2. WORKUP ALGORYHM FOR LIVER
MASS
Mass on scan
History of prior
malignancy
No history of prior
malignancy
3. History
O 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
4. Physical examination and
investigation
O Sign of chronic liver stigmata or portal
hypertention
O Lymphadenopathy
O CBC with PLT , coagulogram , LFT
, hepatitis profile , tumor marker
O Ultrasound , CT scan , MRI
5. 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
6. Find needle biopsy
O commonly used to assist in the diagnosis
of a variety of liver lesions
O 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
7. Malignancy
O Metastatic liver tumors
O HCC
O Cholangiocarcinoma
O Rare tumor hepatoblastoma , Germ cell
tumor , Angiosarcoma , non-Hodgkin
lymphoma
8. Metastatic liver tumors
O Most common metastasis malignant
hepatic neoplasm
O The most common primaries :
breast, lung, colon
O History or findings of extrahepatic
malignancy menifestation
9. O U/S
O multiple and hypoechoic lesion with
Hypoechoic rims and internal heterogeneity
O 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
10.
11. HCC
O Most common primary malignancy liver tumor
O Risk factors for chronic liver disease , viral
hepatitis expect Hepatitis A ,metabolic liver
diseases , expose hepatotoxin
O Male : female > 4 : 1
O Clinical : vary such as asymptomatic
, abdominal pain , weight loss , paraneoplastic
syndrome
O Diagnosis : elevate AFP , CT scan
12. Investigation
O U/S
O round or oval mass with sharp, smooth
boundaries ,vary echogenicity
O CT scan
O Vascular enhancement hepatic
artery
O Liver cirrhotic change , ascites , splenomegaly
O Non contrast phase : hypodense mass
O Contrast phase : arterial phase rapid vascular
enhancement then venous phase
hypodense
13. 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
14.
15. 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,
16. 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
17. Hepatoblastoma
O most common liver cancer in children
O most commonly diagnosed during a
child's first three years of life
O usually present with an abdominal mass
O Patients with familial adenomatous
polyposis (FAP) are risk factor
O Often elevated AFP
O Treatment : Surgical resection, adjuvant
CMT, and liver transplantation
18. Germ cell tumor
O Germ cell tumor is a neoplasm derived
from germ cells.
O can be cancerous or non-cancerous
O Classification
O Germinomatous or seminomatous
O Non-germinomatous or non-seminomatous
19. Classification of
Germ cell tumor
O Germinomatous - 10% have elevated hCG
O Disgerminoma
O Seminoma
O Non-germinomatous
O Embryonal carcinoma
O yolk sac tumor - 100% secrete AFP
O Choriocarcinoma - 100% secrete hCG
O Teratoma
O Polyembryoma
O Gonadoblastoma
O Mixed
20. Germ cell tumor
O Compared to germinomatous
tumors, nongerminomatous tumors tend
to
O grow faster
O 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
21. Treatment of GCT
O 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.
22. Treatment of GCT
O 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)
23. Cholangiocarcinoma
O 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.
24. Cholangiocarcinoma
O 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.
27. Hemangiomas
O Most common benign liver tumors
O Female : male > 3 : 1
O Most are asymptomatic and no malignant
transformation
O 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
28. Hemangiomas
O U/S
O echogenic spot, well demarcated
O CT scan
O Early phase hypodense peripheral
enhancement
O Delay phase contrast fillling mass
O MRI
O High sens and spec , high acurracy
O Hyperdense in T2 and blood fill space
30. Focal nodular hyperplasia
O Most commonly in women and
asymptomatic
O No malignant transformation
O Gross : subcapsular lesion and central
scar
O Surgery indicate in symptomatic patient
31. Focal nodular hyperplasia
O U/S
O Nodule with varying echogenicity
O CT scan
O Non contrast phase low density mass
O contrast phase rapid enhance and
wash out with central scar
O MRI
O Hyperdense and central scar
34. 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
35. hepatic adenomas
O U/S
O often large and in the right lobe of the liver
and hyperechoic lesion
O CT scan
O Non-contrast scan
O well-demarcated low density mass
O Contrast-enhanced scans
O Rapid enhance and wash out same FNH
O No central scar difference from FNH
