Liver Neoplasms

Clinical Features

• The most common benign primary liver tumor.
• Occurrence in the general population ranges from 0.4-20%.
• Arises from endothelial cells that line blood vessels.
• Usually single and small.
• Well-demarcated capsule.
• Usually asymptomatic.
• RUQ pain, early satiety, and signs of portal hypertension may occur with giant haemangiomas.
• Small lesions do not require follow-up imaging or treatment.

Diagnosis

• USS: echogenic spot, well demarcated.
• CT scan: venous enhancement from periphery to center.
• MRI: high-intensity area.
• No need for fine needle aspiration for cytology (FNAC).
• The best diagnostic tests for detection include contrast-enhanced CT scan or MRI.

Treatment

• No need for treatment.
• Surgical resection for large tumor with associated symptoms.

Ultrasound Image of Hemangioma

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Ultrasound Image of Hemangioma

MRI of Hemangioma

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MRI of Hemangioma

• The second most common form of BLT.
• Benign nodule formation of normal liver tissue.
• Central stellate scar.
• More common in young women between the ages of 20 and 30 years.
• No relationship with sex hormones.
• Usually asymptomatic and don’t require treatment.
• May cause minimal pain.

Diagnosis:

• USS: Nodule with varying echogenicity.
• CT: Hypervascular mass with central scar.
• MRI: Iso or hypo intense lesion.
• FNAC: Normal hepatocytes and Kupffer cells with central core.

Treatment:

• No treatment necessary.
• If they are large, surgical removal is recommended to prevent the risk of rupture (but this is uncommon).

Clinical Features

• Are uncommon benign epithelial liver tumors in an otherwise normal-appearing liver.
• Composed of normal hepatocytes, no portal tract, central veins, or bile ducts.
• More common in women (20-44 years).
• Usually in the right lobe, typically solitary (70-80%).
• May be multiple in prolonged contraceptive use, glycogen storage diseases, and hepatic adenomatosis.
• Associated with oral contraceptive use.
• Usually asymptomatic but may have right upper quadrant (RUQ) pain.
• May present with rupture, haemorrhage, or malignant transformation (very rare).

Diagnosis

• USS: Filling defect.
• CT: Diffuse arterial enhancement.
• MRI: Hypo or hyper intense lesion.
• FNAC: May be needed.

Treatment

• Stop hormones or OCPs.
• Observe every 6 months for 2 years.
• If no regression then surgical excision.

• A rare parenchymatous liver disease.
• Characterized by diffuse benign transformation of the hepatic parenchyma into multiple small nodules (composed of regenerating hepatocytes).
• Usually asymptomatic but can lead to the development of non-cirrhotic portal hypertension and its complications - oesophageal variceal bleeding, hypersplenism, and ascites.
• Often associated with rheumatologic, autoimmune, hematologic, myeloproliferative disorders, immune deficiency states, and exposure to certain drugs and toxins.
• Diagnosis is made by liver biopsy and may require an open or laparoscopic biopsy since nodules can be missed.

• May be single or multiple.
• Polycystic liver disease is a hereditary condition that may be part of autosomal dominant polycystic kidney disease or may result from a different genetic mutation that leads solely to autosomal dominant polycystic liver disease.
• Patients are often asymptomatic.
• No specific management required.
• Hydatid cyst.

Simple Cysts

• Simple hepatic cysts are one of the commonest liver lesions, occurring in 2-7% of the population.
• Are solitary more than 50% of the time and asymptomatic more than 90% of the time.
• There may be a slight female predilection.
• Usually incidental findings.
• Size can range up to 20 cm, although most are less than 5 cm.
• Asymptomatic simple cysts require no intervention but should be observed.
• The symptoms are usually related to mass effect, causing pain in the right upper quadrant and occasionally early satiety.
• Nausea, vomiting, and abdominal distension may also be present.
• Rarely, intra-cystic hemorrhage and infection may develop.
• Treatment options for symptomatic cysts include: aspiration with or without sclerosants, laparoscopic unroofing, cystojejunostomy, and resection.

Simple cysts MRI

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Simple cysts MRI

Liver Cysts

• If multiple simple cysts are seen, consider polycystic liver disease.
• This is an inherited condition (autosomal dominant), often found in association with renal cysts.
• The majority of patients with polycystic liver disease remain asymptomatic with preserved liver function and do not require surgical intervention.
• Fenestration is a technique that combines aspiration with surgical deroofing of a cyst in a single procedure.

Complex Cysts

• Radiologically, internal septations are almost always seen in cystadenomas on contrast-enhanced CT or MRI.
• A biliary cystadenoma is an uncommon benign cystic neoplasm of the liver.
• Occur predominantly in middle-aged patients and are more common in women.
• Cystadenomas have irregular borders and a thick stromal layer, and calcifications and mural nodules can occasionally be seen in the walls.
• Variable clinical presentation depending on size and location of the cyst.
• Symptoms may include RUQ pain, obstructive jaundice, palpable liver edge or mass, increasing abdominal girth (large tumors), nausea, vomiting.
• There is no association with OCPs.
• Best treatment is surgical resection as 15% of tumors undergo malignant transformation.

Complex cysts MRI

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Complex cysts MRI

Incidence

• The most common primary liver cancer.
• HCC is the 5th commonest cancer in the world but the 3rd commonest cause of cancer death.
• Worldwide, it is responsible for 600,000 deaths annually.
• The average duration of illness in Nigeria from onset of symptoms to death is 16.3 weeks (approximately 4 months).
• Screening is therefore recommended in high-risk persons for HCC.

Risk Factors

The most important risk factor is cirrhosis from any cause:

1. Hepatitis B (integrates in host DNA)
2. Hepatitis C
3. Significant alcohol consumption
4. Non-alcoholic steatohepatitis
5. Autoimmune hepatitis
6. Genetic haemochromatosis
7. Primary biliary cirrhosis
8. α1-antitrypsin deficiency
9. Aflatoxin
10. Positive family history of HCC

Clinical Features

• Weight loss and RUQ pain (most common).
• Abdominal swelling/mass.
• Asymptomatic in early disease.
• Worsening of pre-existing chronic liver disease.
• Acute liver failure.

O/E:

• Signs of cirrhosis.
• Hard enlarged RUQ mass.
• Liver bruit.

Metastases

• Rest of the liver
• Portal vein
• Lymph nodes
• Lungs
• Bone
• Brain

Systemic Features

• Hypercalcemia
• Hypoglycemia
• Polycythemia

Laboratory Tests

• Lab features of liver cirrhosis may be present.
• AFP (Alpha-fetoprotein)
• Is a tumor marker for HCC.
• Serum AFP value >200ng/ml plus imaging evidence of focal hepatic lesion is highly specific for HCC diagnosis.
• Elevation seen in more than 70% of patients.

Diagnosis

• Clinical presentation
• Elevated AFP
• Abdominal USS
• Triple-phase helical CT scan
• Contrast-enhanced MRI
• The presence of arterial enhancement followed by washout has a sensitivity and specificity of 90% and 95%, respectively.
• Biopsy

Prognosis

• Tumor size
• Extra-hepatic spread
• Underlying liver disease
• Patient performance status

BCLC Classification, Staging and Treatment

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BCLC Classification, Staging and Treatment

Treatment Options for HCC

• Surgery
  1. Hepatic resection
  2. Liver transplantation
• Loco-Regional Therapies
  1. Percutaneous ethanol injection (PEI)
  2. Radiofrequency ablation (RFA)
  3. Microwave ablation
  4. Cryoablation
  5. High intensity focused ultrasound ablation
  6. Transarterial chemoembolization (TACE)
• Systemic chemotherapy (e.g., sorafenib) and radiotherapy
• Symptomatic treatment

Hepatic Resection

• Feasible for small tumors with preserved liver function (no jaundice or portal hypertension).
• The treatment of choice for HCC without background cirrhosis.
• Only 5%-15% of HCC patients are eligible (much less in Nigeria).
• Survival rates: 1 year 97%, 3 years 84%, and 5 years 26%-57%.
• Factors affecting recurrence include: tumor size, number of tumors, vascular invasion, and width of resection margin.

Liver Transplantation

• Performed in patients with non-resectable tumor but confined to the liver or in those with background cirrhosis & poor liver function.
• Only if single tumor ≤ 5cm or maximum of 3 tumors each < 3 cm in diameter.
• No evidence of large vessel invasion nor extra-hepatic spread.
• It requires lifelong immunosuppression, is expensive, and not widely available.

Local Ablation

• For non-resectable tumors.
• For patients not eligible for liver transplantation.
• Percutaneous Alcohol / Ethanol injection.
• Radiofrequency ablation.
• Transarterial chemo-embolization (TACE).
• Temporary measures only.

Percutaneous Ethanol Injection (PEI)

• Minimally invasive percutaneous treatment modality reserved for early HCC not eligible for hepatic resection or transplantation.
• Procedure consists of injection of absolute alcohol directly into tumor nodules under US or CT guidance. Two to 12 ml of alcohol is injected twice/week on an outpatient basis for 2-15 sessions.
• The best survival rates for PEI are obtained for tumors < 3cm and < 3 lesions.
• Other less utilized agents for injection are acetic acid and hot saline.

Ethanol Injection USS

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Ethanol Injection USS

Radiofrequency Ablation (RFA)

• RFA is the preferred ablative treatment for tumors 3-5 cm in diameter.
• It is superior to PEI, requires fewer sessions, has lower local recurrence, and longer overall as well as disease-free survival.
• Indications include:
  1. Very early stage HCC not amenable to resection.
  2. Early stage HCC not suitable for liver transplantation.
  3. Patients with waiting times > 3 months.

Radiofrequency Ablation

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Radiofrequency Ablation

Chemo-embolization

• Inject chemotherapeutic agent selectively in hepatic artery.
• Then inject an embolic agent.
• Embolization may be done alone (transarterial embolization) or combined with selective intra-arterial chemotherapy (TACE) using doxorubicin, mitomycin, or cisplatin and lipiodol (contrast media).
• To be effective, it should be limited to patients with preserved liver function, absence of extrahepatic spread or vascular invasion, and no significant cancer-related symptoms.
• The purpose of embolization is to induce ischemic tumor necrosis via acute (hepatic) arterial occlusion.

Chemo-embolization

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Chemo-embolization

Systemic Chemotherapy

• Sorafenib, an oral multikinase inhibitor, is recommended in patients with advanced HCC.
• Sorafenib is given at a dose of 400mg PO twice daily.
• Improved survival of 11 months has been demonstrated with sorafenib.
• Combination with doxorubicin IV 60mg/m² adds an extra 3 months to the survival.
• Erlotinib, an inhibitor of endothelial growth factor receptor signaling, has also shown promising results.

• Presents in young patients (5-35 years of age).
• Not related to cirrhosis.
• AFP is normal.
• CT shows typical stellate scar with radial septa showing persistent enhancement.

• The most common site for blood-borne metastases.
• Common primaries: colon, breast, lung, stomach, pancreas, and melanoma.
• Mild cholestatic picture (ALP, LDH) with preserved liver function.
• Diagnosis: imaging or FNAC.
• Treatment depends on the primary cancer.
• In some cases, resection or chemo-embolization is possible.