Approach to liver nodules.pptx

Approach to liver Mass
By: Dr. Rebil Heiru (Year III IM Resident)
Moderator: Dr. Fikadu Girma (Internist, Gastroenterologist and
Hepatologist)
May,2021
ADAMA HOSPITAL
MEDICAL COLLEGE

Outline
• Introduction
• General approach
• Malignant liver masses
• Benign liver masses
• Hepatic cysts

Introduction
• Hepatic mass lesions include tumors, tumor-like lesions, abscesses, cysts,
hematomas, and confluent granulomas.
• Hepatic tumors can be primary (from hepatocytes, bile duct epithelium, or
from mesenchymal tissue) or secondary.
• In adults in most parts of the world, hepatic metastases > 10 malignant
tumors of the liver
• In children, 10 malignant tumors > both metastases and benign tumors of
the liver.
• Except for cavernous hemangiomas, benign hepatic tumors are rare in all
geographic regions and in all age groups.

General approach
HX
• Age
• Gender
• Travel history
• OCP, anabolic steroid use
• Previous imaging
• Comorbid illness
• Pain
• Hx of underlying liver dxs
• Recent IDA, DM
PE
• Stigmata’s of CLD
• Hepatomegally
• Palpable mass
• Bruit
• Pallor
• Jaundice
• Peripheral edema

lab
• CBC
• AST, ALT, ALP, Bilirubin
• Viral markers
• Iron levels
• CEA, CA 19-9, AFP
• LDH
• Urine 24 hr 5 HIAA

HCC
Epidemiology
• HCC is the most common primary malignant tumor of the liver
(90%)- 7% of all cancers
• It is the fifth most common cancer in men and the eighth most
common in women
• Ranks fourth in annual cancer mortality rates.
• Men>women 3.7:1 to 2.4:1
• Old Age, highest among 70-79yrs

HCC
Epidemiology….
• Liver cancer incidence/mortality is increasing worldwide
(WHO 1M deaths in 2030)
• Highest increase in incidence in US among all tumor types
• Etiological landscape is changing (↑ in NAFLD↓viral
hepatitis)
• Rare among children

DIAGNOSIS
• Serum Tumor Markers
• AFP
• Fucosylated AFP
• Des-γ-Carboxy Prothrombin
• The roles in the diagnosis of HCC for markers such as glypican-3
(GPC3), Golgi protein 73, hepatocyte growth factor, IGF 1, and
transforming growth factor-β1 await further study.

Imaging
• U/S
• CT
• MRI
• PET
• Hepatic angiography
• Laparascopy

Imaging
• Classic HCC …CT or MR imaging is a mass that shows
1. APHE
2. subsequent washout during PVP or more delayed images,
and
3. delayed capsular or pseudocapsular enhancement
• When present, these 3 major features allow HCC to be
treated without the need for biopsy confirmation
• Tumor thrombus may show arterial phase enhancement
• CT sensitivity 67.5% Specificity 92.5%
• MRI sensitivity 80.6% and specificity 84.8%

• If these criteria are not present but HCC or other
malignancy is considered probable, then a liver biopsy
should be considered for diagnosis.
Diagnosis of HCC cannot be made by imaging in
patients without cirrhosis, even if enhancement and
washout are present, and biopsy is required in these
cases.
• Histological markers gpC3, HSp70, and GS can be
assessed to distinguish high-grade dysplasia from HCC
on histology if HCC cannot be diagnosed based on
routine histology.

• Pathology
• Gross appearance
• Nodular
• Massive
• Diffusely infiltrating
• Microscopic appearance
• Well differentiated
• Moderately differentiated
• Undifferentiated
• Progenitor cell HCC

• Metastases
• Autopsy (40-57%)
• Lungs 50%, LNs 20%...adrenal glands
• Fibrolamellar HCC
• Young
• M=F
• Doesn’t secrete AFP
• Not caused by CHBV/CHCV
• Non cirrhotic liver
• Amenable to surgical Rx… good prognosis
• Mixed type… poor prognosis

Staging
• TNM (doesn’t account the underlying liver dxs)
• Okuda,
• Cancer of the Liver Italian Program,
• Barcelona Clinic Liver Cancer (BCLC),
• Chinese University Prognostic Index,
• Japanese Integrated Staging, and
• Group d’Etude et Traitement du Carcinome Hépatocellulaire

 Definitive dx requires histologic correlation
Immunostaining
GPC3
Heat shock protein 70 (HSP70)
Glutamine synthetase
Gene expression profiling
GPC3
LYVE1 [encoding lymphatic vessel endothelial hyaluronan receptor-1],
BIRC5 [encoding baculoviral inhibitor of apoptosis repeat-containing-5,
or survivin

 The main clinical prognostic factors in patients
with HCC:
Number and size of nodules
Presence of vascular invasion
Extrahepatic spread
Liver function (defined by Child-Pugh’s class)
General tumour-related health status [ECOG]

•Unlike most solid tumours, the co-existence of
two life-threatening conditions, such as cancer
and cirrhosis complicates prognostic
assessments.
•HCC has a poor prognosis when diagnosed
after the onset of symptoms (0-10% 5-year
survival rate).

Treatment
•There have been significant advances in HCC
treatment over the past 10 years, with
improvements in both technology and patient
selection.
•Available therapeutic options can be divided
into curative and noncurative interventions.

Treatment
• Surgical resection
• LT
• Local ablation
• Chemoembolization
• Chemotherapy
• Alternative techniques and combinations
• Cryoablation
• Laser ablation
• External beam radiation
• Y-90
• Sorafenib + TACE

Treatment…
Treatment of HCC
Curative
resection
OLT
Ablation
Noncurative
TACE
TARE
SBRT
Systemic chemotherapy

Treatment of HCC: liver resection
EASL CPG HCC. J Hepatol 2018; doi: 10.1016/j.jhep.2018.03.019
• Surgery is the mainstay of HCC treatment
• Best outcomes of any treatment in well-selected candidates
• 5-year survival of 6080%
• Liver resection and transplantation is first option with early tumours
• Extended to other stages after non-surgical tumour downstaging
Recommendations
Surgical resection is the treatment of choice in patients with HCC arising on a
non-cirrhotic liver
Low Strong
Indications for resection of HCC in cirrhosis should be based on:
• Multi-parametric composite assessment of liver function
• Portal hypertension
• Extent of hepatectomy and expected volume of future liver remnant
• Performance status
• Patient co-morbidities
High Strong
Peri-resection mortality in cirrhotic patients should be <3% High Strong
Level of evidence Grade of recommendation

Assessment of post-resection risk of hepatic
decompensation
• Multi-parametric assessment
• Risk of decompensation based on three
determinants of liver insufficiency
• Portal hypertension
• Extent of resection
• Liver function
• Likelihood of decompensation
• High: >30%
• Intermediate: <30%
• Low: 5%

Extent of resection: anatomical vs. non-
anatomical
Residual region of tumour- bearing
3rd-order portal branch at high risk
of tumour recurrence
A
Anatomical resection (A-A’) removes entirely the
tumour-bearing portal branches bordered by the
landmark veins, while non-anatomical resection (B-B’)
is any other type of resection in which the tumour-
bearing 3rd-order portal region is not fully removed
B
After non-anatomical resection of HCC some part
of the tumour-bearing portal region is left, which is
at high risk of tumour recurrence

Liver resection and tumour parameters
• Indications and choice of surgical technique depend on tumour size and location(s)
Recommendations
Liver resection is recommended for single HCC of any size
• In particular, for tumours >2 cm when hepatic function is preserved and
sufficient remnant liver volume is maintained
Moderate Strong
In properly trained centres, liver resection should be considered via
laparoscopic/minimally invasive approaches, especially for tumours in
anterolateral and superficial locations
Moderate Weak
HCC presenting with two or three nodules within Milan criteria may be
eligible for liver resection depending on:
• Performance status
• Co-morbidities
• Preservation of liver function and remnant volume
Low Weak

Minimally invasive/laparoscopic resection for
HCC
• Laparoscopic-robotic resection for HCC located in superficial- peripheral positions of the liver
provides optimal survival outcomes
• While minimizing complications and hospital stay
Scan detection of liver
tumour
Laparoscopic treatment of the
affected organ through small
openings
Removal of affected
region
Minimal signs of invasive
surgery and rapid patient
recovery

Liver resection contraindications and follow-
up
• A substantial proportion of patients with HCC present with
tumour-related portal vein thrombosis
• Disease at advanced stage and not amenable to curative treatment
• Tumour recurrence complicates 70% of cases at 5 years
Recommendations
• HCC-related macrovascular invasion is a contraindication for liver resection
• Intervention on distal portal invasion – at segmental or sub-segmental level –
deserves investigations within prospectively designed protocols
Moderate
Neoadjuvant or adjuvant therapies are not recommended because they have
not been proven to improve the outcome of patients treated with resection High Strong
Follow-up* after resection with curative intent is recommended because of high
rates of treatable recurrence High Strong

Treatment of HCC: LT
• Together with NAFLD/NASH, HCC is the fastest growing indication for LT
• Milan criteria are the benchmark for selecting patients for LT
• Basis for comparison with other suggested criteria
Recommendations
LT is recommended as the first-line option for HCC within Milan criteria
but unsuitable for resection
High Strong
Consensus on expanded criteria for LT in HCC has not been reached
Patients outside Milan criteria can be considered for LT after successful
downstaging to within Milan criteria, within defined protocols
Moderate Weak
Tumour vascular invasion and extrahepatic metastases are an absolute
contraindication for LT in HCC
High

Local ablation and external radiation
• Tumour ablation techniques have improved along with the imaging-guidance tools required to
ensure their successful application
Recommendations
Thermal ablation with radiofrequency is the standard of care for patients
with BCLC-0 and A tumours not suitable for surgery*
High Strong
In patients with very early stage HCC (BCLC-0) radiofrequency ablation in
favourable locations can be adopted as first-line therapy even in surgical
patients
Moderate Strong
Microwave ablation showed promising results for local control and survival Low
Ethanol injection is an option in some cases where thermal ablation is not
technically feasible, especially in tumours <2 cm
High Strong
External beam radiotherapy is under investigation
• So far there is no robust evidence to support this therapeutic approach in
the management of HCC
Low Weak

Percutaneous ablation
• Thermal injury of
adjacent structure
• Heat sink effect (near
major vessels)
• Multibipolar mode is
less sensitive to heat
sink effect
Advantag
es
Limitatio
ns
• Well-evaluated
treatment (reference)
• Multibipolar mode:
increases volume and
predictability (margin)
of ablation zone • No reliable endpoint to
set the amount of
energy deposition
• Higher and faster
temperature picks
reached than with RFA
(less sensitive to heat
sink effect than
monopolar RFA)
• Limited risk of thermal
injury to neighbouring
critical structures
• Unsensitive to heat sink
effect
• Advantage of
multibipolar mode (no
touch technique,
predictability of
margins)
• Cryoshock with first
device
• Limited clinical data
available with new
devices
• Easy monitoring with
imaging of ice ball
progression
• Only preliminary
clinical data
• General anaesthesia
using curare and major
analgesic drugs is
mandatory
Radiofrequency ablation Microwave ablation Cryoablation Irreversible
electroporation
Monopolar
RFA
Multibipolar
No touch RFA
Active energy
deposition: few
mm
Active energy
deposition: ~1
cm
Ice ball: ~1–3
cm
Cell
membran
e

Transarterial therapies
• Benefits of TACE in appropriately selected patients have been robustly demonstrated
Recommendations
TACE is recommended for patients with BCLC stage B and should be
carried out in a selective manner
High Strong
The use of drug-eluting beads has shown similar benefit to conventional
TACE and either of the two can be utilized
High Strong
TACE should not be used in patients with:
• Decompensated liver disease
• Advanced liver and/or kidney dysfunction
• Macroscopic vascular invasion
• Extrahepatic spread
High Strong

First line systemic treatments

First-line systemic therapies
• VEGFR and multi-kinase inhibitors have shown survival benefits in advanced HCC
• First line: sorafenib and lenvatinib
Recommendations
Sorafenib is the standard first-line systemic therapy for HCC, indicated for
patients with:
• Well-preserved liver function (Child–Pugh A) and with advanced tumours
(BCLC-C)
• Earlier stage tumours progressing upon, or unsuitable for, loco-regional
therapies
High Strong
Lenvatinib is non-inferior to sorafenib and is also recommended in first-line
therapy for patients with:
• Well-preserved liver function, good performance status and advanced
tumours (BCLC-C) without main portal vein invasion
• Tumours progressing with, or unsuitable for, loco-regional therapies
High Strong

Non-inferiority results in advanced HCC

Second line systemic therapies

Cabozantinib vs placebo (CELESTIAL)

Ramuricumab vs Placebo (REACH)

Second-line systemic therapies
*In patients with high baseline alpha-fetoprotein (> 400 ng/ml)
• VEGFR and multi-kinase inhibitors have shown survival benefits in advanced HCC
• First line: sorafenib and lenvatinib
• Second line: regorafenib (and cabozantinib and ramucirumab*)
• Another agent that has shown some promise is the checkpoint inhibitor nivolumab
Recommendations
Regorafenib is recommended as second-line treatment for patients:
• Tolerating and progressing on sorafenib
• With well-preserved liver function (Child–Pugh class A)
• With good performance status
High Strong
Cabozantinib and ramucirumab* have shown survival benefits vs. placebo in this setting - -
Based on uncontrolled but promising data, immune therapy with nivolumab has received
FDA approval in second-line treatment, pending Phase 3 data for conventional approval
• At present, the data are not mature enough to give a clear recommendation
Moderate Weak

Systemic therapies in development
• Other systemic treatments are in development
• Have not yet demonstrated non-inferiority or clinical benefit
• Further clinical trials are required
Recommendations
• Treatments that failed to meet their endpoints in randomized trials are
not recommended
• Further clinical trials are needed to confirm claims of non-inferiority, or any trends of
better outcome identified in subgroup analysis
High
• Patients at BCLC D stage, who are not LT candidates, should receive palliative support,
including management of pain, nutrition and psychological support
• In general, they should not be considered for clinical trials
Low Strong

Overview of EASL recommendations for
treatment
• *Other molecular therapies: sunitinib, linifanib, brivanib, tivantinig, erlotinib, everolimus
• Weak recommendation: more evidence needed

Palliative and best supportive care
• Management of end-stage disease is only symptomatic
• No tumour-directed treatment is indicated
• Psychological burden of end-stage HCC should not be neglected or underestimated
Recommendations
In HCC on cirrhosis:
• Acetaminophen ≤3 g/day to manage pain of mild intensity
• NSAIDs should be avoided whenever possible in patients with underlying cirrhosis
• Opioids to manage pain of intermediate or severe intensity (proactively
avoid constipation)
Low Weak
Bone metastases causing pain, or at significant risk of spontaneous secondary fracture,
benefit from palliative radiotherapy
Low

Hepatic Metastases
 The liver is the most frequent target for metastatic
spread of tumors
• 40% - 50% of adult patients with extrahepatic
primary malignancies.
• Double blood supply of the liver and fenestrations in
the sinusoidal endothelium

• Metastatic disease of the liver is seen much more
commonly than the occurrence of primary hepatic
malignancies
• Metastatic disease of liver is 30X > primary liver
malignancy.
• Most often identified as multiple masses, but also
can present as a solitary or larger confluent mass

• Hepatic metastases commonly originate from primary
sites in the distribution of the portal venous system,
including the pancreas, stomach, and colon.
• Outside this distribution, tumors of the lung and
breast are the most common origins of hepatic
metastases.

Clinical features
• Usually masked by the primary malignancy
• If 10 is asymptomatic… malaise, weight loss, upper abdominal
pain and jaundice
• Hepatomegaly, irregular borders and umblicated nodules
• Friction rub

Hypovascular Metastasis
• Colon, lung, prostate, gastric, and bladder carcinomas
• PVP as hypoenhanced masses relative to the adjacent liver and can also show delayed
enhancement
Hypervascular metastasis:
• NE tumor, RCC, melanoma(ocular), sarcoma, and thyroid ca
• U/S ->hypoechoic halo, central calcification
Wash out
• T2 hyperintense on MR imaging

Treatment and Prognosis
• The extent of replacement of liver tissue by metastases
generally determines the patient’s prognosis.
• Approximately 50% of patients surviving 3 months after
the onset of symptoms and <10% surviving >1yr
• Survival for 5 years can be achieved in up to 60% who
undergo resection of a solitary colon cancer metastasis to the
liver

• Long-term survival has been accomplished most
often by resection of hepatic metastases in patients with
colorectal cancer
• Substantial number of whom have been cured or
have obtained up to 20 years of disease-free
survival.

• If the primary tumor has been removed completely and
metastases are confined to the liver, resection of hepatic
metastases should be considered
• Liver transplantation, with or without chemotherapy,
has been limited to a few patients
• RFA is a valid therapy for colorectal metastases in
patients who are unable to tolerate or refuse surgical
resection.

Intrahepatic Cholangiocarcinoma
• Cholangiocarcinoma (CCA) is classified according to its
anatomic location as:
• Intrahepatic (iCCA; ~30%)
• Perihilar (pCCA; ~50%) and
• Distal (dCCA: ~20%)
• The latter two are also known as extrahepatic
cholangiocarcinomas (eCCA)

• ICCA represents approximately 10% to 20% of all
primary liver cancers and 20% of cholangiocarcinoma
• The M:F ratio is 1.5:1
• Asymptomatic until the tumor is advanced
• The clinical features are then similar to those of HCC
• 165% increase between the late 1970s and the late 1990s

Etiology and Risk Factors
• The strongest association is with Opisthorchis viverrine liver
fluke acquired by ingestion of raw or uncooked fish
• Clonorchis sinensis (weak association), thorotrast (thorium dioxide)
• Congenital and acquired abnormalities of the biliary tract
(biliary atresia, choledochal cysts, hepatholithiasis)→ bile stasis,
chronic inflammation, and infection
• PSC, cirrhosis, smoking, alcohol, DM

DIAGNOSIS
• CA 19-9 is the most frequently used serum tumor marker for
cholangiocarcinoma but has significant limitations
• CA 19-9 levels are also elevated in pancreatic, colorectal, gastric,
and gynecologic cancers and in acute bacterial cholangitis
• In patients with unexplained biliary obstruction without PSC, the
sensitivity of CA 19-9 is 53%, and the negative predictive value is
72% to 92%, for a cutoff value of 100 U/mL.
• Often only the serum ALP level is elevated.

Imaging
• progressive enhancement in arterial, portal venous, and delayed
phases, thereby helping to distinguish it from HCC, which usually
has washout in the later 2 phases.
• Other associated findings may include hepatic capsular retraction,
vascular encasement that may lead to lobar atrophy, and dilatation
of peripheral bile ducts.
• MRCP: site of obstruction and extent of biliary tree involvement
• 5 yr survival <5%

Hepatic haemangiomas: epidemiology
• Most common primary liver tumours
• Prevalence on imaging series: ~5%
• Prevalence on autopsy series: up to 20%
• Most common in women aged 30–50 years
• Female to male ratio ranges from 1.2–6:1
• Can occur in all age groups

Hepatic haemangiomas: clinical
characteristics
• Rarely of clinical significance
• Often solitary and small (<4 cm), although can reach 20 cm in
diameter
• Most patients are asymptomatic even with large
haemangiomas
• Larger tumours (>10 cm) may be symptomatic – associated
with pain and features of KMS (inflammatory reaction
syndrome and coagulopathy)

Hepatic haemangiomas
• Classic appearance on US… US is sufficient for dx!
Homogenous hyperechoic mass
<3cm
Acoustic enhancement
Sharp margins
Lack of halo sign
• MRI 90%
• Needle biopsy 96%
• A hyperechoic mass in a healthy liver  suspect hemangioma

Hemangioma
A, Hemangioma. Ultrasonography demonstrates
a large circumscribed uniformly hyperechoic
mass in the right hepatic lobe
B, Ultrasonography demonstrates atypical hypoechoic
appearance of a large hemangioma (in the setting of an
echogenic liver due to hepatic steatosis).

Hepatic haemangiomas: imaging
EASL CPG benign liver tumours. J Hepatol 2016;65:386–98
T2 T1 CE
Typical haemangioma adjacent to FNH
MRI
CEUS
CE CE
Strongly
hyperintense
Hypointense Lesion shows peripheral and discontinuous enhancement followed by
complete fill-in on delayed-phase imaging

Hepatic haemangiomas: key diagnostic
recommendations
Recommendations
Contrast enhanced imaging (CEUS, CT or MRI) is required in
oncology patients and patients with underlying liver disease II-2 1
Diagnosis by contrast-enhanced imaging is based on a typical
vascular profile, characterized by peripheral and globular
enhancement on arterial phase followed by a central enhancement on
delayed phases
MRI provides additional findings: e.g lesion signal on T1-, T2-
weighted sequences; diffusion imaging
II-2 1
Grade of evidence Grade of recommendation

Hepatic Hemangiomas
Atypical hemangiomas
• Rapidly filling
• strong hyper intensity on T2-weighted images
• enhancement concomitant with that of arterial structures and
• persistent enhancement on delayed phase imaging
• Giant hemangiomas
• may show central heterogeneity related to thrombosis or fibrosis
• Other atypical haemangiomas are very uncommon and include those that
have very slow filling and calcified or hyalinized haemangiomas (also
called sclerosing haemangiomas).

Hepatic haemangiomas…
• Haemangiomas are mostly asymptomatic incidental discoveries
• May change in size during long-term follow-up
• No relationship between size and complications
• Little relationship between symptoms and characteristics
• Benefit of surgery debatable

Hepatic haemangiomas: key
management recommendations
Recommendations
Due to its benign course, imaging follow-up is not required for
typical haemangioma II-2 1
Pregnancy and OCPs are not contraindicated III 2
Conservative management is appropriate for typical cases II-2 1
Refer to benign liver tumour MDT in the presence of KMS, growing
lesions or lesions that are symptomatic by compression III 1

FNH: epidemiology
• Clinically relevant prevalence: 0.03%
• autopsy series: 0.4–3%
• Up to 90% of patients are female
• Average age at presentation: 35–50 years

FNH: clinical characteristics
• Most cases are solitary and <5 cm; multiple FNH in 20–30% of
cases
• Hyperplastic hepatocellular lesions resulting from arterial
malformation
• Size is stable over time in most cases
• Most cases are asymptomatic and complications are extremely
rare

FNH: imaging
• Usually associates several findings
1. Lesion homogeneity, excluding the central scar
2. Slight difference from adjacent liver tissue on pre-contrast US, CT and MRI
3. Strong, homogeneous enhancement on arterial phase CEUS, CT or MRI with
a central vascular supply; becomes isointense to liver tissue on portal venous
and delayed phases
4. Central scar best seen on MRI
5. Lack of capsule with often lobulated contours

FNH: key diagnostic recommendations
• MRI sensitivity
• Lesion >3 cm – very good
• Lesion <3 cm – second imaging modality advised, such as CEUS
• Refer to a specialist centre if in doubt with two imaging modalities
Recommendations
CEUS, CT, MRI: nearly 100% specificity with a combination of
typical imaging features
II-2 1
MRI has the highest diagnostic performance overall
Highest diagnostic accuracy by CEUS is achieved in FNH <3
cm
II-2 1

FNH: key management
recommendations
• In the absence of symptoms a conservative management
approach is recommended
• No indication for discontinuing OCPs
• Follow-up during pregnancy is not necessary
Recommendations
For a typical FNH lesion, follow-up is not necessary unless
there is underlying vascular liver disease
III 2
Treatment is not recommended II-3 2
If imaging is atypical, or the patient is symptomatic, refer to a
benign liver tumour MDT
III 1

FNH: management algorithm
Suspected
FNH
Contrast-enhanced
imaging (preferably
MRI)*
Diagnosis FNH
certain
Diagnosis FNH
doubtful
Discharge, no
follow-up
needed
Confirmed
FNH
Biopsy
CEUS
<3 cm
>3 cm
Diagnosis
uncertain
Map-like pattern of GS
is specific to FNH
GS immunohistochemical staining
is useful in difficult cases

HCA: epidemiology/clinical
characteristics
• Epidemiology
• Reported prevalence: 0.001–0.004%
• ~10x less common than FNH
• Most common in women (10:1 female to male), especially aged 35–40 years
• Potential role of sex hormones
• 30–40-fold increase in incidence with long-term OCP use
• Incidence among males is associated with androgenic steroids

HCA: epidemiology/clinical
characteristics
• Recent increase in prevalence associated with rising obesity and
metabolic syndrome
• Significant risk of haemorrhage and malignant transformation
• Especially with lesions ≥5 cm
HCAs need to be followed more closely than other benign tumours!

HCA: molecular classification
• Molecular subtype is highly associated with risk of transformation to HCC
β-HCAs exhibit the highest risk of malignancy; men are at a higher risk of malignancy

HCA: key diagnostic recommendations
• Imaging features reflect the tumour molecular subtype
• Imaging should be fat sensitive and use contrast agents to look
for dilated vascular spaces
• EASL CPG benign liver tumours. J Hepatol 2016;65:386–98
Recommendations
MRI is superior to all other imaging modalities
Due to its intrinsic properties to detect fat and vascular spaces it offers the
opportunity to subtype HCA up to 80%
II-2 1
MRI has >90% specificity for positive identification of HNF-1α or
inflammatory HCA
Identification of β-catenin-activated HCA and distinction from unclassified
HCA or HCC is not possible with any current imaging technique
II-2 1

HCA: key management
recommendations
• HCAs have the potential for haemorrhage or malignant
transformation
• Management should involve a benign liver tumour MDT
Recommendations
Base treatment decisions on sex, size and pattern of progression III 2
Discontinuation of OCPs and weight loss should be advised II-2 1
Resection irrespective of size is recommended in men and in all cases of proven
β-catenin mutation
II-3 2
Observe women for 6 months after lifestyle change.
• Resection is indicated with lesions ≥5 cm and those continuing to grow
• Reassess lesions <5 cm at 1 year with annual imaging thereafter
II-3
II-3
III
2
2
2
Bleeding HCAs with haemodynamic instability should be embolized and a residual
viable lesion on follow-up imaging is an indication for resection
III 2

HCA and Pregnancy
• Requires close follow up (6-12wks U/S)
• Follow size
•  in size and associated  risk of rupture…involve obstetrician
• HCA <5cm, no evidence of growth or not exophytic mass…no
evidence for C/S… vaginal delivery can be pursued
• Surgery is preferrable than IR
• If HCA located peripherally, small and before 24 wks

Hepatic Cysts
•Hepatic cysts are abnormal fluid-filled
spaces in the hepatic parenchyma and biliary
tree.
3 main types:
Fibrocystic diseases of the liver
Cystadenomas and cystadenocarcinomas
Hydatid cysts

•Fibrocystic diseases of the liver
•originate from abnormal persistence or
defects in the progressive remodeling of the
ductal plate during development, resulting in
dilated fluid filled spaces, including
•hepatic and choledochal cysts,
•portal fibrosis, and ductal plate malformations

•Fibrocystic disorders of the liver include
Simple hepatic cysts
PCLD
Fibrocystic disease associated with autosomal
recessive polycystic kidney disease
Von myenburg complexes
Carolis disease

Simple Cysts
• Simple hepatic cysts are thought to be congenital in
origin and have a frequency of about 2.5% of the
population.
• Usually smaller than 5 cm in diameter
• If >3 considered part of PCLD
• Asymptomatic and discovered incidentally during upper
abdominal imaging

•They occur more often in women than in men,
•Prevalence increases with age.
•When symptomatic, they can produce
complications including intracystic bleeding,
infection, rupture, or compression of adjacent
organs.
•RX: percutaneous drainage or sclerosing (doxy)

Polycystic Liver Disease
• PCLD is a rare condition in which multiple
cysts form in the hepatic parenchyma
• PCLD usually presents in association with
ADPKD
• Cysts range in diameter from a few millimeters
to 10 cm or more.
• They contain clear, colorless, or straw-colored fluid

• The cysts usually are asymptomatic and
discovered incidentally during upper abdominal
imaging.
• Symptoms occur in patients with more
numerous
and larger cysts (10% to 15% of patients,
usually women), generally with markedly enlarged
livers.

• Protuberant abdomen
• Inability to bend over, and shortness of breath
• Severe pain: rupture or infection of a cyst, bleeding
into a cyst, or torsion of a pedunculated cyst
• Jaundice is evident in approximately 5% of
patients
• Ascites: is the result of portal hypertension

Mgt
Open surgical cyst fenestration (deroofing or
marsupialization)
leaves the cysts open to drain into the peritoneal
cavity
successful in up to 90 % of cases

ECHINOCOCCAL CYST
• Echinococcal (hydatid) cysts of the liver are caused by
the larval form of Echinococcus granulosus
• Usually acquired from infected dogs.
• These are fluid-filled structures limited by a parasite-derived
membrane, which contains germinal epithelium.

Treatment
• Treatment of hydatid disease usually involves anthelminthic therapy
combined with either surgical resection of the cyst or percutaneous
aspiration
• Albendazole is highly effective

References
• Sleisenger and Fordtran's Gastrointestinal and Liver disease,
11th edition.
• UpToDate
• EASL-CPG-on-Management-of-benign-liver-tumours
• EASL-CPG-Management-of-hepatocellular-carcinoma
• AASLD guideline for the management of HCC
• Radeopedia.org

Approach to liver nodules.pptx

Recomendados

Recomendados

Más contenido relacionado

La actualidad más candente

La actualidad más candente (20)

Similar a Approach to liver nodules.pptx

Similar a Approach to liver nodules.pptx (20)

Más de RebilHeiru2

Más de RebilHeiru2 (6)

Último

Último (20)

Approach to liver nodules.pptx

Notas del editor