Download Hepatic Adenoma

Chapters 59 & 62
Hepatic and Biliary Neoplasms
Lisa Spiguel, MD
True or False: The caudate lobe is Couinaud’s
segment IV.
True or False: The portal veins divide the right and
left lobes into anterior and posterior segments.
The Right Lobe is comprised of which
segments:
1. IV-VII
2. V -VIII
3. I-IV
4. II-V
Couinaud’s Segmental Anatomy
Couinaud’s
• Classification system based on the vascular supply to
the liver
• Allows the ability to resect segments without damaging
those remaining
• Hepatic Veins:
– Right hepatic vein: Anterior and posterior division of right
lobe
– Middle hepatic vein: Divides right and left lobes (Cantlie’s
Line)
– Left Hepatic vein: Medial and Lateral division of left lobe
• Portal Veins:
– Superior and inferior division
True or False: Viral hepatitis remains the most
common cause of chronic liver disease and cirrhosis
worldwide.
Which of the below criteria is not included in
Child Turcotte-Pugh Score?
1. Ascites
2. Albumin
3. ALT
4. Bilirubin
5. Encephalopathy
Which of the below criteria is not included in
MELD Score?
1. INR
2. Creatinine
3. ALT
4. Bilirubin
Chronic Liver Disease
• Assessing Liver Function
• Viral Hepatitis remains the most common cause of chronic liver disease
and cirrhosis worldwide
• World Health Organization estimates more than 500 million people with
Hepatitis C ( 180) or B (350)
• Other Common Causes:
– Non-alcoholic liver disease
– Cholestatic Liver Disease: Primary sclerosing cholangitis
• Symptoms:
– Early: Fatigue, weight loss, muscle wasting
– Advanced: Splenomegaly, encephalopathy, ascites, variceal bleeding,
jaundice
• Classification Systems:
– Child-Turcotte-Pugh
– Model for End-Stage Liver Disease (MELD)
Indications for Transplantation:
Meld > 15
Child Class C
A 73 yr-old woman presents with complaints
of an increase in her abdominal size and early
satiety. You perform a physical exam and
palpate a mass in the right upper quadrant of
the abdomen. Her CT scan is demonstrated
below. What is the procedure of choice for
her treatment?
1.
2.
3.
4.
Right hepatectomy
Wedge resection
Laparoscopic Unroofing
Plan for liver transplant
A 73 yr-old woman presents with complaints of an
increase in her abdominal size and early satiety.
You perform a physical exam and palpate a mass in
the right upper quadrant of the abdomen. Her CT
scan is demonstrated below. What is her
diagnosis?
1.
2.
3.
4.
Simple hepatic Cyst
Hemangioma
Hepatocellular carcinoma
Hepatic Cystadenoma
A 35 yr-old woman presents with complaints of
RUQ pain, fevers and chills. She was
hospitalized approximately 2 weeks ago for
perforated diverticulitis for which she was
discharged three days ago doing better. A CT
abdomen/Pelvis was performed and is
demonstrated below. What is the treatment of
choice for her?
1. Percutaneous drainage and gram
negative antibiotic coverage
2. Avoid percutaneous drainage and iv flagyl
3. Avoid percutaneous drainage and
Albendazole therapy
4. To OR for Laparoscopic marsupialization
A 35 yr-old woman presents with complaints of
abdominal discomfort for the past week. A CT
abdomen/Pelvis was performed and is
demonstrated below. What is her diagnosis?
1.
2.
3.
4.
Hydatid Cyst
Pyogenic Liver Abscess
Simple hepatic cyst
Amoebic Abscess
True or False: Flagyl is first line treatment for a
Hydatid Cyst.
Cystic Liver Lesions
Simple Cysts
Cystadenomas
Infectious
Cystic Liver Lesions
Simple Cysts
• More common in women
• Increased in right lobe
• Symptoms: Pain, infection, bowel compression, rare
bleeding
• Tx: If symptomatic: Laparoscopic unroofing/marsupialization
Cystic Liver Lesions
Cystadenoma/
Cystadenocarcinoma
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•
•
•
Most common primary cystic neoplasm of the liver
Accounts for 5% of all cystic lesions of the liver
Arise from biliary epithelium
Propensity toward local recurrence and malignant
degeneration to Cystadenocarcinoma
• Imaging: Papillary-like fronds or septa
• Dx: Elevated CA 19-9 and CEA of cyst fluid/ Mucin
• Tx: Wedge resection (cystadenomas), formal
resection (cystadenocarcinomas)
Cystic Liver Lesions
Infectious
• Echinococcus Cyst
•
•
•
•
•
Right Lobe
Dx: ELISA for IgG Ab
against Echinococcus/
Hemagglutinin
CT: Ectocyst (calcified
wall)
Tx: Do not aspirate
Treat Albendazole 
Pack bowel with
hypertonic saline, inject
cyst with ETOH, Aspirate
contents, remove cyst
wall, Albendazole post op
• Pyogenic Abscess
•
•
•
•
•
Right Lobe
MC type of hepatic
abscess
MC organism: E. Coli
2nd to biliary tract
disease with
ascending infection
or biliary
manipulation, or any
intraabdominal
infection drains via
portal to liver
Tx: Percutaneous
drainage + Abx, ERCP
to rule out biliary
obstruction
• Amoebic Abscess
•
•
•
•
•
•
Recent travel to
Mexico or Latin
America
Entamoeba Histolytica
2nd to Amoebic colitis
Right Lobe
Dx:
Agglutinin+Immunoelectrophoresis Ab
tests
Tx: Flagyl, Aspiration
is difficult (Anchovy
Paste)
True or False: Focal Nodular Hyperplasia is
recommended for excision due to increased
future risk of malignancy
A 31 yr-old woman presents to the ED with RUQ
Pain and orthostatic symptoms. Her vitals are
37.2/118/100/50/18/99% 2LNC. A CT was
performed that is demonstrated. What is the
most likely underlying etiology?
1.
2.
3.
4.
Hepatic Adenoma
Hepatocellular carcinoma
Hepatic Cyst
Focal Nodular Hyperplasia
Which of the following below demonstrates a
classic “central stellate scar” on CT and MRI?
1.
2.
3.
4.
Liver Cyst
Hepatic Adenoma
Focal Nodular Hyperplasia
Hepatocellular Carcinoma
True or False: Surgical resection is indicated for
both symptomatic and asymptomatic
hemangiomas due to the increased risk of rupture
and hemorrhage.
True or False: 99m-Technitium sulfur colloid scans
can be used to differentiate hepatic adenomas
from Focal Nodular Hyperplasia. Hepatic
adenomas demonstrate uptake while FNH does
not demonstrate uptake.
Which of the below is not a criteria in the Milan
Staging for Hepatocellular carcinoma?
1. Absence of macrovascular invasion
2. Single tumor less than or equal to 6 cm
3. Three or less tumors all less than or equal to
3 cm in size
4. All of the above are criteria
Which two agents are used for TACE?
1. Sorafenib, Cisplatin
2. Cisplatin, Doxorubicin
3. Sorafenib, Doxorbicin
4. Sorafenib alone
True or False: Sorafenib is the only systemic medical
therapy with proven efficacy for HCC therapy.
Solid Liver Lesions
Hepatic Adenoma
Focal Nodular
Hyperplasia
Hemangioma
Hepatocellular
Carcinoma
Solid Liver Lesions
Hepatic Adenoma
• Rare tumor of the liver, prevalence is 1%
• Associated with OCPs: 5-fold increase in risk in women on OCPs
for > 5 years
• Other causes: glycogen storage disease, steroid use
• Dx: MRI/CT – Bright uniform enhancement on arterial phase
• 99m-Technitium sulfur colloid scan – No uptake
• Tx:
• Asymptomatic <4-5 cm in women on OCPs  Stop OCP and
serial imaging at 6 and 12 months, if regression the
observation
• > 5 cm: Resect due to rupture and malignant degeneration
Solid Liver Lesions
Focal Nodular
Hyperplasia
•
•
•
•
•
•
2nd Most common benign neoplasm of the liver
Typically asymptomatic found incidentally
Risk of rupture and bleeding are rare
Not premalignant
Dx: MRI/CT: Peripheral enhancement with central stellate scar
Tx: Observation
Solid Liver Lesions
Hemangioma
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•
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•
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•
Most common benign solid neoplasm of the liver
Typically in patients 40-60 yrs of age
More common in women
Associated with use of OCPs
Typically asymptomatic, with incidental finding on imaging
Rarely rupture or bleed
Dx: MRI/CT: Pathognomic pattern of initial peripheral, nodular
enhancement with progressive infilling of the lesion on delayed
images
• Tagged RBC scan to confirm diagnosis, Avoid biopsy
• Tx: Observation unless symptomatic  enucleation or formal
hepatic resection
True or False: The gallbladder is different from the
GI tract in that it lacks a muscularis mucosa and
submucosa.
True or False: Gallbladder cancer is found
incidentally in 5% of patients following an elective
cholecystectomy.
A cholecystectomy is performed on a 70 yr old
woman for biliary colic. On final pathology, the
pathologist reports that the gallbladder cancer
that invades into the muscular layer of the
gallbladder and all margins are free. What T
Stage is this?
1. T1
2. T2
3. T3
4. T4
What is the best treatment plan for the prior
patient?
1. Take the patient back for a radical resection
with at minimum resection of 1-2 cm rim of
normal liver around the gallbladder fossa
with formal lymphadenectomy
2. Take the patient back for a radical resection
with an extend right hepatectomy
3. Tell the patient that this is an unexpected
finding however due to the depth you do
not need any further surgery.
4. None of the above
Gallbladder Cancer
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Rare malignancy with dismal outlook
5 yr survival < 5%
6-7,000 Cases annually
More common in women, 7th decade of life
70-90% of patients with gallbladder cancer also have stones
< 0.5% of patients with stones have gallbladder cancer, 20 yr risk of developing cancer
in patients with gallstones is < 0.5%
Larger stones > 3cm are associated with 10-fold increase in risk
Porcelain gallbladder is not necessarily associated with gallbladder cancer
Only 1% of gallbladder cancer is found incidentally following cholecystectomy
Clinical presentation: Varies: jaundice, weight loss, anorexia, increase abdominal girth,
hepatomegaly, ascites, palpable mass
LFTs elevated
Dx: US/CT/MRI:
Tx:Simple Cholecystectomy for T1 (lamina propria or muscular layer) tumors, without
lymphadenectomy (100% 5 yr survival)
T2 (Into perimuscular connective tissue) Radical cholecystectomy
T3/T4 tumors require radical cholecystectomy with at times formal resection of
segments IV/V or extended right hepatectomy segments IV-VIII (50% 5 yr survival)
Incidental finding following lap chole: T2 or higher with no evidence of mets: radical resection and
excision of port sites
Systemic chemo: 5-FU and Mitomycin C
A 60 yo man is evaluated for a newly diagnosed
cholangiocarcinoma of the distal CBD following a
work up for painless jaundice. The surgical
treatment of choice is?
1. Liver transplantation
2. Resection of the CBD with primary
anastomosis
3. This patient is not a surgical candidate
4. Pancreaticoduodenectomy
Bile Duct Carcinoma/Cholangiocarcinoma
• Incidence of Hilar Cholangiocarcinoma is 1/100,000 per year
• Increased incidence in male, and average age of 50-70
• Risk Factors: Primary sclerosing cholangitis, ulcerative colitis, choledochal cysts, biliary
tract infection, chemicals (nitrosamines, dioxin, asbestos, polychlorinated biphenyls)
• Classified based on location: Intrahepatic, Extrahepatic (upper third, middle third,
lower third of bile duct)
• Sx: painless jaundice, vs mild RUQ pain, pruritus, anorexia, malaise, weight loss,
cholangitis symptoms in 10-30%
• Tx: Surgical resection: Complete resection of tumor and adequate biliary drainage
• Hilar tumors: Neoadjuvant chemo 5-Fu followed by transplantation
• Intrahepatic tumors: Formal liver resection to negative margins
• Extrahepatic tumors: Distal tumors pancreaticoduodenectomy