Resident Teaching Conference:

Transcription

1 Resident Teaching Conference: Evaluation of the Dreaded Liver Mass May 6, 2011 Sunil Geevarghese, MD, HS 00 Matt Landman, MD

2 Anatomy Overview Couinaud anatomy Resection nomenclature Functional Assessment Child Class MELD Physical Exam Imaging/Cases

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4 Functional Assessment of Liver Labs: Tbili, INR, Albumin What is MELD? MELD = 3.8[Ln serum bilirubin (mg/dl)] [Ln INR] + 9.6[Ln serum creatinine (mg/dl)] + 6.4

5 Child-Pugh-Turcotte

6 Physical Exam Findings of Cirrhosis 1. Ascites 2. Encephalopathy 3. Spontaneous bacterial peritonitis 4. Variceal hemorrhage 5. Palmar erythema 6. Muscle wasting 7. Jaundice 8. Ecchymosis 9. Dupuytren s contracture 10. Fetor hepaticus 11. Glossitis 12. Spider angiomata 13. Gynecomastia 14. Hemorrhoids 15. Itching 16. Edema 17. Fatigue 18. Asterixis 19. Testicular atrophy 20. Terry s nails 21. Clubbing 22. Muehrcke s lines 23. Caput medusa

7 Imaging

8 Imaging Triple-phase contrasted CT: FNH: central scar; hyperintense on arterial phase and isointense on portal venous phase Hepatic adenoma: well-demarcated; isointense with peripheral enhancement Hemangioma: fills with contrast from outside to inside over several minutes HCC: hyperintense on arterial phase and hypointense on hepatic venous phase

9 FNH vs. Adenoma Sulfur colloid scan uptake into adenoma is decreased due to decreased Kupffer cells; preserved in FNH Adenoma is photopenic relative to surrounding liver MRI Adenoma: hyperintense on T1-weighted images due to fat or glycogen FNH central scar with high signal intensity on T2-weighted images early lesion contrast enhancement with delayed scar enhancement on T1-weighted images Eovist is excreted in the biliary tree so adenomas (with lack biliary structures) do not take up the contrast

10 Cystic lesions Simple cysts Polycystic liver disease Cystadenoma (Ca in 15%) After CT, U/S to clarify: Septations Mural nodularity Hypervascularity

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12 Cyst vs. Cystadenoma Hemorrhage within cyst can lead to difficulty in distinguishing MRI demonstrates well-defined homogeneous lesions with low signal intensity on T1-weighted images with high signal intensity on T2-weighted images: simple cysts do not enhance w gadolinium Aspiration is not needed for diagnosis Symptomatic cysts (early satiety, biliary obstruction) can be treated with laparoscopic fenestration (after frozen section to r/o cystadenoma)

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16 Polycystic Liver Disease Occurs in patients with PCKD. Over 50% of these patients have multiple hepatic cysts by age 60. The form distinct from PCKD is less common and is not associated with cerebral aneurysm. Most are asymptomatic. Rare symptoms include pain, hemorrhage and cyst infection. Fenestration or resection may be required.

17 Hemangioma Multiple vascular channels supported by collagenous walls lined by a single layer of endothelial cells Issues: Compression and consumptive coagulopathy Resection unnecessary: enucleation is preferable

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19 Cholangiocarcinoma 3 subtypes: sclerosing, nodular and papillary Nodular (intrahepatic liver mass) is rare (<20%) Though mostly sporadic, risk factors include: PSC Choledochal cysts Oriental cholangiohepatitis Biliary parasites such as Chlonorchis

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22 Hepatocellular Carcinoma 4 th leading cancer death worldwide and 3 rd most common among men Associated with hepatitis B and C: average year lag time between virus and cirrhosis/hcc Presentation and therefore mgmt varies: non-cirrhotic: resection compensated cirrhotic: resection vs. tx with TACE decompensated cirrhotic: tx with TACE or palliation with TACE alone or Sorafenib

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24 Cases

25 Case #1 69 y/o M CC to PCP: stomach problems HPI: Early satiety slowly over 4-5 months Mild nausea Bloating Urine orange 17lb unintentional weight loss in 5 months No changes in stool color, heartburn or jaundice

26 Case #1 Physical Exam Hepatomegaly ~8-10cm below costal margin Mild right upper quadrant tenderness Otherwise negative

27 Case #1 Next step? Labs: Tbili AST AlkP ALT - 96

28 Case #1 Next step? Imaging Options? CT Scan ( )

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36 CT Scan dilatation of the intrahepatic bile ducts and the common bile duct is dilated to 1.7 cm in diameter. The dilatation ends abruptly in the head of the pancreas and below this the duct appears to contain water dense material. Below this the common bile duct is again seen and at this level is of normal caliber. It can be traced to the duodenum. Next Step?

37 Case #1 EUS tracing the bile duct up towards the hilum of the liver, I appreciated a filling defect of heterogenous echotexture in the mid-portion of the common bile duct. Above this significant dilation of the duct was noted at 17mm. This filling defect was not calcified (as a stone would appear) but it was not uniformly hypoechoic as a mass typically is). There was an approximately 1.5cm lymph node in the periportal position Other Steps?

38 Case #1 FNA Bile Duct FNA atypical ductal cells Periportal Lymph Node negative for malignancy

39 Case #1 ERCP This demonstrated a diffusely dilated common hepatic duct and upper portion of the common bile duct, with a diameter of approximately 15 mm, as well as diffuse intrahepatic biliary dilation. There was an abrupt cutoff of contrast in the midportion of the bile duct Stents x 2 Bile Duct Brushings Rare atypical but degenerated ductal cells

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44 Case #1 Removal of stents 1 week later Repeat ERCP mild intrahepatic biliary dilation as well as diffuse dilation of the upper and middle thirds of the common bile duct, approximately 14 mm in diameter. There appeared to be a stricture in the distal portion of the duct, followed by a return to a normal caliber common bile duct just below the stricture and above the level of the papilla. Pathology Atypical cells suspicious for malinancy

45 Case #1 Cholangitis resolved Labs: CA CEA 3.5 Surgical consultation Plan?

46 Case #1 Operation Exploratory laparotomy Tru-Cut liver biopsy pancreaticoduodenectomy with end-to-side pancreaticojejunostomy, hepaticojejunostomy x2 (accessory right hepatic duct and common hepatic duct), antecolic gastrojejunostomy Stamm catheter gastrojejunostomy

47 Case #1 Pathology: MODERATELY DIFFERENTIATED ADENOCARCINOMA OF THE COMMON BILE DUCT, 4.3 CM IN GREATEST DIMENSION, WITH DIRECT EXTENSION INTO THE PANCREATIC PARENCHYMA, AND WITH INVOLVEMENT OF THE AMPULLA OF VATER. PERINEURAL INVASION IS PRESENT; GALLBLADDER WITH REACTIVE CHANGES, NEGATIVE FOR MALIGNANCY; 16 REGIONAL LYMPH NODES NEGATIVE FOR MALIGNANCY (0/16); ALL SURGICAL MARGINS NEGATIVE FOR MALIGNANCY

48 Case #1 Stage? Adjuvant therapy? Post-operative follow-up Imaging CA Recurrence

49 Case #2

50 Case #2 60 y/o M Presents in consultation for liver mass HPI: H/o cirrhosis secondary to HCV Followed by GI for routine surveillance with ultrasound and AFP Mass noted on ultrasound AFP 11.2 (previous normal) Generally patient with fatigue, malaise Did not tolerate PEG IFN/ribaviran therapy

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56 Case #2 Liver mass in cirrhosis Likely diagnosis Other possibilities? Child s Class? Tbili 0.7 INR 1.1 Albumin 4.2 Minimal encephalopathy, slight ascites Platelets 120K Next step? Transplantation? Resection? Percutaneous ablation/tace?

57 Case #2 Operation Exploratory laparotomy portal lymphadenectomy intraoperative ultrasound, cholecystectomy left lateral sectionectomy

58 Case #2 Pathology LYMPH NODE, PORTAL- NEGATIVE FOR MALIGNANCY. LIVER, SEGMENT 1 AND 2, PARTIAL HEPATECTOMY: MODERATELY-DIFFERENTIATED HEPATOCELLULAR CARCINOMA, 4.7 CM IN GREATEST DIMENSION, NEGATIVE FOR VASCULAR INVASION, NEGATIVE SURGICAL RESECTION MARGIN; BACKGROUND LIVER WITH ESTABLISHED CIRRHOSIS GALLBLADDER, CHOLECYSTECTOMY: AUTOLYZED GALLBLADDER WITH CHOLESTEROLOSIS AND CHOLELITHIASIS; NEGATIVE FOR MALIGNANCY. Stage?

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60 Case #3

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73 Case #4

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