Liver mass Mazen Hassanain

Radiology Arterial enhancement: adenoma, FNH, hemangioma, HCC, NET mets Portal enhancement: CRC liver mets

Liver adenoma Women 20 – 40 Right hepatic lobe Typically solitary 80% Multiple adenomas described in patients with prolonged contraceptive use, glycogen storage diseases, and hepatic adenomatosis. Size from 1 to 30 cm Malignant transformation, spontaneous hemorrhage, and rupture

Adenomas are more numerous, larger, and more likely to bleed in patients with adenomas who take OCPs Regression of adenomas has been observed after discontinuation of OCPs with recurrence during re-administration or pregnancy 59% maternal and 62% fetal mortality

Regular septa, portal tracts, bile ductules are absent, and few Kupffer cells CT: Contrast-enhanced scans may show peripheral enhancement during the early phase with subsequent centripetal flow during the portal venous phase MRI: hyperintense on T1 and on T2 images and enhance further with gadolinium administration

Treatment Symptoms, size, number, location, and certainty of the diagnosis. OCP ? Pregnant Patients who present with abdominal pain and hypotension have a mortality of up to 20% Emergency surgery is associated with a mortality of 6% Preoperative selective arterial embolization using coils may control bleeding and reduce mortality

Liver hemangioma Most common benign mesenchymal hepatic tumors 40% multiple Giant High output cardiac failure, hypothyroidism and Kasabach-Merritt syndrome Symptoms

US: well-demarcated homogeneous hyperechoic mass. CT: peripheral nodular enhancement in the early phase, followed by a centripetal pattern or "filling in" during the late phase MRI: smooth, well-demarcated homogeneous mass that has low signal intensity on T1-weighted images and is hyperintense on T2-weighted images

FNH Most common non-malignant hepatic tumor predominantly in women 95% solitary and Sinusoids and Kupffer cells are typically present,

US: central scar in only 20% CT: FNH is isodense during the portal phase. A central scar may be present in the fibrolamellar variant of HCC. Sulfur colloid: 85% MRI: isointense on T1-weighted images, an isointense to slightly hyperintense mass appears on T2-weighted images

HCC Chronic liver disease, particularly viral hepatitis Median survival 6 to 20 months Large size (Milan), vascular invasion, and nodal metastases are all associated with a poor outcome AFP 200

US: 60% sensitivity and 97% spacifity MRI: increased T2 signal intensity No biopsy except if no risk factors Dx either –Single typical imaging + AFP –Two typical imaging

CRC liver mets 50% will develop liver mets Fong criteria Pre-operative chemotherapy era Surgical removal is the only hope for cure RFA proved to be inferior to surgery but better than chemo only Current survival is 28months with chemo only

NET liver mets Lung –Poorly-differentiated neuroendocrine carcinomas Gastroenteropancreatic –Well-differentiated (eg, carcinoid tumors) if they are noninvasive and show benign behavior –Low-grade malignant (ie, with invasion of the muscularis propria or beyond, or metastases) are classified as well-differentiated neuroendocrine carcinomas

Symptoms: –None –Pressure –Hormonal Diagnosis –Somatostatin receptor scintigraphy: 90% Predicts response to treatment 50% in insulinoma Less for liver mets

Chromogranin A –Most sensitive marker available and indicate prognosis Treatment: –Curative intension –Symptoms control –Debuliking as may prolong survival

Octereotide Resection (with or without primary) RFA (no long term results) Embolization (Bland, chemo, radio) Systemic chemotherapy –Cytotoxic: Streptozocin, 5-fu, Interferon –Targeted therapy: VEGF, TKI Liver transplantation: limited isolated disease with highly selected pts,

Prognosis –Site of origin (rectum and appendix) –Size on discovery (less than 1cm) –The presence and extent of metastases on discovery –Histology depth of tumor invasion, vascular and lymphatic invasion, cellular atypia, areas of focal necrosis, and an increased mitotic index –The presence of the carcinoid syndrome –Median survival 5 – 8 years