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1 Benign Liver Masses Adil Abdalla, MBBS Creighton University-CHI Health August 25, 2018 Financial Disclosure Nothing to disclose Financial Disclosure 1
2 Objectives To assess patients with benign liver tumors To recognize the key radiologic findings To understand indications of intervention Case: A 41 yr old woman who is undergoing an US scan for infertility evaluation is noted to have a 3cm hyperechoic mass in the Lt lobe of the liver. She is otherwise well and has no risk factor or physical exam findings to suggest chronic liver disease. LFTs and AFP levels are normal. What is the most appropriate next step in the care of this patient? 1. Hepatic artery embolization. 2. Contrast-enhanced MRI. 3. No further treatment or testing. 4. Radiology-guided biopsy of the mass 5. Surgical resection of the mass 2
3 Primary Liver Lesions Liver lesions Cyst Abscess Neoplasm Malignant tumors Benign tumors Differential Diagnosis of Liver Mass? Is it an incidentaloma? Clinical circumstances -Age. -Sex. -OCP. -Chronic liver disease. -Travel -Extrahepatic malignancies. Imaging characteristics: -Modality. -Numbers, size, features 3
4 You have a liver mass!!! Having an answer: -Benign Vs malignant? -Primary Vs metastatic? Avoid extensive testing. Avoid unnecessary biopsy or surgery. Are the symptoms connected to the presence of a liver mass? Incidentalomas: Most Often Benign Benign lesion are common: Incidence 7-9 % Autopsy up to 20% of population Concerns of benign masses: Difficulty to differentiate form malignancy. Few have the potential for complications Important to recognize the features of the common benign liver tumors. 4
5 Benign Liver Masses Hepatocellular: Adenoma Focal nodular hyperplasia Nodular regenerative hyperplasia Regenerating nodules Mesenchymal: Hemangioma Angiolipoma Leiomyoma Infantile Hemangioendothelioma Benign Tumors Cholangiocellular: Bile duct adenoma Biliary cystadenoma Others: Hamartoma Teratoma Pancreatic rest Adrenal rest Adapted from Bahirwani et al, Aliment pharmacol Ther 2008 Benign Liver Masses Hemangioma 55% FNH 21% Adenoma 19% Others 5% Modified from 5
6 Accuracy of US, CT, MRI and Angiography in evaluating liver masses Accuracy Specificity Positive predictive value Negative predictive value Benign lesions 98.7% 100% 100% 98.6% HCC 99.6% 98.9% 99.3% 100% Metastatic lesion 99.1% 98.8% 96.9% 100% Torzilli et al, hepatology 1999 Hemangioma From: Tumors of the Liver and Intrahepatic Bile Ducts by Ishak 6
7 Hemangioma Most common benign tumor of the liver. Prevalence 3-20%. Size 1 20 cm Female: Male = 3-6:1, age Possible hormonal influence Arise from endothelial lining, well demarcated capsule. Symptoms very rare. Bleeding: exceedingly rare even with large lesions. No malignant transformation. Gandolfi et al, Gut 1991 Bahirwani et al, Aliment Pharmacol Ther 2008 Choi et la, J Clin gatroentrol Hemangioma, Radiological Findings US: Well demarcated hyperechoic mass. Unenhanced CT: Hypo-attenuated mass. Contrast-enhanced CT: Sequential opacification (peripheral to centripetal fill-in). Jay Heiken, Cancer Imaging 2007 Choi et al, J Clin Gatroentrol
8 MRI T1: early enhanced MRI T2: high intensity MRI T1: delayed enhanced Jay Heiken, Cancer Imaging 2007 Choi et al, J Clin Gatroentrol 2005 Hemangioma, Treatment Stop, leave it alone. If treatment is needed (extremely rare): -Enucleation. -Resection. -Embolization. -Hepatic irradiation. -Transplantation. Nghiem et al, AJR Am J Roentgenol Bahirwani et al, Aliment Pharmacol Ther 2008 Choi et al, J Clin Gatroentrol
9 Focal Nodular Hyperplasia From: Tumors of the Liver and Intrahepatic Bile Ducts by Ishak Focal Nodular Hyperplasia Second most common benign tumor of the liver. Prevalence 2.5-8%. Mainly in women, 3 rd -4 th decades. Female: Male = 8:1 Size: mostly 3-5 cm, near the surface. Asymptomatic (only ~10% with symptoms). Bahirwani et al, Aliment Pharmacol Ther 2008 Choi et al, J Clin Gatroentrol
10 Focal Nodular Hyperplasia, cont. Pathogenesis: focal congenital malformation of the hepatic vasculature. -Increase local blood flow. -Hyperplasia. No clear association with OCP (may accelerate growth). Complications: -Bleeding: extremely rare. -No malignant potential. Geders et al, Hepatology 1995 Shortell et al, Surg Gynecol Obstet Fukukura et al, J Hepatol 1998 FNH CT Pre: Homogenous and isoattenuating Arterial: Bright with hypodense central scarring Portal venous phase Characteristic (not present): radiating hypodense fibrous bands and septa that arise from the scar, seen in delayed films Delay phase Bahirwani et al, Aliment Pharmacol Ther
11 FNH MRI: Unenhanced T1: isointense, hypointense central scar T2: mass isointense, scar hyperintense Gadolinium-enhanced: mass enhancement, hypointense scar and fibrous septa Delayed postcontrast: mass isointense, scar hyperintense Jay Heiken, Cancer Imaging 2007 Focal Nodular Hyperplasia, Treatment: Asymptomatic patients, clear diagnosis: -No further treatment is necessary. -Close F/U during pregnancy. Symptomatic Patients: -Surgical resection. -Transarterial embolization. Choi et al, J Clin Gatroentrol
12 Hepatic Adenoma (HA) From: Tumors of the Liver and Intrahepatic Bile Ducts by Ishak Hepatic Adenoma (HA) Mostly in femals (>30 years), F: M=4:1 Mostly solitary, well circumscribed, round, uncapsulated (or pseudocapsule). Symptomatic in ~25-50% of patients. Annual incidence: -No OCP: per million -> 5 years OCP: per million Sherlock S, Gut 1975 Rooks et al, JAMA 1979 Bahirwani et al, Aliment Pharmacol Ther
13 Etiologic Factors and Diseases Associated with Adenoma Shrinks when OCP stopped From: Tumors of the Liver and Intrahepatic Bile Ducts by Ishak Hepatic Adenoma, Histology Proliferation of hepatocytes No portal tract or bile ductules. 13
14 Hepatic Adenoma, Potential for Serious Complications > 5 cm: -Rupture, malignancy. Increasing size: -Rupture, malignancy. If not decrease when OCP stopped -Malignancy. Risk of malignant transformation~ 10%. Mortele et al, Clin Liver Dis Bahirwani et al, Aliment Pharmacol Ther 2008 Choi et al, J Clin Gatroentrol 2005 Adenoma, US and CT US: variable and nonspecific: -Hypoechoic: simple -Hyperechoic: fat, hemorrhage -Mixed-echoic: fat, hemorrhage and necrosis. CT: heterogeneous due to fat, hemorrhage, and necrosis. -Contrast CT: enhancement, but less than FNH. -Portal phase: isodense. 14
15 Adenoma, MRI with Gadobenate Dimeglumine Arterial, hyperenhancement Venous, isoenhancement Delayed hepatobiliary Roberts, Mayo GI Board Review, 3 rd Ed Do We Need To Get Beta Catenin Staining for Adenoma? Normal (negative) Staining Positive Staining 15
16 Hepatic Adenoma, Treatment If < 5cm, stop OCP and F/U US. If has potential risk of complications or causing symptoms: -Surgical enucleation -Resection -Transplantaion -Arterial embolization. Grazioli et al, Radiographics 2001 Terkivatan et al, Arch Surg 2001 Choi et al, J Clin Gatroentrol 2005 Adenoma: Multiple Lesion Multiple Hepatic Adenomas Liver Adenomatosis (>10) Females > males Female =male Prolonged OCP GSD Normal LFT No OCP No GSD Possible high AP, GGT Treatment: -Stop any OCP, no pregnancy, US q 6 months. -Liver transplant: if risk factors present. Choi et al, J Clin Gatroentrol
17 Benign Masses with Atypical Imaging Features Technetium-99m labeled RBC scintigraphy: defect in the early scan, prolonged and persistent uptake on delay scans diagnostic for hemangioma. Scintigraphy with 99m TC-sulfur-colloid: high uptake by FNH, low or absent in adenoma. MRI with Gadobenate Dimeglumine (Gd-GOPA): FNH enhances on delayed scans, adenoma does not. Jay Heiken, Cancer Imaging 2007 Bahirwani et al, Aliment Pharmacol Ther 2008 Grazioli et al, Radiology 2005 Choi et al, J Clin Gatroentrol 2005 When Do We Need Liver Biopsy? Only in equivocal cases in which all imaging modalities fail to establish a firm diagnosis. Issues with biopsies: -Cost -Morbidity -Mortality -Seeding -Non-diagnostic 17
18 Algorithm, Liver Mass, Asymptomatic patient LFTs, viral serology, AFP, CBC Normal, nonspecific LFTs Abnormal Cystic US Solid Evaluation R/O HCC, met Simple cystic structure Yes No Dynamic CT or MRI Observe Further evaluation Modified from Choi et al, J Clin Gatroentrol 2005 Algorithm, Liver Mass, Asymptomatic patient Dynamic CT or MRI Characteristic imaging of hemangioma Yes No Observe Central scar on CT or MRI Yes No 99mTc scintigraphy Probable adenoma Characteristic increased uptake No Biopsy Yes Focal nodular hyperplasia Observe Resection Biopsy Modified from Choi et al, J Clin Gatroentrol
19 Conclusion Hemangioma: Peripheral to centripetal fill-in. FNH: Central scar. Adenoma: Sometimes difficult to diagnose. Risk for complications. Most patients die with a benign liver lesion rather than from it Case #1: A 41 yr old woman who is undergoing an US scan for infertility evaluation is noted to have a 3cm hyperechoic mass in the Lt lobe of the liver. She is otherwise well and has no risk factor or physical exam findings to suggest chronic liver disease. LFTs and AFP levels are normal. What is the most appropriate next step in the care of this patient? 1. Hepatic artery embolization. 2. Contrast-enhanced MRI. 3. No further treatment or testing. 4. Radiology-guided biopsy of the mass 5. Surgical resection of the mass 19
20 Case #2: A 35 yr old male bodybuilder was seen by PCP for RUQ fullness and dyspepsia. US showed a 6 cm hepatic lesion. He does not have any liver disease and basic labs are normal. MRI ordered by GI demonstrated a large, sub-capsular, homogeneously-enhancing mass in segment 2. Biopsy of the lesion confirmed a hepatic adenoma. Your recommendation would be? 1. Repeat imaging in 6 months. 2. Refer to UNMC for liver transplant evaluation. 3. No further treatment or testing. 4. Refer for surgical resection. 20
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