH)
A
Hyperplastic hepatocellular lesions resulting from vascular malformation
3
Q
Incidence of Focal Nodular Hyperplasia (FNH)
A
- Second most common benign liver tumor.
- Clinically relevant in 0.03%.
4
Q
Age of Focal Nodular Hyperplasia (FNH)
A
Average age at presentation 35–50 years.
5
Q
Sex of Focal Nodular Hyperplasia (FNH)
A
90% of patients are female.
6
Q
what is Focal Nodular Hyperplasia (FNH) often associated with?
A
Often associated with other vascular anomalies.
7
Q
Genetics in Focal Nodular Hyperplasia (FNH)
A
Upregulation of Extracellular matrix (ECM) genes associated with TGF-β signaling.
8
Q
CP of Focal Nodular Hyperplasia (FNH)
A
9
Q
Relation between Focal Nodular Hyperplasia (FNH) & OCP
A
None
10
Q
Dx of Focal Nodular Hyperplasia (FNH)
A
- Radiological Imaging
- Biopsy
11
Q
Rad Imaging of Focal Nodular Hyperplasia (FNH)
A
12
Q
Bx in Focal Nodular Hyperplasia (FNH)
A
Biopsy is rarely required because imaging is mostly diagnostic.
13
Q
Managment of Asymptomatic Focal Nodular Hyperplasia (FNH)
A
14
Q
Managment of Symptomatic Focal Nodular Hyperplasia (FNH)
A
15
Q
Def of Hepatocellular Adenoma (HCA)
A
Benign neoplasms with various types of clonal benign hepatocellular proliferations.
16
Q
Prevelance of Hepatocellular Adenoma (HCA)
A
7-12 per 100,000.
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.
17
Q
Age of Hepatocellular Adenoma (HCA)
A
Average age at presentation 35–40 years.
18
Q
Sex of Hepatocellular Adenoma (HCA)
A
10:1 female to male.
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.
20
Q
CP of Hepatocellular Adenoma (HCA)
A
21
Q
Molecular Classification of Hepatocellular Adenoma (HCA)
A
22
Q
what gene mutation is most associated with HCC?
A
β-catenin with inflammatory features
23
Q
Dx of Hepatocellular Adenoma (HCA)
A
- MRI
- Biopsy
24
Rad Imaging of **Hepatocellular Adenoma (HCA)**
25
Bx of **Hepatocellular Adenoma (HCA)**
26
General Precautions in Managment of **Hepatocellular Adenoma (HCA)**
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Managment of **Asymptomatic Hepatocellular Adenoma (HCA)**
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Managment of **Symptomatic Hepatocellular Adenoma (HCA)**
29
........ is recommended in men and in all cases of proven β catenin mutation
Resection irrespective of size
30
Number in Hepatic Adenomatosis
>3 liver adenomas.
31
CP of Hepatic Adenomatosis
Presentation, genetics, and imaging similar to solitary lesions.
32
TTT of Hepatic Adenomatosis
- Treatment is based on the size of the largest tumor.
- Liver resection may be difficult to offer.
- Followed the same as solitary adenomas.
33
Def of **Nodular Regenerative Hyperplasia**
Benign hepatic condition.
34
Incidence of **Nodular Regenerative Hyperplasia**
2.1 to 2.6% in the general population.
35
Pathology of **Nodular Regenerative Hyperplasia**
- Normal parenchyma transformed into small regenerative nodules.
- Result of ischemia either related to thrombosis or phlebitis
36
CP of **Nodular Regenerative Hyperplasia**
- Rarely symptomatic.
37
Similarities between **Nodular Regenerative Hyperplasia** and micronodular cirrhosis & How to Diffrentiate?
- Shares common features with micronodular cirrhosis:
- Differentiate based on → Absence of fibrous septa between nodules
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INVx in **Nodular Regenerative Hyperplasia**
39
TTT of ****Nodular Regenerative Hyperplasia****
Treatment geared toward management of the underlying etiological condition.
40
Incidence of **Hepatic Hemangioma**
- Most common primary liver tumors.
- Ultrasound studies have placed the frequency at 0.7% to 1.5%.
41
Age of ****Hepatic Hemangioma****
Most common in women aged 30–50 years
42
Sex in **Hepatic Hemangioma**
- Female to male ratio ranges from 1.2–6:1.
- Can occur in all age groups.
**No definite relationship to OCP use. .**
43
CP of **Hepatic Hemangioma**
44
Dx of **Hepatic Hemangioma**
- US
- Contrast Enhanced Imaging
- Biopsy
45
US in **Hepatic Hemangioma**
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Contrast enhanced Imaging in **Hepatic Hemangioma**
47
Bx in **Hepatic Hemangioma**
Biopsy is rarely needed.
48
Managment of **Hepatic Hemangioma**
49
Another name of **Hepatobiliary Cystadenoma**
Hepatobiliary Mucinous Cystic Lesions
50
What is **Hepatobiliary Cystadenoma**?
Primary cystic neoplasms of the biliary tree
51
Etiology of **Hepatobiliary Cystadenoma**
Etiology remains unclear
52
Incidence & Prevelance of **Hepatobiliary Cystadenoma**
Incidence and prevalence are not clear since most current impression in the literature are still based on the earlier criteria of cystadenoma/cystadenocarcinoma.
53
Age & Sex of **Hepatobiliary Cystadenoma**
Middle-aged females almost exclusively affected.
54
Site of **Hepatobiliary Cystadenoma**
- 90% is intrahepatic.
- 10% arise in the extrahepatic biliary tree.
55
Size of **Hepatobiliary Cystadenoma**
- Tumors tend to be large compared with other hepatic lesions.
- In the largest series, tumor size averaged greater than 10 cm.
56
Types of **Hepatobiliary Cystadenoma**
Mucinous or serous; mucinous is more common.
57
Histology of **Hepatobiliary Cystadenoma**
Mucinous epithelium characterized by presence of an ovarian-like mesenchymal stroma (maybe focal).
58
Hepatic counterpart of pancreatic mucinous cystic neoplasm (MCN)
...
59
CP of **Hepatobiliary Cystadenoma**
60
Complications of **Hepatobiliary Cystadenoma**
61
Labs in **Hepatobiliary Cystadenoma**
Absence of CA19-9 or CEA cannot rule out HB-MCN
62
Rad in **Hepatobiliary Cystadenoma**
63
FNAC in **Hepatobiliary Cystadenoma**
Fine needle aspiration is not sensitive or specific enough.
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Managment of ****Hepatobiliary Cystadenoma****
65
Pathological Classification of liver Malignancies
66
Most common of all hepatic neoplasms
Hemangioma
67
Most common malignant hepatic tumors
Metastatic lesions
68
Most common primary hepatic malignancy
Hepatocellular carcinoma
69
Incidence of **HCC**
- Most common 1ry malignant liver tumor.
- 4th most common cancer worldwide.
- 2nd most common cause of cancer related death worldwide.
70
Geographic Distribution of **HCC**
- High incidence in China and Africa,
- Lower in Europe and North America.
71
Curability of **HCC**
Only 20-30% are curable.
72
RF for **HCC**
73
Dx of **HCC**
74
Screening in HCC?
- Asian studies confirm benefit.
- Western studies conflicting
- Variation in tumor doubling may make more frequent screening necessary but reduce cost effectiveness.
75
Methods of screening for **HCC**
AFP + US or CT every 12 months.
76
Milan Criteria for Liver Transplantation in HCC
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
Imaging in **HCC**
78
What does Imaging show in **HCC**?
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Prognostic Factors in **HCC**
80
Managment Lines in **HCC**
- Resection
- Locoregional therapy
- Transplant
- Medical therapy
81
Indications of resection in **HCC**
82
Locoregional Therapy in ****HCC****
83
Indications of Transplantation in **HCC**
84
Medical Therapy of **HCC**
- Some advances in chemotherapy
- Sorafenib and other anti-angiogenesis factors
85
Incidence of **Fibrolamellar HCC**
Approximately 1% of all HCC.
86
age of **Fibrolamellar HCC**
Predominately younger Caucasian individuals (80% between age 10- 35).
87
Sex in **Fibrolamellar HCC**
Women slightly more affected.
88
CP of **Fibrolamellar HCC**
89
Def of **Cholangicarcinoma**
- 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
Histology of **Cholangicarcinoma**
>90% → adenocarcinoma.
<10% → squamous, sarcoma, small cell, lymphoma
91
Incidence of **Cholangicarcinoma**
2nd most common 1ry hepatic malignancy.
92
Geographic Distrubtion of **Cholangicarcinoma**
Highest incidence in Southeast (SE) Asia (Hep B, parasitic infections),
93
Age in **Cholangicarcinoma**
Uncommon before age 50.
94
Types of **Cholangicarcinoma**
95
Risk Factors for **Cholangicarcinoma**
96
CP of **Cholangicarcinoma**
- Jaundice
- Vague RUQ pain
- Pruritis
- Anorexia & Wt. loss.
97
Labs in **Cholangicarcinoma**
- CA 19-9 (>100 has sensitivity of 70-90%, specificity of 85-98%.)
- Bilirubin.
- AP, GGT (hilar).
- ALT, AST.
98
Rads in **Cholangicarcinoma**
99
Findings in Triphasic CT in **Cholangicarcinoma**
100
Managment of **Cholangicarcinoma**
101
Suregry in **Cholangicarcinoma**
102
Liver Transplanation in **Cholangicarcinoma**
103
Def of **Hepatic Epitheliod Hemangioendothelioma (HEHE)**
Rare malignant neoplasm from vascular endothelium.
104
Sex in **Hepatic Epitheliod Hemangioendothelioma (HEHE)**
Predominately females.
105
Prognosis of **Hepatic Epitheliod Hemangioendothelioma (HEHE)**
Unpredictable prognosis
106
CP of **Hepatic Epitheliod Hemangioendothelioma (HEHE)**
- Usually multifocal tumor (misdiagnosed as metastatic lesions).
- Appears on the background of normal liver histology.
107
TTT of **Hepatic Epitheliod Hemangioendothelioma (HEHE)**
- More than 90% of patients are unresectable and transplant is an option.
108
Incidence of **Hepatoblastoma**
Most common liver malignancy in infants and young children.
109
Age of **Hepatoblastoma**
Most present at <3yo → Upper abdominal mass.
110
What is **Hepatoblastoma** associated with?
Associated with:
1) Beckwith-Wiedmann syndrome,
2) Wilm’s tumor,
3) Familial adenomatous polyposis (FAP), 4) Hemihypertrophy,
5) Glycogen storage diseases.
111
CP of **Hepatoblastoma**
- Usually in right lobe, well circumscribed, 5 – 20 cm diameter.
- Aggressive tumors → invade locally, spread to regional LN, lungs, adrenals, brain, BM.
112
Dx of **Hepatoblastoma**
- CT/MRI.
- Elevated AFP (very high levels, tens of thousands).
- Liver biopsy.
113
TTT of **Hepatoblastoma**
- Cure requires gross tumor resection.
- Can downsize with neoadjuvant chemo.
- Transplant can be option if remains unresectable after chemo.
114
Types of Sacrcomas in liver
- Angiosarcoma
- Epithelioid Hemagioendothelioma
- Embryonal (undifferentiated)
- Other primary types
115
Incidence of Hepatic Angiosarcoma
Most common 1ry sarcoma of liver.
116
Age in Hepatic Angiosarcoma
Peak incidence in 60-70 y.
117
Sex in Hepatic Angiosarcoma
Male predominance (3:1).
118
Risk Factors in Hepatic Angiosarcoma
Thorotrast exposure, vinyl chloride, arsenic.
119
TTT of **Epithelioid Hemagioendothelioma**
Excellent results with transplant.
119
Behaviour of Epithelioid Hemagioendothelioma
Low grade angiosarcoma.
120
Behaviour of **Embryonal (undifferentiated)**
Highly malignant childhood cancer.
121
Age in **Embryonal (undifferentiated)**
Peak incidence in 6-10 y.
122
Other Primary Sarcomas of the liver
- Fibrosarcoma.
- Leiomyosarcoma.
- Liposarcoma.
- Hepatobiliary rhabdomyosarcoma.
123
Incidence of **2ry malegnancies of the liver**
- Most common hepatic malignancies.
- 95% of hepatic neoplasms at autopsy.
124
Most Common Sources of **2ry malegnancies of the liver**
**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
Direct Sources of **2ry malegnancies of the liver**
From the gallbladder, bowel, or stomach.
126
Venous Sources of **2ry malegnancies of the liver**
From abdominal or pelvic viscera. (The commonest route)
127
Lymphatic Sources of **2ry malegnancies of the liver**
From malignant glands in the porta hepatis.
128
Arterial Sources of **2ry malegnancies of the liver**
From tumors elsewhere.
129
Types of **2ry malegnancies of the liver** according to time of occurence
Synchronous to 1ry tumor
- Same time with 1ry tumor.
Metachronous to 1ry tumor
- 6-12 months after 1ry.
130
Types of lesion **2ry malegnancies of the liver**
- Neuroendocrine.
- Colorectal.
- Others (Melanoma, breast, prostate...)
131
Labs in **2ry malegnancies of the liver**
- 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
Rads in **2ry malegnancies of the liver**
Ultrasound & CT & MRI scanning.
133
Laproscopy & LUS in **2ry malegnancies of the liver**
The best method for detection of metastatic disease.
134
Managment of **2ry malegnancies of the liver**
- Surgical Resection
- Chemotherapy
- Chemoembolization.
- Radiofrequency.
135
Indications of surgery in secondary liver Cancers
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
procedure in secondary liver Cancers
- Anatomical resection of recognized anatomical segments or lobes.
- Non-anatomical.
137
Chemotherapy in secondary liver Cancers
- Chemotherapy Systemic: Indicated in the presence of other organ
- Regional Systemic: Involvement. indicated if liver is only organ with metastases.
138
Done
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