Flashcards in Liver, etc. 9 - Focal Liver Lesions Deck (61):
What are solid liver lesions in older patients most likely to be?
Malignant - usually metastases if the patient does not have liver disease (then it is more likely to be a primary liver cancer)
What is the most common solid liver tumour in non cirrhotic patients?
What are the causes of a benign focal liver lesions? (4)
HaemangiomaFocal nodular hyperplasiaAdenomaLiver cysts
What are the 2 causes of malignant focal lesions of the liver?
Primary liver cancersMetastases
What are the types of primary liver cancers? (6)
Hepatocellular carcinomaCholangiocarcinomaFibrolamellar carcinomaHepatoblastomaAngiosarcomaHaemangioendothelioma
Clinical features of haemangioma:-more common in M or F?- blood supply?- size/ number of them?- border?- symptoms?
FemalesHypervascular tumourUsually single and smallWell demarcated capsuleusually asymptomatic
Diagnosis of haemangioma?
US: echogenic spot, well demarcatedCT: venous enhancement from periphery centreMRI: high intensity areaNo need for FNA
Treatment for haemangioma?
No need for treatment
What is a focal nodular hyperplasia?
Benign nodule formation of normal liver tissue (hyper plastic growth of normal hepatocytes)
What is usually the cause of a focal nodular hyperplasia?What 2 other conditions is FNH therefore associated with?
Congenital vascular anomaly - hyperplastic response to abnormal arterial flowOsler-Weber-RenduLiver haemangioma
What is the classical appearance of a focal nodular hyperplasia?
Central scar containing a large artery, radiating branches to the periphery (Hub and spoke) - not always
What 3 things are present on histology focal nodular hyperplasia?
SinusoidsBile ductulesKupffer cells
What age groups and gender are focal nodular hyperplasia more common in?
Young and middle age women (no relation with sex hormones)
Symptoms of focal nodular hyperplasia?
Usually asymptomatic, amy cause minimal pain
Diagnosis of focal nodular hyperplasia?
US: nodule with varying echogenicityCT: hypervascular scar with central scarMRI: Iso or hypo intenseFNA: normal hepatocytes and cupful cells with central core
Treatment of focal nodular hyperplasia?
No treatment necessary(no change required regarding pregnancy and hormones - some older texts give mixed message)
What is a hepatic adenoma?
Benign neoplasm composed of normal hepatocytes - most are solitary fat containing lesionsNo portal tract, central veins or bile ducts
Clinical features of hepatic adenoma:Which sex is it more common in?What is it commonly associated with?Symptoms?What can it rarely present with?
FemalesContraceptive hormonesUsually asymptomatic but may have RUQ pain - symptoms are size relatedMay present with rupture, haemorrhage or malignant transformation (very rare)
What lobe of the liver are hepatic adenomas commonly found in?
The right lobe
What is multiple adenomas called?What is this associated with?
AdenomatosisGlycogen storage diseases
What has been identified within adenomas that confer malignant risk?
Identifiable oncogene mutations
How are hepatic adenomas related to Oral Contraceptive?
Related to duration of OC use (>2 years) and oestrogen component, but adenomas have been described with even 6 months of OS use
What can happen do hepatic adenomas after discontinuation of Oral contraceptives?
Diagnosis of hepatic adenoma?
US: filling defectCT: diffuse arterial enhancementMRI: hypo or hyper intense lesionFNA: may be needed
Treatment for a hepatic adenoma?
Stop hormonesObserve every 6m for 2yif no regression then surgical excisionNew guidelines suggest that male patients should have them removed straight away as they are more prone to developing a malignant transformation
Difference between an adenoma and focal nodular hyperplasia appearance?
Adenoma = purely a hepatocyte tumour which is cold on nuclear sulfur colloid scanFocal nodular hyperplasia = contains all the liver ultrastructure including ES and bile ductules (isointense on sulfur colloid scan) - central scar
Malignant risk with adenoma and focal nodular hyperplasia?
Adenoma = malignant degenerationFocal nodular hyperplasia = no malignant risk
Type of cystic lesions of the liver? (5)
SimpleHydatidAtypicalPolycystic lesionPyogenic or amoebic abcess
Clinical features of a simple cyst:-Appearance-Biliary tree communication?-Symptoms?
-liquid collection lined by an epithelium - solitary and uniloculated- no biliary tree communicationMost of the time asymptomatic but symptoms can be experienced in relation to:-intracsytic haemorrhage-infection-rupture (rare)-compression
Management of a simple cyst?
No follow up necessaryif in doubt, image in 3-6 monthsIf symptomatic or uncertain of diagnosis (complex cystic lesion), then consider surigcal intervention
What organism causes hydatid cysts?
Where are endemic regions for hydatid cysts?
Eastern europe central americasouth americamiddle eastnorth africa
How can patients with hydatid cysts present?
Disseminated diseaseerosion of cysts into adjacent structures and vessels (IVC)
How is a hydatid cyst diagnosed?
Based on history, appearance and serologic testing-detection of anti-echinococcus antibodies
Possible management for hydatid cysts? (3)
Surgery - most common form of treatment medicalprecutaneous drainage
What are the 2 types of treatment that can be given for a hydatid cyst?
Types of conservative surgery for hydatid cyst? (2)
Open cystectomyMarsupialization (slit cut in cyst to allow it to continually drain)
Types of radical surgery for a hydatid cyst?
Risks of surgery for a hydatid cyst?
Operative morbidityAnaphylacisDissemination of infection
Medical treatment for a hydatid cyst?
What does PAIR stand for (percutaneous drainage)?
What causes polycystic liver disease?
Embryonic ductal plate malformation of the intrahepatic biliary tree - numerous cysts throughout liver parenchyma
What are the causes of numbers cysts throughout the liver parenchyma?
Von meyenburg complexesPolycystic liver diseaseAutosomal dominant polycystic kidney disease
What is von memenburg complexes?
Microhamartomas - benign cystic nodules throughout the liver - cystic bile duct malformations, originating from the peripheral biliary tree - remnants develop into small hepatic cysts and usually remain silent during life - incidental finding
Difference between polycystic liver disease and autosomal dominant polycystic kidney disease?
Liver function is preserved and renal failure rare in polycystic liver disease where as renal failures common in polycystic kidney disease often with extra-kidney manifestations
Treatment of polycystic liver disease with symptoms due to volume of tumours?
Conservative treatment to half cyst growth - invasive procedures are only required in severe cases (aspiration/ liver transplant)
What type of pharmacological therapy leads to a beneficial outcome in polycystic liver disease by relieving symptoms and reducing liver volume?
Clinical features of a liver access?
High feverLeukocytosisAbdominal painComplex liver lesionHistory of abdo or biliary infection or dental procedure
Management of liver abscess?
Initial empiric broad spectrum antibioticsAspiration/ drainage percutaneouslyEchocardiogramOperation if no clinical improvement (open drainage/ resection)4 week antibiotic therapy with repeat imaging
What is the most common primary liver cancer?
Most important risk factor for hepatocellular carcinoma?
Cirrhosis of any cause
Most common symptoms of HCC?
Weight loss and RUQ pain (can be asymptomatic)
What is a tumour marker for HCC?
Alfa fetoprotein - values greater than 100ng/ml = highly susceptive of HCC
Treatment of HCC if a small tumour with no evidence of raised portal pressure?
Treatment of HCC if single tumour less than 5cm or less than 3 tumour less than 3cm each?
Treatment of HCC if multiple tumour and evidence of dissemination?
Palliative, local ablation, chemoembolisaiton
Treatment of a non-resectable patient e.g. advanced liver cirrhosis?
Local ablation - alcohol injection, radio frequency ablation - temporary measure only
What is chemoembolisation?
TransArterial ChemoEmbolisation = inject chemo selectively into hepatic artery then inject an embolic agent (only for patients with early cirrhosis
What systemic therapy can be given for advanced HCC?
Sorafenib - multikinase inhibitor of vast endothelial gf receptor
What is the type of lung cancer that is often seen in young patients (5-35) and is not related to cirrhosis - also causes a normal AFP?