Focal liver lesionFaculty of surgerySongkhla hospital

WORKUP ALGORYHM FOR LIVER MASS

Mass on scan

History of prior malignancy No history of prior malignancy

HistoryO Symptoms - abdominal pain/ pressure

effect,fever,anoraxia,weight loss

O Patient characteristics (age, gender, use of OCP, risk factors for chronic liver disease )

O History or findings of extrahepatic malignancy

Physical examination and investigation

O Sign of chronic liver stigmata or portal hypertention

O LymphadenopathyO CBC with PLT , coagulogram , LFT ,

hepatitis profile , tumor markerO Ultrasound , CT scan , MRI

O Study show accurate preoperative evaluation of liver mass lesions without fine-needle biopsy about 98% by history and lab (including tumor markers) and a variety of imaging studies

Find needle biopsyO commonly used to assist in the

diagnosis of a variety of liver lesionsO Disadventage

O Increase risk of bleeding and seeding of neoplastic cells

O Some type liver lesion cannot diagnosis such as hepatic adenomas and focal nodular hyperplasia

MalignancyO Metastatic liver tumors O HCCO Cholangiocarcinoma O Rare tumor hepatoblastoma , Germ

cell tumor , Angiosarcoma , non-Hodgkin lymphoma

Metastatic liver tumors O Most common metastasis malignant

hepatic neoplasmO The most common primaries : breast, lung, colon

O History or findings of extrahepatic malignancy menifestation

O U/S O multiple and hypoechoic lesion with

Hypoechoic rims and internal heterogeneityO CT

O Hypovascular or hypervascular mass depend on metastasis origin

O MRI O metastatic lesions appear as low signal areas

on T1-weighted images and moderately high signal on T2-weighted images

HCCO Most common primary malignancy liver

tumorO Risk factors for chronic liver disease , viral

hepatitis expect Hepatitis A ,metabolic liver diseases , expose hepatotoxin

O Male : female > 4 : 1O Clinical : vary such as asymptomatic ,

abdominal pain , weight loss , paraneoplastic syndrome

O Diagnosis : elevate AFP , CT scan

InvestigationO U/S

O round or oval mass with sharp, smooth boundaries ,vary echogenicity

O CT scanO Vascular enhancement ( ถู�กเลี้��ยงด้�วย hepatic

artery)O Liver cirrhotic change , ascites , splenomegalyO Non contrast phase : hypodense massO Contrast phase : arterial phase rapid

vascular enhancement then venous phase hypodense

Hepatocellular carcinoma, CT of the liver before (a) and 15 sec (b), 45 sec (c) and 90 sec (d), respectively, following intravenous contrast medium administration

Fibrolamellar hepatocellular carcinoma (FCHC)

O FHCC is a rare form of hepatocellular O Approximately 200 new cases are

diagnosed worldwide each year.O FHCC often does not produce AFP O However, FHCC is elevated neurotensin

levels.O FHCC generally occurs in young adults

(~27yr.) without underlying cirrhosis.O FHCC grows slowly and has better

prognosis,

Fibrolamellar hepatocellular carcinoma (FCHC)

O The histopathology of FHCC is characterized by laminated fibrous layers, interspersed between the tumor cells. 

O FHCC has a high resectability rate

HepatoblastomaO most common liver cancer in childrenO most commonly diagnosed during a

child's first three years of lifeO usually present with an abdominal massO Patients with familial adenomatous

polyposis (FAP) are risk factorO Often elevated AFPO Treatment : Surgical resection, adjuvant

CMT, and liver transplantation 

Germ cell tumorO Germ cell tumor is a neoplasm

derived from germ cells.O can be cancerous or non-cancerous O Classification

O Germinomatous or seminomatousO Non-germinomatous or non-

seminomatous

Classification of Germ cell tumor

O Germinomatous - 10% have elevated hCGO Disgerminoma O Seminoma

O Non-germinomatousO Embryonal carcinomaO yolk sac tumor - 100% secrete AFPO Choriocarcinoma - 100% secrete hCGO TeratomaO PolyembryomaO Gonadoblastoma

O Mixed

Germ cell tumorO Compared to germinomatous tumors,

nongerminomatous tumors tend to O grow fasterO earlier mean age at time of diagnosis

(~25 vs 35 years)O lower 5 year survival rate

O The survival rate for germinomatous tumors is higher because these tumors are very sensitive to radiation and CMT

Treatment of GCTO Women with benign germ cell tumors such

as dermoid cysts are cured by ovarian cystectomy or oophorectomy

O In general, all patients with malignant germ cell tumors will have the same staging surgery that is done for epithelial ovarian cancer.

O If the patient is still interested in having children, an alternative is unilateral salpingoophorectomy, while the uterus, the ovary, and the fallopian tube on the opposite side can be left behind. 

Treatment of GCTO Most patients with germ cell cancer

will need to be treated with combination CMT for at least 3 cycles.

O The CMT regimen most commonly used in germ cell tumors is called PEB (or BEP) and consists of bleomycin, etoposide, a platinum-based antineoplastic (cisplatin)

CholangiocarcinomaO It has an annual incidence rate of 1–

2 cases per 100,000 in the Western world

O rates of cholangiocarcinoma have been rising worldwide over the past several decades.

CholangiocarcinomaO It may be suspected in a patient

with obstructive jaundice. O CT scanning is an important role in the

diagnosis of cholangiocarcinoma.O may be challenging in patients with

primary sclerosing cholangitis (PSC)O  ERCP advantages include the ability to

obtain biopsies and to place stents or perform other interventions to relieve biliary obstruction.

Benign

Benign O HemangiomasO Focal nodular hyperplasiaO hepatic adenomasO Simple cysts

HemangiomasO Most common benign liver tumorsO Female : male > 3 : 1O Most are asymptomatic and no malignant

transformationO Large hemangiomas can cause symptoms

as a result of compression of adjacent organs or intermittent thrombosis

O Surgery may be considered an option if the patient is symptomatic

O Gross : round pink or red capsule

HemangiomasO U/S

O echogenic spot, well demarcatedO CT scan

O Early phase พบ hypodense peripheral enhancement

O Delay phase พบ contrast fillling mass ทั่��วๆ

O MRI O High sens and spec , high acurracy O Hyperdense in T2 and blood fill space

Peripheral nodular enhancement follow by gradual centripetal enhancement

Focal nodular hyperplasia

O Most commonly in women and asymptomatic

O No malignant transformationO Gross : subcapsular lesion and

central scarO Surgery indicate in symptomatic

patient

Focal nodular hyperplasia

O U/SO Nodule with varying echogenicity

O CT scanO Non contrast phase พบ low density

massO contrast phase พบ rapid enhance and

wash out with central scarO MRI

O Hyperdense and central scar

HomogeneousIsoattenuation

Immediate Intense enhancement

Central scar 2/3

FNH & Hemangioma

Symptomatic : Surgery

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Hepatic Adenomas

O Benign epithelial liver tumor that usually occurs in non-cirrhotic liver

O most commonly seen in premenopausal women older than 30 years of age and relate with oral contraceptives use

O About 50 % abdominal pain and 30 % bleeding

O Risk of malignant transformation 10%O Surgery indicate in mass > 4 cm , no

decrease size when stop pill

hepatic adenomasO U/S

O often large and in the right lobe of the liver and hyperechoic lesion

O CT scanO Non-contrast scan

O well-demarcated low density massO Contrast-enhanced scans

O Rapid enhance and wash out same FNHO No central scar difference from FNH

HA

Thank you