Table of contents
Liver Tumors / Cysts
Hepatocellular Carcinoma
- HCC is a 3rd leading cancer cause worldwide.
- Incidence rates rising in Western countries, and 80% have cirrhosis.
- Risk factors:
- Male sex
- Chronic Hep B/C infection.
- Hemochromatosis
- Alpha-1-antitrypsin deficiency
- (Any kind of cirrhosis)
- Screening / Surveillance
- Cross-sectional imaging (Ultrasound is least epensive, CT - better resolution, detection of early stage).
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Screening guidelines for HCC:
- All patients with cirrhosis should be screened for HCC q6mo (every 6 months) with cross-sectional imaging.
- Serum AFP --> Not sufficient diagnostic accuracy alone for early detection.
(Can do q12mo if hard to follow)
- Some patients do q12mo if hard to get back to clinic to do this screening.
- Diagnosis:
- Lesions >2cm in diameter can be diagnosed with contrast enhanced CT/MRI/Angiography.
- HCC derive their blood supply from neovascularization (from branches of hepatic artery). This characteristic allows it to be identified by contrast-enhanced imaging (contrast CT or MRI).
- If positive for HCC --> can diagnose and treat as HCC. (Biopsy may not be required)
- If negative --> does not rule out malignancy (can consider biopsy?)
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Diagnosis of HCC:
- At least TWO imaging studies showing lesion with HCC features
(Arterial hypervascularization with delayed venous contrast washout)
OR - If only one imaging study available, can diagnose if serum AFP level ≥ 400
- At least TWO imaging studies showing lesion with HCC features
- Image guided biopsy: ONLY for patients in whom radiologic criteria are equivocal or inconsistent with HCC.
- Negative biopsy result in cirrhosis does not confidently exlude HCC.
- Tumor seeding from biopsy described, but rare.
- 1 - 2 cm indeterminate lesions --> enhanced follow-up with more frequent imaging is required.
- Lesions >2cm in diameter can be diagnosed with contrast enhanced CT/MRI/Angiography.
- Treatment:
- Guided by Barcelona Classification for Liver Cancer (BCLC)
---> see flow chart (look in MKSAP16 PMID: 18477802)- Manage based on stage of liver disease (Childs-Pugh Classification - A/B/C/D)
- Examples:
- Early stage liver disease with small lesion + stable liver function: resect lesion. (enough liver preserved)
- Multiple small lesions (3 of ≤ 3cm) and early stage disease --> liver transplant.
- Indeterminant stage or multinodular disease --> Transarterial hepatic artery chemoembolization (TACE)
- Advanced stage, portal invasion --> Sorafenib
- Transplantation is most effective for early disease.
- Guided by Barcelona Classification for Liver Cancer (BCLC)
Hepatic Cysts
- Hepatic cysts --> benign liver finding commonly on liver imaging.
- Usually a thin wall with no internal structures, asymptomatic.
- Classified:
- Small Simple cysts < 4cm --> not significant.
- Large Simple cysts > 4cm --> rarely symptoms (abdo pain, nausea, discomfort)
- Laparoscopic fenestration can be done (slits made in cysts allowing to drain).
- Needle aspiration not effective (recur).
- Usually not symptomatic, if symptoms --> concern for cystadenoma
- Non-Simple Cysts: (On ultrasound)
- Wall irregularity + Internal echos --> cystadenomas.
- Cystadenoma:
- Risk of malignant transformation to a cystadenocarcinoma.
- Must resect all suspected cystadenomas.
- b/c hard to distinguish cystadenoma from cystadenocarcinoma on imaging and histology.
Focal Nodular Hyperplasia
- Benign liver lesion --> hypertrophic liver reaction to an anomlaous artery
- FNH: most found incidentally.
- Diagnosis: Radiographically (see anomalous artery as a pathognemonic "central scar")
- If no central scar, hard to distinguish hyperplasia vs. adenoma.
- Sometimes liver biopsy is needed.
- 5cm indeterminate lesion in a non-cirrhotic liver can be monitored by U/S q6mo to confirm no growth. (avoids liver biopsy).
- Management:
- No malignant potential, no other complications.
- Reasurre patient.
Hepatic Adenoma
- Commonly confused with focal nodular hyperplasia (FNH) (sometimes hard to distinguish radiologically)
- Histologically sheets of hepatocytes without biliary structures.
- Common in women, associated with oral contraceptives.
- Management:
- Risk of malignant transformation or rupture associated with bleeding.
- If > 5cm OR pregnancy considered
- Surgical resection (to reduce risk of rupture or malignant transformation)
- If < 5cm in diameter:
- Discontinue OCP AND sequential imaging (check regression)
Hepatic Hemangioma
- Common benign liver findings.
- >5cm --> called giant hemangioma.
- Symptoms:
- RUQ fullness / discomfort.
- Diagnosis: Contrast CT or MRI (peripheral nodular enhancement, followed by centripetal filling).
- Management:
- Excellent prognosis.
- Small hemangiomas can be reassured.
- Even giant hemangioma: risk of bleeding too low to warrant resection.
- Consider surgery for:
- Symptomatic hemangiomas or sequential growth.
Biliary Neoplasms
Gallbaldder Cancer
- Most common biliary malignancy
- Risk Factors: >50yo, Female, Gall stones, obesity, gallbladder pollyps >1cm, chronic infection (salmonela typhii), porcelain gall bladder.
-
To prevent gall bladder cancer, prophylactic cholecystectomy considered in: - Gall bladder polyps >1cm
- Gall stones >3cm
- Porcelain gall bladder
- Uncommon, but fatal, diagnosed in advanced stage.
- Symptoms: Nonspecific: abdo discomfort, nausea, weight loss
- Labs: normal until obstructive jaundice develops
- Diagnosis:
- Often diagnosed intra-op during cholecystectomy for gall bladder symptoms OR on abdo imaging.
- U/S, CT, MRI can reveal abnormalities in gall bladder wall.
- Management:
- Depends on stage.
- Localized --> Open cholecystectomy.
- Advanced Tumors --> Curative therapy not possible.
- Palliative: operative diversion of bile flow, endoscopic stenting.
- Chemotherapy/Radiation benefits not demonstrated.
Cholangiocarcinoma
- Cancer derived from biliary tree (not gall bladder or ampulla)
- Risk Factors: Primary sclerosing cholangitis, biliary atresia, chronic infection (liver flukes), biliary cists.
- Screening: No evidence for screening (imaging +/- tumor markers possible)
- Suspect in patients with PSC with signs of clinical decompensation.
- Management:
- Classified:
- Intrahepatic:
- Often asymptomatic until advanced (RUQ discomfort, weight loss, fever, ALP can be up)
- If advanced: poor prognosis, curative resection often not possible.
- Hilum (Klatskin tumor)
- Jaundice (complete obstruction of biliary tree)
- Suspect diagnosis: imaging shows bile duct dilatation + obstructing lesion
- Diagnosis: Endoscopic cholangiography with brushings/biopsy
- Management: Resection (if not invated intrahepatic ducts), poor survival
- Liver transplant also done, but no data yet.
- Extrahepatic (distal):
- Presentation / diagnosis is same as Hilum Tumor.
- Management: resection (curative intent)
- Intrahepatic:
- Chemo/Rads benefit unknown
- Classified:
Ampullary Adenocarcinoma
- RARE, often in hereditary polyposis syndromes (FAP).
- FAP patients should undergo regular endoscopy to screen.
- Presents: obstructive jaundice. Dx: endoscopic biopsy and imaging with CT.
- Resectable, good prognosis. (Whipple procedure is recommended)
Biliary Cysts
- Diagnosis considered when dilatation of bile duct is found without evidence of obstructing lesion.
- Symptoms: chronic intermittent abdo pain, recurrent bouts of cholangitis / jaundice.
- Diagnosis:
- Abdo CT / US can suggest cysts --> DO MRCP or ERCP
- To diagnose use: MRCP, ERCP, or EUS (Endoscopic Ultrasound)
- --> define cystic dilatation with no obstruction
- Abdo CT / US can suggest cysts --> DO MRCP or ERCP
- Management:
- 20-fold increase risk of cholangiocarcinoma --> should be resected.
- Surgical resection of the entire cyst + hepaticojejunostomy formation indicated.
- Reduces risk of malignancy and alleviates further cholangitis.
- 20-fold increase risk of cholangiocarcinoma --> should be resected.
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