Workup of a Solid Liver Lesion Joseph B. Cofer MD FACS Chief Quality Officer Erlanger Health System Affiliate Professor of Surgery UTHSC-Chattanooga I have no financial or other relationships with any drug or device producer (unfortunately) and have nothing to disclose Chattanooga Family Practice Update 17 June, 2016 Points Scored 1 2 3 Encephalopathy (grade) None 1 + 2 3 + 4 Ascites Absent Slight Moderate Bilirubin 1 2 2 3 >3 Albumin >3.5 2.8 3.5 <2.8 Prothrombin Time 1 4 4 6 >6 (seconds prolonged) (For PBC Bilirubin 1 4 4 10 >10 Total Score Class 5-6 A 7-9 B 10-15 C Pugh, Brit. J. Surg., 1973 Child, Turcotte, Major Problems in Clinical Surgery, 1964 Model End Stage Liver Disease (MELD) Serum Creatinine Total Bilirubin INR MELD Score=10{0.957 Ln(Scr) + 0.378 Ln(TBil) + 1.12 Ln(INR) + 0.643)} MELD <24 - CPT 5-9 MELD 24 CPT 10 Solid Benign Liver Tumors Hemangiomas Focal nodular hyperplasia Liver cell adenoma 1
Solid Benign Liver Tumors Hemangiomas Focal nodular hyperplasia Liver cell adenoma Reasons for Resecting Benign Liver Lesions Symptoms Hemorrhage or risk of hemorrhage Risk of malignant transformation Inability to exclude malignancy 2
Liver Hemangioma Nearly all (>90%) hemangiomata are asymptomatic, and discovered incidentally Liver Hemangioma is the most common solid benign lesion in the liver More common in young women and are probably congenital Malignant transformation has never been well documented 80-90% solitary lesions Liver Hemangioma Symptoms are probably related to the hemangioma growing and stretching Glisson s capsule, or the lesions become so large they press on surrounding organs Most lesions are asymptomatic and <4 cm in size Spontaneous rupture and hemorrhage, though serious, is quite rare (0-3%) Indications for treatment: Severe symptoms w/o other explanation Hemorrhage R/O Malignancy Diagnosis-Liver Hemangioma Ultrasound Labeled red blood cell scan MRI Angiography CT scan Biopsy usually not necessary, but is possible Therapy - Hemangioma Observation acceptable in over 90% of cases Electively resect larger symptomatic lesions Embolization? Irradiation? 3
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Hepatic Adenoma Hepatic Adenoma Histologic appearance of neoplasm Clinical presentation suggests rapid growth Necrosis with hemorrhage may occur (30% of cases), and may be higher during pregnancy and early postpartum Tumors may reach very large size and be multiple in 10-15% of patients Appear in young women and correlates with duration of using oral BCP and age over 30 Incidence in those who have used oral BCP for more than 2 years is 3-4/100,000 A few well documented cases demonstrate progression to malignancy The risk of malignant degeneration and hemorrhage usually leads to a recommendation of resection Tumors may regress following the withdrawal of exogenous hormonal stimulation 5
Focal Nodular Hyperplasia - FNH Much more common in young women May be localized reaction to injury manifested by scar tissue with nodular regeneration and vascular hypertrophy Most small lesions found incidentally at surgery for another reason FNH may be seen as a hot spot on a Technetium- 99 sulfur colloid scan due to the presence of Kupffer cells CT/MRI Central Scar FNH In general, there are few symptoms and resection is not recommended for all FNH except the most peripheral lesions and those causing symptoms For small lesions, excisional biopsy will be both diagnostic and curative There is NO conclusive evidence for malignant degeneration of FNH 6
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Hepatocellular Carcinoma (HCC) 250,000 deaths from HCC each year world wide Most common in Mozambique, Taiwan, and Southeast China (100 / 100K) Uncommon in North America, Canada, Britain (3-5 / 100K) Environmental factors seem to play a dominant role over racial or genetic factors Age of onset varies with location Male:Female 8:1-4:1 Association with cirrhosis Pathogenesis - HCC HCC Most cases of HCC occur in an area where viral hepatitis is endemic and develop in a background of cirrhosis Japan HCV (60%), age>50 Africa, Asia, and China HBV, Aflatoxin B, men 35-50 Hemochromatosis America 4,000,000 are infected with HCV Western World Uncommon Elderly Long standing cirrhosis AFP positive 60-80% Chemo TX? Resectability? Africa / Far East Common Young Less so AFP positive Chemo TX no benefit Resectability usually not possible Symptoms - HCC Insidious in onset When advanced, patients present with pain and weight loss Duration of symptoms usually only 4-6 weeks Diagnosis - HCC Physical exam - no findings, till late Alpha-fetoprotein 60-80% Imaging CXR - Mets Angiography - highly vascular Ultrasound - cystic vs. solid / vessels CT - nonspecific MRI - relationship to vessels Laparoscopy 8
Treatment - HCC Resection-5 year survival 25-30% Chemotherapy Radiation Transplantation-5 year survival 60-70 % Transplantation for HCC Consider if: Tumor not otherwise resectable due to cirrhosis or location Unicentric ( <3 tumors, largest < 3 cm) Tumor <5 cm No extrahepatic disease (including nodes) Portal vein open 9
Liver Metastases N = 153 Colorectal 118 Intestinal 6 Kidney 5 Adrenal 5 Breast 4 Gastric 2 Ovarian 2 Melanoma 2 Liver Metastases from Colorectal Cancer Natural history: Left untreated, metastatic lesions to the liver from colorectal cancers are associated with survival of 3-24 months Occasional long term 5-year survivors have been documented 10
Liver Metastases from Colorectal Cancer Prognosis 20-25% five-year disease free survival for patients who successfully have resection of hepatic colorectal carcinoma metastasis Less than 5% mortality and 20-25% associated morbidity Questions? 11