6/11/2015 Benign Focal Hepatic Lesions: Derek DuBay, MD Associate - - PDF document

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6/11/2015 Benign Focal Hepatic Lesions: Derek DuBay, MD Associate - - PDF document

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6/11/2015 Benign Focal Hepatic Lesions: Derek DuBay, MD Associate Professor of Surgery Liver Transplant and Hepatobiliary Surgery UAB Department of Surgery Focal Hepatic Lesions More Common 1. Hepatic Cyst 2. Hepatic Hemangiomas 3. Benign

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Benign Focal Hepatic Lesions:

Derek DuBay, MD Associate Professor of Surgery Liver Transplant and Hepatobiliary Surgery UAB Department of Surgery

  • 1. Hepatic Cyst
  • 2. Hepatic Hemangiomas
  • 3. Benign Focal Hepatic Lesions
  • Focal Nodular Hyperplasia
  • Adenoma
  • 4. Hepatic Abscess

Focal Hepatic Lesions

More Common Less Common

Case #1

  • 56yo BM with painless jaundice
  • PMHx: Obesity, DM2, CRI, polycystic kidney dz
  • Exam: Liver palpable below rt costal margin
  • US: Polycystic liver-kidney disease, cannot

readily visualize bile ducts

  • Dominant cyst 1800 cc aspirated. Jaundice

transiently resolved-recurred

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Liver Regeneration

Hepatic Cysts

MRI Venous Phase MRI T2 ERCP Postop CT Postop ERCP

Hepatic Cysts

  • Simple Cysts: 5% Incidence F>>M
  • Polycystic Liver Disease
  • Neoplastic Cysts

 Biliary Cystadenoma/ Cystadenocarcinoma

  • Diagnosis: US, CT Scan, MRI
  • Treatment

 Lap. fenestration of symptomatic simple cysts  Resection of neoplastic cysts

Hansman MF et al. Am J Surg 2001; 181:404 Lewis WD et al. Arch Surg 1998; 123:563

Symptomatic Giant Simple Hepatic Cyst

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Symptomatic Giant Simple Hepatic Cyst

Adult Polycystic Liver Disease

  • More common in women.
  • May or may not be associated with

polycystic kidney disease.

  • Microscopically: cysts are lined with simple

biliary epithelium without communication to the biliary tract.

Adult Polycystic Liver Disease

  • Symptoms

 Usually asymptomatic.  If symptomatic, symptoms are usually related to

mass effect.

  • Complications

 Common: infection or hemorrhage into cyst.  Rare: rupture, portal hypertension, vena cava

compression, conversion to malignancy, or hepatic insufficiency.

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Adult Polycystic Liver Disease

Type Size Number Location Type I Large (10 cm) Few Superficial Type II Medium sized (5-7 cm) Multiple Scattered Type III Small-to-medium sized (<5 cm) Multiple Scattered

Polycystic Liver Disease

  • Treatment

 Type I and II  Cystic wall resection.  Some cases may require hepatic resection.  Type III  Partial hepatectomy if two adjacent liver segments can be spared.  Some cases may require liver transplantation.

Case #2

  • 42yo WF with progressive RUQ fullness/

discomfort, especially when bending over

  • PMHx: none
  • Exam: Liver palpable below rt costal margin
  • Labs: AFP, CEA, CA19-9 wnl
  • Dx with 9cm cavernous hemangioma 7 years
  • ago. Progressive increase to 16cm correlating

with symptoms.

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Liver Regeneration

Hepatic Hemangioma

CT Arterial Phase CT Venous Phase

Liver Regeneration

Hepatic Hemangioma

CT MRI

Hepatic Hemangioma

  • 2-7% Incidence F>>M; 1/3 multiple
  • >5cm “Giant Hemangioma”
  • Change in size common
  • Symptoms: fullness, discomfort, early satiety
  • Diagnosis: MRI > CT, US, tagged RBC scan
  • Treatment

 Observation  Enucleate Giant Symptomatic Hemangioma

Pietrabissa A et al. Br J Surg 1996; 83:915 Terkivatan T et al. Br J Surg 2002; 89:1240

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Hepatic Hemangioma

  • Kasabach-Merritt Syndrome

 Rare complication.  Coagulopathy  Intervascular coagulation, clotting, and fibrinolysis in the hemangioma.  Can become systemic.

Case #3

  • 29yo HF Air Force complains of RUQ softball-

sized mass that moves/becomes uncomfortable during physical activity.

  • PMHx: none (not on OCP)
  • Exam: RUQ palpable mass
  • Labs: AFP, CEA, CA 19-9 wnl
  • Imaging

 US: 12cm solid mass  CT: Adenoma vs. FNH  Radionucleotide study: No defect  MRI: central scar

Liver Regeneration

Benign Focal Hepatic Lesions

Focal Nodular Hyperplasia

CT Arterial Phase CT Venous Phase CT Coronal View Intraoperative View

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Focal Nodular Hyperplasia

  • Hyperplastic response to a congenital

arterial malformation.

  • Macroscopically: Well-circumscribed,

nonencapsulated, globular and lobulated tumor.

  • Microscopically: benign-appearing

hepatocytes with fibrous septae radiating from a central scar.

Benign Focal Hepatic Lesions

Focal Nodular Hyperplasia

  • Incidence?
  • F>>M ?hormonal influence?
  • Asymptomatic unless large
  • Symptoms: fullness, discomfort, early satiety
  • Diagnosis: MRI (EOVIST), CT
  • Treatment

 Observation  Embolization of symptomatic lesions

Mathieu D et al. Gastro 2000; 118:560 Nagorney DM et al. World J Surg 1995; 19:13

Case #4

  • 21yo WF with acute RUQ pain
  • PMHx: Aplastic anemia, CNI-induced renal

failure, morbid obesity

  • Meds: Tacrolimus, high dose OCP
  • Exam: Peritonitis with shock
  • Imaging

 Outside imaging: “AVM”  CT: Ruptured hepatic lesion

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Ruptured Hepatic Adenoma Postoperative Image

Benign Focal Hepatic Lesions

Hepatic Adenoma

Benign Focal Hepatic Lesions

Hepatic Adenoma

  • Strong hormonal influence
  • 4 per 100,000 females using OCPs
  • Risk factors Obesity, glycogen storage disease,

DM, hemachromatosis, anabolic steroids

  • Risks:

 RUPTURE (higher risk: exophytic lesions, >5cm)  MALIGNANT DEGENERATION (up to 20% reported in

adenomas >4cm)

Barthelemes L et al. HPB Surg 2005; 7:186 Terkivatan T et al. Arch Surg 2001; 136:1033

Benign Focal Hepatic Lesions

Hepatic Adenoma

Genetics

  • ~50% HNF1α mutations

 Low association with HCC  Overall benign clinical course

  • ~15% β-Catenin Alternations

 Nuclear translocation  High association with HCC

  • ~35% no alterations in HNF1α or β-Catenin

 Benign course

Zucman-Rossi J et al. Hepatology 2006; 43(3):515-24 Monga SP et al. Cancer Res 2002; 62:2064-71

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Benign Focal Hepatic Lesions

Hepatic Adenoma

  • Diagnosis: EOVIST MRI, CT
  • Treatment:

 Stop OCPs  Weight loss  Ablation  Resection

  • Special Problem: Pregnancy

Barthelemes L et al. HPB Surg 2005; 7:186 Terkivatan T et al. Arch Surg 2001; 136:1033

Hepatic Adenoma Benign Focal Hepatic Lesions

Hepatic Adenoma

Diagnostic Imaging

  • Typically have fat present

 MRI in/ out of phase imaging

  • No bile ductules

 Non-enhancing on EOVIST imaging

  • Few if any Kupffer cells

 Photopenic on liver spleen scan

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Benign Focal Hepatic Lesions

EOVIST MRI: Adenoma vs. FNH

FNH Adenoma Arterial Phase Venous Phase Hepatobiliary Phase

Case #5

  • 56yo WF with symptomatic cholelithiasis, 2

days s/p lap chole with bile leak

  • PMHx: HTN
  • SHx: Works as scrub tech for the surgeon who

did the lap chole

  • Exam: RUQ peritonitis, JP bilious
  • Labs: WBC 21k, Tbili 2, ALP 140
  • US: RUQ fluid collection consistent with a
  • biloma. No biliary ductal dilatation.

Hepatic Abscess

Divided Rt Hepatic Artery Hepatic Abscess Hepatic Abscess Drain 5 Months Later

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Hepatic Abscess

  • Formerly due to perforated appendicitis/

diverticulitis

  • Current epidemiology:
  • Diagnosis: CT Scan
  • Treatment

 Treat Underlying Condition  Appropriate Antibiotics  Drainage for Focal Abscess  Amebic: Metronidazole

Hansen PS et al. APMIS 1998; 106:396 Huang CJ et al. Ann Surg 1996; 223:600

UAB Liver Tumor Clinic

Referrals: 205 996 5970 (phone) 205 996 9037 (fax) 800 UAB MIST

Question 1

  • A 35 year old woman who has been on oral contraceptives for 10

years presents with a 6 month history of right upper quadrant

  • discomfort. CT reveals a 6.5cm tumor in segment IV.

Complications of this tumor include which of the following?

  • A. 5% lifetime risk of malignant transformation
  • B. 90% to 95% risk of spontaneous rupture and intraperitoneal

hemorrhage

  • C. 30% risk of spontaneous thrombosis
  • D. Compression of the portal vein leading to portal hypertension
  • E. Compression of the common hepatic duct, leading to
  • bstructive jaundice
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Question 1

  • A 35 year old woman who has been on oral contraceptives for 10

years presents with a 6 month history of right upper quadrant

  • discomfort. CT reveals a 6.5cm tumor in segment IV.

Complications of this tumor include which of the following?

  • A. 5% lifetime risk of malignant transformation
  • B. 90% to 95% risk of spontaneous rupture and intraperitoneal

hemorrhage

  • C. 30% risk of spontaneous thrombosis
  • D. Compression of the portal vein leading to portal hypertension
  • E. Compression of the common hepatic duct, leading to
  • bstructive jaundice

Question 2

  • A 63 year old female with a history of unresectable

cholangiocarcinoma and biliary stenting presents with a one week history of fevers, chills and jaundice. CT reveals multiple rim- enhancing fluid collections in the liver. What is the most likely diagnosis?

  • A. Echinococcal cysts
  • B. MRSA bacteremia
  • C. Pyogenic liver abscess
  • D. Polycystic liver disease

Question 2

  • A 63 year old female with a history of unresectable

cholangiocarcinoma and biliary stenting presents with a one week history of fevers, chills and jaundice. CT reveals multiple rim- enhancing fluid collections in the liver. What is the most likely diagnosis?

  • A. Echinococcal cysts
  • B. MRSA bacteremia
  • C. Pyogenic liver abscess
  • D. Polycystic liver disease
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Question 3

  • Which of the following organisms is the most common cause of

pyogenic liver abscess?

  • A. Echinococcus
  • B. Schistosoma mansoni
  • C. Escherichia coli
  • D. Entamoeba hystolitica

Question 3

  • Which of the following organisms is the most common cause of

pyogenic liver abscess?

  • A. Echinococcus
  • B. Schistosoma mansoni
  • C. Escherichia coli
  • D. Entamoeba hystolitica

Question 3

  • A 35 year old asymptomatic female has been diagnosed with focal

nodular hyperplasia (FNH) of her liver. How should you advise her to proceed with treatment?

  • A. She will likely require surgery
  • B. She may be observed
  • C. She should be referred to a medical oncologist for

chemotherapy

  • D. She should be referred to a radiation oncologist
  • E. She should receive an oral TNF alpha inhibitor
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Question 3

  • A 35 year old asymptomatic female has been diagnosed with focal

nodular hyperplasia (FNH) of her liver. How should you advise her to proceed with treatment?

  • A. She will likely require surgery
  • B. She may be observed
  • C. She should be referred to a medical oncologist for

chemotherapy

  • D. She should be referred to a radiation oncologist
  • E. She should receive an oral TNF alpha inhibitor