Moffitt Pearls 2/14/18 – GI Report – Liver Masses

Thank you to Bennett and Scott for presenting the case of an middle aged man presenting from an outside hospital with RUQ pain found to have a rapidly growing hepatic mass (10 -> 20 cm in 6 weeks) extending into the R pleural cavity. We had a great discussion of possible liver lesions summarized below and are awaiting the pathology review from OSH biopsy. Given the rapid growth we discussed the possibility of a vascular component to this mass in addition to infectious causes (s/p biopsy) vs. lymphoma of the liver. Keep us updated!!

Key Pearls

  1. In the majority of patients (as Dr. Ostroff was alluding to), a proper diagnosis can be made based on the characteristics on imaging modalities.
  2. The majority of lesions < 1.0 cm are benign. Benign liver lesions are found in more than 20% of the general population[1], including haemangioma (4%), focal nodular hyperplasia (FNH, 0.4%) and hepatic adenomas (0.004%).
  3. Liver mets in a normal liver usually come from colon, stomach, lung and prostate. Importantly, mets are a rare finding in a cirrhotic liver.

Liver Lesions

Benign

 

Risk Factors Symptoms Dx Tx
Hepatic hemangioma Most common liver lesion; F>M Rarely causes pain US – well-circumscribed; peripheral enhancement None; no risk of bleed or CA
Cyst 5% of individuals; F>M Asx Rapid arterial uptake; hypodense lesions None
Focal Nodular Hyperplasia Hyperplastic growth around a preexisting arterial malformation Asx Solitary lesion None
 

Hepatic adenoma

Uncommon; M>F RUQ pain; palpable mass; fevers leukocytosis US or CT – no uptake with contrast Surgery (emergent if converts to bleeding)
Pyogenic Liver Abscess Ass w/ biliary stenting or acute ascending cholangitis; higher risk in DM Fevers, tender liver, leukocytosis Aspirate and Cx; US or CT; loculated single or multiple rim enhancement 4-6 weeks of abx

 

+/- Perc drainage

Amebic liver abscess Amoebiasis; endemic to Mexico Fevers, tender liver, leukocytosis Can’t culture; serology & empiric abx; Halo sign on CT “rim enhancement” Cholestatic LFTs; r/o IgG Echinococcal Metronidazole

 

If persistent then drain

Echinococcal cyst Ingestion of tapeworm eggs (fecal-oral); infected dogs/livestock If cysts rupture -> 2° echinococcis or anaphylactic shock Cholesttaic LFTs; eosinophilia; Test for IgG echinococcal Mebendazole

 

Avoid puncturing cyst

 

 

Malignant Risk Factors Symptoms Dx Tx
HCC Cirrhotics (EtoH, HBV, HCV, NASH…) Wt. loss, RUQ discomfort; HSM; jaundice; ascites – U/S or CT

-AFP – trend & prognosticate; -CEA (non-specific)

Resection, transplant, chemo
Biliary Tract Cancer CA of GB or intra-or extra hepatic biliary tract Abd pain, biliary obstruction, LFTs abnl Intrahepatic Ca; solid mass withing liver, Extra-hepatic: duct dilation, rim-enhancing (unlike HCC) Surgical resection, but often too large, embolization + chemo
Liver mets 20:1 more common than HCC, but uncommon in cirrhotic livers

-CRC, gastric, pancrearic, neuroendocrine

Looks for rise in CEA or LFTs in pt with hx of CRC or other CA CT or U/S Resection is confined to one lobe; radioablation
Heptic angiosarcoma 2% of primary liver cancers; Abd pain, weakness, wt loss, HSM, jaundice, CHF 31%; hepatic failure; intra-abd bleeding LFTs abnl

Ateriography “vascular lakes”

Mean life expectancy 6 months +/- chemo therapy or surgery
Lymphoma   B-symptoms, weight loss, fevers, RUQ abd pain Multiple, fast growing lesions Chemotherapy

 

References: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2710776/

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

w

Connecting to %s