In the Name of GOD
Liver Masses General Overview
Behzad Nakhai, M.D.,FICS
Fellowship in HepatoBiliary Surgery
Asso Professor Iran University of Medical Sciences
Tehran , Islamic Republic of Iran
Liver Masses In General
 Liver
Cystic
Masses
Benign
Masses
 Liver
Metastatic
Masses
 Liver
Malignant
Masses
 Liver
Liver in General
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1/50 of total body weight
Its Size reflects complexity of its Function
8 Segments through (Cantlie Line)
75% Portal vein & 25% Hepatic artery
80% Removal = Normal life
Total Hepatic Blood Flow:
– (1500cc / Min / 1.73 m2 of body surface)
Metabolic Functions of the
Liver
Glucose production & storage
 Urea formation (amino acid metabolism)
 Synthesis of proteins & clotting factors
 Detoxification of drugs & other substance
 Bile acid & Bilirubin production
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Types of Liver Cells
Hepatocytes
–
{ Parenchymal cells }
 Macrophages
–
{ Kupffer cells }
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Benign Lesions of the Liver
Introduction
Are Common
 Diagnostic Difficulty with Malignancy
 Unknown Etiology ( May be Congenital )
 Necrosis,Thrombosis,Haemorrhage,Rupture
 L.F.T are Normal
 US & CT Scan are Diagnostic
 Biopsy rarely indicated
 Diagnostic Laparascopy is now available
 Lesions may be Cystic or Solid
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Benign Lesions of the Liver
Liver Cysts
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Degenerative Cyst
Dermoid Cyst
Lymphatic Cyst
Endothelial Cyst
Retention Cyst
Proliferative cyst
– Cystadenomas
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Parasitic Cysts
– Hydatid Cyst
– Amebic Cyst
Benign Lesions of the Liver
Benign Liver Tumors
 Hamartoma
 Adenoma
 Focal
Nodular Hyperplasia
 Hemangioma
Benign Liver Tumors
Hamartoma
Composed from normal Liver tissues
 Mesenchymal Hamatomas may be
rapidly growing in children
 Firm, Nodular & Surface location
 May be Solitary or Multiple
 Malignant Transformation do not occur
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Benign Liver Tumors
Adenoma
Is seen with Oral Contraceptive
 60-80% with Mestranol
 May developed during Pregnancy
 Adenomatosis may seen
 Severe Pain or Mass effect may occur
 Malignant Transformation occur
 Liver Resection / Liver Transplantation
is indicated
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Benign Liver Tumors
Focal Nodular Hyperplasia
Occurs in Women in Reproductive age
 HyperVascular Pattern in Angiogram
 Patients are Asymptomatic
 Possible precursor to HCC
 Resection is indicated only for
Symptomatic FNH
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Benign Liver Tumors
Hemangioma
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Most common benign tumor of Liver
Is seen in the 3rd to 5rd decades
Are less than 5 cm in diameter
May be Single or Multiple
Usually are Asymptomatic
Complications are rare
May be Cavernous & Lobulated
Malignant transformation do not occur
Liver Resection rarely indicate
Malignant Liver Tumors
Origin
 From
liver Cells:HCC, Fibrolamellar Ca
 From Biliary Cells : ICCA
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From Mesodermal Cells:Angiosarcoma,Sarcoma
Malignant Liver Tumors
Hepatocelluler Carcinoma( HCC )
90% of all Primary Liver Malignancy
 4Th Malignancy in the world
 Common in Asia & Africa
 More common in Males
 May seen even in Children
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Malignant Liver Tumors
Risk Factor of HCC
Cirrhosis due to : HCV,HBV,Hemochromatosis
 Alcoholic & Postnecrotic Cirrhosis
 Aflatoxin Longstanding Toxemia
 Parasite Infestation of Clonorchis (ICCA)
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Malignant Liver Tumors
Pathology of HCC
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Hepatocellular Ca
– Hepatocytes
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Hepatoblastoma
– Immature Hepatocyte
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Fibrolamellar Ca
– Eosinophili Hepatocyte
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Small HCC (< 2 Cm)
Unifocal Expansive
Infiltrating
Multifocal
Vascular Invasion
Malignant Liver Tumors
Diagnosis of HCC
Ultrasonography
 Serial Alpha _ Fetoprotein
 Alkaline phosphatase
 Hepatic Arteriography
 Liver Isotope Scan
 CT & MRI
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Malignant Liver Tumors
Clinical Presentation of HCC
 Weight
loss & Weakness 80 %
 Abdominal Pain & Fullness 50%
 Portal Hypertension
 Jaundice 20-50 %
 Hypoglycemic Interval
 Ascites
Malignant Liver Tumors
Fibrolamellar Carcinoma
 Occur
in Western Hemisphere
 Younger Age 20 to 35 years
 More common in Lt Lobe
 Occur in Normal Liver
 Better prognosis than HCC
 Better Response to Surgery
Malignant Liver Tumors
IntraHepatic CholangioCarcinoma
 Rare
Tumour
 Normal underlying Liver
 May seen in Caroli & PSC
 May be local or diffuse
 Have a poor Prognosis
Malignant Liver Tumors
AngioSarcoma
Most frequent Sarcoma of the liver
 1% of All Primary Malignancy of Liver
 Involved Entire liver
 An Association with(Anabolic Steroids,Estrogens,OCP)
 Male to Female 3/1
 Age Time Of Diagnosis 50_ 70
 May Progress to Haemangioendothelioma
 Poor Prognosis
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Malignant Liver Tumors
Treatment Options of HCC
Liver Resection
 Liver Transplantation
 Systemic Chemotherapy ?
 TransArterial Embolization ( Lipiodol)
 Percutaneous Ethanol Injection
 CryoSurgery ( liquid Nitrogen )
 Radiation Therapy ?
 RF I .T. T
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Hepatic Metastatic Neoplasms
B. Nakhaei, M.D
Most Common Malignancy of the Liver
 1/20 Primary to Secondary
 Liver is Second only to Regional lymph nodes
 25%_ 50% of dying patients have Liver
Metastasis
 Mitotic count of Metastasis is 5 times greater
than Primary Lesion
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Routes of Metastasis to the Liver
 Portal
Circulation
 Lymphatic spread
 Hepatic Arterial System
 Direct Extension
Liver
Metastasis
Clinical Manifestations :
Hepatic pain
 Ascites
 Jaundice
 Anorexia
 Weight loss
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Hepatic nodularity
 Audible friction rub
 Portal hypertension
 Flushing Syndrome
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Liver Metastasis
Timing of Appearance
 Precocious ( Carcinoid of the Ileum)
 Synchronous
( Most GI Cancers )
 Metachronous ( Ocular Melanoma)
Liver Metastasis
Surgical treatment if :
Control of primary tumor
 No systemic or intra- abdominal Metastases
 Good patient,s condition
 Extent of hepatic involvement
 No more than 4 metastases
 Primaries in Colon & Rectum & Wilms,
 Debulking for other tumor ( ovary , stomach,
breast , cervix ,.... )
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References
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HepatoBiliary & Pancreatic Surgery
– James Garden 2th Edition 2001
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Principles of Surgery
– Schwartz 7th Edition 1999
ACS Surgery 2001
 Text Book of Surgery
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– Sabiston 16Th Edition 2001
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B, Nakhaei, M.D.