Liver Tumors

Dr Rajendra Desai
MS, DNB, MCh (GI Surgery), FRCS
Dept of General Surgery
Shadan Institute of Medical Sciences

WORKUP ALGORITHM FOR LIVER

MASS
Mass on scan

History of prior
malignancy

No history of prior
malignancy

History

O Symptoms - abdominal pain/ pressure

effect,fever,anorexia,weight loss

O Patient characteristics (age, gender,

use of OCP, risk factors for chronic liver

disease )

O History or findings of extra-hepatic

malignancy

Physical examination and inv

estigation
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

O Study show accurate preoperative

evaluation of liver mass lesions witho

ut fine-needle biopsy about 98% by h
istory and lab (including tumor mark
ers) and a variety of imaging studies

Fine needle biopsy

O commonly used to assist in the

diagnosis of a variety of liver lesions

O Disadvantage

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

Malignancy
O Metastatic liver tumors
O HCC

O Cholangiocarcinoma

O Rare tumor hepatoblastoma ,

Germ cell tumor , Angiosarcoma , no

n-Hodgkin lymphoma

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

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 moderate

ly high signal on T2-weighted images

Hepatocellular
Carcinoma

Epidemiology
OHepatocellular carcinoma is the 5th most common

malignancy worldwide & the 3rd cause of cancer rel

ated death with male-to-female ratio

5:1 in Asia
2:1 in the United States

OTumor incidence varies significantly, depending on

geographical location.

OHCC

with age.
O
O

53 years in Asia
67 years in the United States.

Incidence of HCC

Etiology

Hepatitis B
-increase risk 100 -200 fold
- 90% of HCC are positive for (HBs Ag)

Hepatitis C

Cirrhosis
- 70% of HCC arise on top of cirrhosis

Toxins

Autoimmune hepatitis
States of insulin resistance- Overweight in males Diabetes
mellitus

-Alcohol

-Tobacco

- Aflatoxins

Incidence according to
etiology

Abbreviations: WD, Wilsons disease; PBC, primary biliary cirrhosis, HH,

hereditary hemochromatosis; HBV, hepatitis B virus infection; HCV, hepatitis C
virus infection.

Signs & symptoms

O Nonspecific symptoms
O
O
O
O

abdominal pain
Fever, chills
anorexia, weight loss
jaundice

O Physical findings
O
O
O
O

abdominal mass in one third

splenomegaly
ascites
abdominal tenderness

(a)

Guidlines

which patients are at high risk for the

development of HCC and should be offered surve
illance

(b) what investigations are required to make a

definite
diagnosis

(c) which treatment modality is most appropriate

in a given clinical context.

Guidlines

(a) which patients are at high risk for the

development of HCC & should be offered surveillance

- M &F with established cirrhosis due to HBV and/ or HCV, particularly

those with ongoing viral replication

- M &F with established cirrhosis due to genetic haemochromatosis

- M with alcohol related cirrhosis who are abstinent from alcohol or likely
to comply with treatment
- M with primary biliary cirrhosis

Abdominal US and AFP/ 6 months

Diagnosis
(b) what investigations are required to make a definite diagnosis
AFP produced by 70% of HCC
> 400ng/ml
AFP over time

1)

2)

Imaging
- focal lesion in the liver of a patient with cirrhosis is highly likely to
be HCC
- Spiral CT of the liver
- MRI with contrast enhancement

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

Diagnosis

3)

Biopsy is rarely required for

seeding
diagnosis
in 13%.
Biopsy of potentially operable lesions
should be avoided where possible

Diagnosis
Cirrhosis +
Mass > 2 cm

Raised
AFP

Normal
AFP

Confirmed
diagnosis

CT, MRI

Diagnosis
Cirrhosis + Mass < 2 cm

Normal AFP

Raised AFP

CT, MRI
Assess for surgery

Confirme
d
diagnosis

lesion by
exam
FNAC or
biopsy

Treatment (Surgery)

O The only proven potentially curative therapy for

HCC

O Hepatic resection or liver transplantation

O Patients with single small HCC (5 cm) or up to

three lesions 3 cm

O Involvement of large vessels (portal vein, Inferior

vena cava) doesnt automatically militate against a

resection; especially in fibrolamellar histology

O No

randomised controlled trials comparing the

outcome of surgical resection and liver transplanta
tion for HCC.

Treatment (Surgery)
O Hepatic resection should be considered in HCC and a

non-cirrhotic liver (including fibrolamellar variant)

O Resection

can be carried out in highly selected

patients with cirrhosis and well preserved hepatic fu
nction (Child-Pugh A) who are unsuitable for liver tra
nsplantation. It carries a high risk of postoperative d
ecompensation.

O Perioperative mortality in experienced centres

remains between 6% and 20% depending on the exte

nt of the resection and the severity of preoperative l
iver impairment.

O The majority of early mortality is due to liver failure.

Treatment (Surgery)
O Recurrence rates of 5060% after 5 years after

resection are usual (intrahepatic)

O Liver transplantation should be considered in any

patient with cirrhosis

O Patients with replicating HBV/ HCV had a worse

outlook due to recurrence and were previously not c

onsidered candidates for transplantation.

O Effective antiviral therapy is now available and

patients with small HCC, should be assessed for tran

splantation

Treatment (non-Surgical)
should only be used where surgical therapy is not
possible.
1) Percutaneous ethanol injection (PEI)

O has been shown to produce necrosis of small HCC.

O It is best suited to peripheral lesions, less than 3

cm in diameter

2) Radiofrequency ablation (RFA)

O High frequency ultrasound to generate heat

O good alternative ablative therapy

O No survival advantage
O Useful for tumor control in patients awaiting liver

transplant

Treatment (non-Surgical)
3) Cryotherapy
O

intraoperatively to ablate small solitary tumors outside a

planned resection in patients with bilobar disease

4) Chemoembolisation
O

O
O
O
O

Concurrent
administration
of
hepatic
arterial
chemotherapy (doxirubicin) with embolization of hepatic
artery
Produce tumour necrosis in 50% of patients

Effective therapy for pain or bleeding from HCC

Affect survival in highly selected patients with good liver

reserve
Complications: (pain, fever and hepatic decompensation)

Treatment (non-Surgical)
5) Systemic chemotherapy

O very limited role in the treatment of HCC with poor

esponse rate
O Best single agent is doxorubicin (RR: 10- 20%)
O Combination chemotherapy didnt
response but
survival
O should only be offered in the context of clinical trials

6) Hormonal therapy

- Nolvadex, stilbestrol and flutamide

7) Interferon-alfa
8) retinoids and adaptive immunotherapy (adjuvant)

Selection of agents for targeted therapy in HCC

Name

Target

Gefitinib
Erlotinib
Lapatanib
Cetuximab
Bevacizumab
Sorafenib (Nexavar)
Sunitinib
Vatalanib
Cediranib
Rapamycin
Everolimus
Bortezomib (Velcade)

EGFR
EGFR
EGFR
EGFR
VEGF
Raf1, B-Raf, VEGFR , PDGFR
PDGFR, VEGFR, c-KIT, FLT-3
VEGFR, PDGFR, c-KIT
VEGFR
mTOR (mammalian target of
rapamycin)

mTOR
Proteasome

Targeting angiogenesis for HCC

O HCC is one of the most vascular tumor
O Major driver of angiogenesis is vascular

endothelial growth factor (VEGF)

O Sorafenib and bevacezumab target VEGF in HCC

O Bevacizumzb: Median OS of approximately 12

months
O Bevacizumab + erlotinib: Medain OS 15-17

months

HCC (Whats ahead?)

O Combinations therapy
O Bevacizumzb or Sorafenib + Erlotinib
O Sorafenib + mTOR inhibitor

O Early sequential therapies

Fibrolamellar hepatocellular
carcinoma (FCHC)
O FHCC is a rare form ofhepatocellular
O Approximately 200 new cases are

diagnosed worldwide each year.

O FHCC often does not produceAFP
O However, FHCC is elevatedNeurotensin
and Vitamin B12 Binding protein levels.
O FHCC generally occurs in young adults
without underlyingcirrhosis.
O FHCC grows slowly and has better
prognosis,

Fibrolamellar hepatocellular
carcinoma (FCHC)
O The histopathology of FHCC is

characterized by laminated fibrous la

yers, interspersed between the tumo
r cells.
O FHCC has a highresectability rate

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 : Surgicalresection,adjuvant
CMT, andliver transplantation

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

Cholangiocarcinoma
O It has an annualincidencerate of

12 cases per 100,000 in the

Western world
O rates of cholangiocarcinoma have
been rising worldwide over the past
several decades.

Cholangiocarcinoma
O It may be suspected in a patient

withobstructive 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
obtainbiopsiesand to place stentsor
perform other interventions to relieve bili
ary obstruction.

Benign
O Hemangiomas

O Focal nodular hyperplasia

O hepatic adenomas
O Simple cysts

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 org
ans or intermittent thrombosis
O Surgery may be considered an option if
the patient is symptomatic
O Gross : round pink or red capsule

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

Peripheral nodular enhancement

follow by gradual centripetal
enhancement

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

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

Homogeneous
Isoattenuation

Immediate
Intense enhancement
Central scar 2/3

FNH & Hemangioma

Symptomatic :
Surgery

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

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

HA

Thank you