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GS44 General Surgery and Thoracic Surgery
Liver Toronto Notes 2019 BENIGN LIVER NEOPLASMS
Hemangioma (cavernous)
• pathogenesis:mostcommonbenignhepatictumour;resultsfrommalformationofangioblasticfetal tissue
• riskfactors:F:M=3:1 • clinical features
■ usually small and asymptomatic
■ consumptive coagulopathy if giant (in children) • investigations
■ contrast CT (well-demarcated hypodense mass with peripheral enhancement on arterial phase with centripetal filling on delayed phases), U/S (homogenous hyperechoic mass), MRI
■ avoid biopsy: may result in hemorrhage • treatment
■ usually none
Focal Nodular Hyperplasia
• pathogenesis:unclear,mayberegenerativeresponsetohyperperfusionfromanomalousarteriesat centre of nodule
• riskfactors:female,age20-50
• clinicalfeatures:asymptomatic,rarelygrowsorbleeds,andnomalignantpotential
• investigations:centralstellatescaronCTscan,MRI,biopsymayberequired
• treatment:maybedifficulttodistinguishfromadenoma/fibrolamellarHCC(malignantpotential)
■ if confirmed to be FNH → no treatment required
Adenoma
• definition:benignglandularepithelialtumour
• riskfactors:female,age20-50,estrogen(OCP,pregnancy),obesity,andtype1glycogenstoragedisease • clinicalfeatures:asymptomatic,25%presentwithRUQpainormass,maypresentwithbleeding
• investigations:CT(well-demarcatedmasses,oftenheterogeneousenhancementonarterialphase,
isodense on venous phase without washout of contrast), U/S, MRI, biopsy often needed • treatment
■ stop anabolic steroids or OCP
■ excise, especially if large (>5 cm), due to risk of transformation to HCC and spontaneous rupture/
hemorrhage
MALIGNANT LIVER NEOPLASMS
Primary
• mostcommonlyhepatocellularcarcinoma(HCC)andcholangiocarinomas
Neoplasms
Differential Diagnosis of Metastatic Liver Mass
Some GU Cancers Produce Bumpy Lumps Stomach
GenitoUrinary cancers (kidney, ovary, uterus) Colon
Pancreas Breast Lung
Staging Criteria for Hepatocellular Carcinoma
Milan Criteria*
UCSF Criteria*
Toronto Criteria*
1 tumour ≤5 cm
Up to 3 tumours each ≤3 cm
1 tumour ≤6.5 cm
Up to 3 tumours each ≤4.5 cm, total diameter ≤8 cm
No tumour size of number restrictions
No systemic symptoms Not poorly differentiated
*Each criteria assumes no extrahepatic and no macrovascular invasion
Child-Turcotte-Pugh Score (Prognosis of Chronic Liver Disease/Cirrhosis, Including Post-Operatively)
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•
•
•
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othersincludeangiosarcoma,hepatoblastoma,andhemangioendothelioma epidemiology:3rdleadingcauseofcancerdeathworldwide,9thinUnitedStates;highestinAfrica, China, Taiwan
riskfactors
■ chronic liver inflammation: cirrhosis from any cause, chronic hepatitis B (inherently oncogenic) and hepatitis C, hemochromatosis, α1-antitrypsin deficiency, and non-alcoholic steatohepatitis
■ medications: OCPs (3x increased risk), steroids
■ smoking, alcohol, betel nuts
■ chemical carcinogens: aflatoxin, microcystin, and vinyl chloride (associated with angiosarcoma)
clinicalfeatures
■ RUQ discomfort and right shoulder pain
■ jaundice, weakness, weight loss, and ± fever (if central tumour necrosis)
■ hepatomegaly, bruit, and hepatic friction rub
■ ascites with blood (sudden intra-abdominal hemorrhage)
■ paraneoplastic syndromes: hypoglycemia, hypercalcemia, erythrocytosis, and watery diarrhea ■ metastasis: lung, bone, brain, and peritoneal seeding
investigations
■ elevated ALP, bilirubin, and α-fetoprotein (80% of patients)
■ U/S (poorly-defined margins with internal echos), triphasic CT (enhancement on arterial phase and
washout on portal venous phase), and MRI
■ liver enzyme and liver function tests: AST, ALT, ALP, bilirubin, albumin, and INR
treatment
■ cirrhosis is a relative contraindication to tumour resection due to decreased hepatic reserve ■ surgical: resection (10% of patients have resectable tumours)
■ liver transplant; may use bridging therapy while awaiting transplant
◆ absolute contraindications: extrahepatic disease and vascular invasion
◆ relative contraindications: dependent on liver transplant protocol based on staging criteria
followed by transplant centre
Albumin (g/L) Ascites
Bilirubin (μmol/L)
(mg/dL)
Coagulation (INR)
Hepatic Encephalopathy
Points
5-6 7-9 10-15
1 Point
>35 Absent
<34 <2.0 <1.7 None
Class
A B C
2 Points
28-35
Easily controlled
34-51
2.0-3.0
1.7-2.3
Minimal (Grade I-II)
One Yr Survival
100% 81% 45%
3 Points
<28
Poorly controlled
>51
>3.0
>2.3
Advanced (Grade III-IV)
Two Yr Survival
85% 57% 35%