Liver Cysts

Question 1

primary liver tumor categories

Answer 1

non-neoplastic and neoplastic

Question 2

neoplastic primary liver tumors

Answer 2

focal nodular hyperplasia and focal fatty change with focal fatty sparing (super rare and probably don’t need to know)

Question 3

primary neoplastic liver tumors in adults

Answer 3

adenoma, HCC, cholangiocarinoma (epithelial)

hemangioma, (epithelioid hemangioendothelioma), angiosarcoma (mesenchymal)

Question 4

cystic lesions of the liver

Answer 4

most are congenital - fibropolycystic liver disease

Question 5

secondary metastatic liver tumors

Answer 5

hematopoietic malignancy and solid organ malignancy (tumors represent metastasis or origin)

Question 6

benign entities

Answer 6

biliary microhamartoma, isolated cysts/polycystic liver disease, hepatic ademona, hemangioma

Question 7

malignant entities

Answer 7

hepatocellular carcinoma, angiosarcoma, metastatic tumors

Question 8

liver cysts that are asymptomatic

Answer 8

biliary microhamartoma

Question 9

symptomatic liver cysts

Answer 9

space-occupying lesion - isolated cyst or polycystic liver disease (with or without kidney cysts)

parasitic cysts and hydatid cyst (liver)

biliary obstruction with periodic jaundice and cholangitis - choledochal cysts

Question 10

fibropolycystic liver disease

Answer 10

a broad spectrum of inherited liver disease with shared embryologic maldevelopment as an etiology

Question 11

biliary microhamartoma

Answer 11

less common lesions, in 6% of population, usually found incidental at autopsy or during surgeries. could potentially metastasize to liver

Question 12

biliary microhamartoma histopathology

Answer 12

• multi cystic lesions near portal tracts (periportal) that contain bile
• small meshwork of cytologically bland, angulated duct like structures embedded within a fibrous stroma
• contain greenish brown inspissated bile in duct lumen
• cyst is lined by biliary type epithelium (cuboidal) and other side has mesothelium - same as liver surface

Question 13

polycystic liver disease inheritance and gene affected

Answer 13

autosomal dominant - defect in ADPKD1 gene on chrom 16

Question 14

polycystic liver disease population affected

Answer 14

75% age 70 + , women may present during pregnancy

Question 15

polycystic liver disease histology

Answer 15

multiple unilocular cystic lesions resembling solitary cysts, lined by cuboidal to flat biliary epithelium, contains thin straw colored fluid

Question 16

hepatic adenoma

Answer 16

benign epithelial neoplasm

Question 17

hepatic adenoma risk factors

Answer 17

oral contraceptive use, anabolic steroids, glycogen storage disease

Question 18

hepatic ademona population affected

Answer 18

females more than males, esp during child bearing years, women <10% are malignant, males up to 50% malignant

Question 19

hepatic ademona histology

Answer 19

• hepatocytes with minimal atypic arranged in 1-2 cell thick cords
• no mitotic figures
• no portal areas
• large caliber vessels with little supporting stroma (bleeding risk (into peritoneal cavity) if rupture or compressed by other tissue!) / associated thrombi

Question 20

treatment for hepatic ademona

Answer 20

1. many will regress following withdrawal of steroids, contraceptive, affecting agent
2. consider resecting symptomatic or if >5cm
3. adenomas in men have a higher risk for malignant transformation and could be excised

Question 21

hepatic adenoma presentation

Answer 21

hepatic mass or RUQ pain, spontaneous bleeding is common and may be life threatening

Question 22

multiple adenomas

Answer 22

stop affecting agents, may need to be resected if cysts persist

Question 23

most common primary hepatic tumor

Answer 23

hemangioma

Question 24

Hemangioma

Answer 24

benign tumor of mesenchymal/vascular origin, clusters of blood-filled cavities lined by flattened endothelial cells

Question 25

hemangioma populations affected

Answer 25

adults >children | women>men

Question 26

do we biopsy hemangioma?

Answer 26

no because risk of hemorrhage!

Question 27

histology of hemangioma

Answer 27

sponge-like dilated vascular channels on lower power view cavernous vascular spaces filled with blood, separated by thin connective tissue septa, on high power view may see thrombi since hemangioma are blood stasis - may see fibrous scarred nodules

Question 28

hepatocellular carcinoma HCC

Answer 28

primary malignant tumor of the liver

Question 29

etiology of hepatocellular carcinoma

Answer 29

usually develops in the setting of chronic liver disease/cirrhosis suspicion increased in patients with previously compensated cirrhosis who become decompensated

Question 30

alpha-fetoprotein AFP

Answer 30

glycoprotein that is normally produced during gestation by the fetal liver (cancer will restart secreting this protein) serum concentration elevated in patients with HCC

Question 31

how to spot progression of cirrhosis to hepatocellular carcinoma

Answer 31

surveillance imaging and serial AFP measurements, but elevated AFP may also be seen in patients with chronic liver disease without HCC (so not diagnostic but helps the probability)

Question 32

hepatocellular carcinoma histology

Answer 32

HCC with thick cell plates and atypical cells - large, dark, pleomorphic nuclei, increased nuclear to cytoplasmic ratio, 6-10 cell plate hepatic thickness

Question 33

HCC treatment

Answer 33

resection, but often hard to resect -radiofrequency ablation or TACE

Question 34

TACE

Answer 34

transarterial chemo embolization embolic microspheres with chemo drug injected obstruct blood supply and treat with chemo shrinks the tumor to allow resection or to be a transplant candidate

Question 35

aggressive malignant disease of mesenchymal origin (endothelium of blood vessels)

Answer 35

angiosarcoma

Question 36

most common malignant mesenchymal tumor of the liver

Answer 36

angiosarcoma - but still rare as 2% of primary liver cancers

Question 37

Angiosarcoma etiology

Answer 37

associated with exposure to environmental carcinogens including arsenic, vinyl chloride, and thorium dioxide as well as anabolic steroids

Question 38

angiosarcoma patient population

Answer 38

older individuals, most patients who get the tumors don't have the etiology exposures

Question 39

angiosarcoma prognosis

Answer 39

very poor with rapid progression, high rate of recurrence and metastasis, and resistance to chemotherapy and radiation

Question 40

angiosarcoma histology

Answer 40

high power view shows atypicl endothelial cells with enlarged hyperchromatic nuclei (which create strong anastomoses of vascular channels) infiltrating the surrounding hepatic tissue in a destructive pattern

Question 41

liver metastases in cirrhotic liver

Answer 41

metastases rarely develop in a cirrhotic liver; therefore, a tumor found within a cirrhotic liver is HCC until proven otherwise most common hepatic malignant tumors are secondary! so why are mets in the liver? they don't develop there initially! metastatic tumors are more common than primary, resemble tumor or origin

Question 42

why do metastases happen in the liver?

Answer 42

- nutrient rich dual blood supply - humoral growth factors from pancreas - common sites of origin with colon, stomach, pancreases, breast, lung, skin/eye

Question 43

when leukemia or lymphoma involve the liver

Answer 43

- leukemia and lymphoma cause diffuse liver enlargement without discrete nodules and infiltration of liver parenchyma by tumor cells - atypical lymphoid infiltrate in sinusoids