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