1/9/2008

LIVER    MASSES LIVER    MASSES

͞ƉĂƚŝĞŶƚƐĚŽŶŽƚĐŽŵĞǁŝƚŚLiver  Masses they  come  
with  Signs  and  Symptoms͟
Surgery  II ‡ many  would  be  ASYMPTOMATIC  with  the  
Department  of  Surgery   liver  mass  being  an  incidental  finding
Faculty  of  Medicine  &  Surgery ‡ pain  and  tenderness  that  may  mimic  
biliary  tract  disease  and  other  GI  problem
Renato  M.  Reyes,  MD
General  &  Transplant  Surgery

Liver  Masses LIVER    MASSES

‡ upper  quadrant  mass  /   ‡ jaundice  of  cholestatic  or  
hepatomegaly  on  physical   obstructive  nature
examination
‡ fever  and  chills  that  mimic   ‡ abnormal  liver  function  tests
cholecystitis,  cholangitis  or  liver  
abscess

Liver  Function  Tests Liver  Function  Tests

‡ SGOT  &  SGPT are  general  markers  of   ‡ Prothrombin  Time capability  for  
hepatocyte  injury synthesis  of  clotting  factors

‡ Alkaline  Phosphatase is  elevated  in   ‡ Albumin measures  synthetic  capability  

biliary  obstruction  and  primary  and  secondary   and  nutritional  status
liver  malignancy

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Liver    Masses Liver    Masses

‡ tumor  markers  like  AFP  and  CEA   ‡ Serum  AFP is  normal  in  the  
for  primary  and  metastatic  liver   majority  of  patients  with  
cancers  respectively fibrolamellar  variant  of  HCC  
‡ weight  loss  and  general  debility (Hepatocellular  Carcinoma)  and  
in  up  to  40%  of  patients  with  HCC

radiologic  modalities  for  

Solitary  Focal  Liver  Lesion
LIVER    MASSES
‡ Patient  known  or  suspected  to  
‡ UTZ -­‐ cheap  &  intraoperative have  an  extrahepatic  
‡ CT  Scan -­‐ most  popular malignancy
‡ MRI  Scan -­‐ challenging  CT  especially  for ‡ Patient  known  to  have  
vascular  lesions
‡ PET  Scan -­‐ specially  for  metastatic  lesions cirrhosis

HCC  is  likely  in  a  Liver  Mass  on  a  Patient  Known   Focal  Liver  Mass  with  no  underlying Liver  Disease  with  
to  have  Cirrhosis normal AFP

‡ If  the  Liver  Mass  is  new  and  of   ‡ Lesion  may  be  a  hemangioma which  can  be  
confirmed  by  an  MRI  or  blood  pool  study
recent  occurrence ‡ Lesion  may  be  a  simple  cyst and  a  repeat  CT  
‡ Rising  level  of  AFP is  recommended  in  6  months
‡ Lesion  may  be  an  abscess which  can  be  
‡ AFP  is  >  500  ug/L correlated  clinically

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Focal  Liver  Mass  with  no  underlying  Liver  Disease  with  

normal    AFP
Malignant  Liver  Tumors
‡ If  lesion  is  solid  and  symptomatic  consider  
resection
‡ Lesion  may  be  focal  nodular  hyperplasia
‡ Metastatic  Tumors
and  technicium  scan  or  MRI  may  be  helpful ‡ Hepatocellular  Carcinoma
‡ Consider  biopsy  to  confirm  the  diagnosis
‡ Cholangiocarcinoma

the  most  common  tumor  of  

the  LIVER  is   ͞ŵĞƚĂƐƚĂƚŝĐ͟ Hepatocellular  Carcinoma

͞ĂŶĞdžƚĞŶƐŝǀĞĂŶĚĨƌƵŝƚůĞƐƐ ‡ In  the  great  majority  of  cases,  CIRRHOSIS

operation  was  avoided  when   is  in  the  background
‡ In  this  scenario,  the  issue  of  remaining  
metastatic  spread  to  the  
reserve  liver  function  plays  a  great  role  in  
ůŝǀĞƌŝƐĚĞƚĞƌŵŝŶĞĚ͟ the  treatment

Cholangiocarcinoma Benign  Focal  Liver  Lesions

‡ The  outstanding  picture  will  be  that  of  an   ‡ Cysts
OBSTRUCTIVE  form  of  jaudice
‡ Cavernous  Hemangiomas
‡ Liver  Function  is  preserved  in  contrast  to  
Hepatocellular  Carcinoma
‡ Focal  Nodular  Hyperplasia
‡ Hepatic  Adenomas
‡ Abscesses  (pyogenic  /  amoebic)

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Clinical  Differentiation   Radiologic  Differentiation  of  LIVER  

of  LIVER  MASSES MASSES
‡ Primary  or  Metastatic
‡ History:  OCP  /  Hepatitis  /  Alcohol ‡ Solid  /  Cystic  /  Complex
‡ PE:  Solid  vs.  Cystic ‡ Presence  or  Absence  of  Diffuse  Liver  
‡ Alteration  of  Liver  Function:   Disease
Cholestatic  vs.  Hepatocellular ‡ Solitary  /  Multiple
‡ Symptomatology:  Infectious  vs.   ‡ Presence  or  Absence  of  Bile  Duct  
Neoplastic Dilatation

from  Impression  to  Confirmation Histologic  Confirmation  of  Liver  Masses

‡ A  clinical  diagnosis  can  be  made  in   ‡ Percutaneous  Liver  Biopsy

the  great  majority  of  instances
‡ ͞ůŝŶŝĐĂů/ŵƉƌĞƐƐŝŽŶŝƐĨŽůůŽǁĞĚďLJ
,ŝƐƚŽůŽŐŝĐŽŶĨŝƌŵĂƚŝŽŶ͟
‡ Laparoscopic  Guided  Liver  Biopsy
‡ UTZ  Guided  Liver  Biopsy
‡ CT  Guided  Liver  Biopsy