The document discusses the workup and diagnosis of liver masses. It describes various benign and malignant liver lesions including hemangioma, focal nodular hyperplasia, hepatic adenoma, liver cysts, hepatocellular carcinoma, and metastases. Multiphasic CT is useful for characterizing lesions based on enhancement patterns in the arterial, portal venous, and delayed phases. Biopsy may be needed to confirm diagnosis of suspicious lesions.
3. WORKUP ALGORYHM FOR LIVER MASS
Mass on scan
History of prior
malignancy
No history of prior
malignancy
4. History
• Symptoms - abdominal pain/ pressure
effect,fever,anoraxia,weight loss
• Patient characteristics (age, gender, use
of OCP, risk factors for chronic liver
disease )
• History or findings of extrahepatic
malignancy
5. Physical examination and investigation
• Sign of chronic liver stigmata or portal
hypertention
• Lymphadenopathy
• CBC with PLT , coagulogram , LFT , hepatitis
profile , tumor marker
• Ultrasound , CT scan , MRI
6. Find needle biopsy
• commonly used to assist in the diagnosis of a
variety of liver lesions
• Disadventage
– Increase risk of bleeding and seeding of neoplastic
cells
– Some type liver lesion cannot diagnosis such as
hepatic adenomas and focal nodular hyperplasia
8. Understanding the phases
• Liver has dual blood supply
• Normal parenchyma is supplied for 80% by the
portal vein and only for 20% by the hepatic
artery
• All liver tumors get 100% of their blood supply
from the hepatic artery
9. Arterial phase
• In the arterial phase hypervascular tumors will
enhance via the hepatic artery, when normal
liver parenchyma does not yet enhances,
because contrast is not yet in the portal
venous system.
• Hypervascular tumors will enhance optimally
at 35 sec after contrast injection
10. Portal venous phase
• To detect hypovascular tumors
• Scanning is at about 75 seconds
13. Delayed Phase
• Begins at about 3-4 minutes after contrast injection
and imaging is best done at 10 minutes
• Valuable for washout of contrast(HCC),retention of
contrast(heamangioma),retention of contrast in
fibrous tissue (capsule of HCC, central scar of FNH)
16. Hemangioma
Clinical Features
• The commonest liver tumor
• 5% of autopsies
• Usually single small
• Well demarcated capsule
• Usually asymptomatic
17. Hemangioma
Diagnosis and Management
Diagnosis
• US: echogenic spot, well demarcated
• CT: venous enhancement from periphery to center
• MRI: high intensity area
• No need for FNA
Treatment
• No need for treatment
20. Focal Nodular Hyperplasia (FNH)
Clinical Features
• Benign nodule formation of normal liver tissue
• Central stellate scar
• More common in young and middle age
women
• No relation with sex hormones
• Usually asymptomatic
• May cause minimal pain
21. Focal Nodular Hyperplasia (FNH)
Diagnosis and Management
Diagnosis:
• US: Nodule with varying echogenicity
• CT: Hypervascular mass with central scar
• MRI: iso or hypo intense
• FNA: Normal hepatocytes and Kupffer cells with
central core.
Treatment:
• No treatment necessary
• Pregnancy and hormones OK
24. Hepatic Adenoma
Clinical features
• Benign neoplasm composed of normal
hepatocytes no portal tract, central veins, or
bile ducts
• More common in women
• Associated with contraceptive hormones
• Usually asymptomatic but may have RUQ pain
• May presents with rupture, hemorrhage, or
malignant transformation (very rare)
25. Hepatic Adenoma
Diagnosis and Management
DX
• US: filling defect
• CT: Diffuse arterial enhancement
• MRI: hypo or hyper intense lesion
• FNA : may be needed
Tx
• Stop hormones
• Observe every 6m for 2 y
• If no regression then surgical excision
28. Liver Cysts
• May be single or multiple
• May be part of polycystic kidney disease
• Patients often asymptomatic
• No specific management required
• Hydated cyst
31. HCC: Incidence
• The most common primary liver cancer
• The most common tumor in Saudi men
• Increasing in US and all the world
32. HCC: Risk Factors
The most important risk factor is cirrhosis from
any cause:
1. Hepatitis B (integrates in DNA)
2. Hepatitis C
3. Alcohol
4. Aflatoxin
5. Other
33. HCC: Clinical Features
• Wt loss and RUQ pain (most common)
• Asymptomatic
• Worsening of pre-existing chronic liver dis
• Acute liver failure
O/E:
• Signs of cirrhosis
• Hard enlarged RUQ mass
• Liver bruit (rare)
36. HCC: labs
• Labs of liver cirrhosis
AFP (Alfa feto protein)
• Is an HCC tumor marker
• Values more than 100ng/ml are highly
suggestive of HCC
• Elevation seen in more than 70% of pt
37. HCC: Diagnosis
• Clinical presentation
• Elevated AFP
• US
• Triphasic CT scan: very early arterial perfusion
• MRI
• Biopsy
41. 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
43. HCC: Liver Transplantation
• Best available treatment
• Removes tumor and liver
• Only if single tumor less than 5cm or less than
3 tumors less than 3 cm each
• Recurrence rate is low
• Not widely available
44. HCC: Resection
• Feasible for small tumors with preserved liver
function (no jaundice or portal HTN)
• Recurrence rate is high
45. HCC: Local Ablation
• For non resectable pt
• For pt with advanced liver cirrhosis
• Alcohol injection
• Radiofrequency ablation
• Temporary measure only
48. HCC: Chemoembolization
• Inject chemotherapy selectively in hepatic
artery
• Then inject an embolic agent
• Only in pt with early cirrhosis
• No role for systemic chemotherapy
50. Fibro-Lamellar Carcinoma
• Presents in young pt (5-35)
• Not related to cirrhosis
• AFP is normal
• CT shows typical stellate scar with radial septa
showing persistant enhancement
51. Hepatoblastoma
• most common liver cancer in children
• most commonly diagnosed during a child's first
three years of life
• usually present with an abdominal mass
• Patients with familial adenomatous polyposis
(FAP) are risk factor
• Often elevated AFP
• Treatment : Surgical resection, adjuvant CMT,
and liver transplantation
52. Secondary Liver Metastases
• The most common site for blood born metastases
• Common primaries : colon, breast, lung, stomach,
pancreases, and melanoma
• Mild cholestatic picture (ALP, LDH) with preserved
liver function
• Dx imaging or FNA
• Treatment depends on the primary cancer
• In some cases resection or chemoembolization is
possible
53.
54.
55. Pre contrast Arterial Phase Portal venous
phase
Delayed
Hepatocelluar Ca Low attenuation Homogenous
enhancement
Washout of
lesion
Isodense
Adenoma Low attenuation Homogenous
enhancement 85%
Iso or
hypodense
Iso or hypodense
Haemangioma Low attenuation Peripheral puddles Partial Fill in Complete fill in
FNH Iso/Low
attenuation
Homogenous
enhancement
Hypodense Isodense
Metastasis(hypervascular) Low attenuation Homogenous
enhancement
Hypodense
Metastasis Low attenuation Hypodense Hypodense
Cyst Low attenuation No enhancement
Abscess Low attenuation may
have irregular margins
Transient regional
increase enhancement
Ring
enhancement
Multiphasic CT of Liver
Only a minority of tumors contain calcifications, cystic components, fat or hemorrhage and will be detected on a NECT.
Tumors enhance in arterial phase.
Liver will enhance in the portal venous phase
Will be visible as hyperdense lesions in a relatively hypodense liver
also called the hepatic phase because there already must be enhancement of the hepatic veins
HCC Cirrhotic liver with a single nodule in the right lobe showing marked arterial phase enhancement and early wash off in the portovenous phase are diagnostic features of a HCC.
