2. In the Name of GOD L iver Masses General Overview Behzad Nakhai, M.D.,FICS Fellowship in HepatoBiliary Surgery Asso Professor Iran University of Medical Sciences Tehran, Islamic Republic of Iran

3. Liver Masses In General n Liver Cystic Masses n Liver Benign Masses n Liver Metastatic Masses n Liver Malignant Masses

4. Liver in General Liver in General n 1/50 of total body weight n Its Size reflects complexity of its Function n 8 Segments through (Cantlie Line) n 75% Portal vein & 25% Hepatic artery n 80% Removal = Normal life n Total Hepatic Blood Flow: – (1500cc / Min / 1.73 m2 of body surface)

5. Metabolic Functions of the Liver n Glucose production & storage n Urea formation (amino acid metabolism) n Synthesis of proteins & clotting factors n Detoxification of drugs & other substance n Bile acid & Bilirubin production

6. Types of Liver Cells Types of Liver Cells n Hepatocytes – { Parenchymal cells } n Macrophages – { Kupffer cells }

7. Benign Lesions of the Liver I Benign Lesions of the Liver Introduction n Are Common n Diagnostic Difficulty with Malignancy n Unknown Etiology ( May be Congenital ) n Necrosis,Thrombosis,Haemorrhage,Rupture n L.F.T are Normal n US & CT Scan are Diagnostic n Biopsy rarely indicated n Diagnostic Laparascopy is now available n Lesions may be Cystic or Solid

8. Benign Lesions of the Liver Liver Cysts n Degenerative Cyst n Dermoid Cyst n Lymphatic Cyst n Endothelial Cyst n Retention Cyst n Proliferative cyst –Cystadenomas n Parasitic Cysts –Hydatid Cyst –Amebic Cyst

9. Benign Lesions of the Liver Benign Liver Tumors Benign Lesions of the Liver Benign Liver Tumors n Hamartoma n Adenoma n Focal Nodular Hyperplasia n Hemangioma

10. Benign Liver Tumors Hamartoma n Composed from normal Liver tissues n Mesenchymal Hamatomas may be rapidly growing in children n Firm, Nodular & Surface location n May be Solitary or Multiple n Malignant Transformation do not occur

11. Benign Liver Tumors Adenoma Benign Liver Tumors Adenoma n Is seen with Oral Contraceptive n 60-80% with Mestranol n May developed during Pregnancy n Adenomatosis may seen n Severe Pain or Mass effect may occur n Malignant Transformation occur n Liver Resection / Liver Transplantation is indicated

12. Benign Liver Tumors Focal Nodular Hyperplasia n Occurs in Women in Reproductive age n HyperVascular Pattern in Angiogram n Patients are Asymptomatic n Possible precursor to HCC n Resection is indicated only for Symptomatic FNH

13. Benign Liver Tumors Hemangioma n Most common benign tumor of Liver n Is seen in the 3rd to 5rd decades n Are less than 5 cm in diameter n May be Single or Multiple n Usually are Asymptomatic n Complications are rare n May be Cavernous & Lobulated n Malignant transformation do not occur n Liver Resection rarely indicate

14. Malignant Liver Tumors Origin n From liver Cells:HCC, Fibrolamellar Ca n From Biliary Cells : ICCA n From Mesodermal Cells:Angiosarcoma,Sarcoma

15. Malignant Liver Tumors Hepatocelluler Carcinoma( HCC ) Malignant Liver Tumors Hepatocelluler Carcinoma( HCC ) n 90% of all Primary Liver Malignancy n 4Th Malignancy in the world n Common in Asia & Africa n More common in Males May seen even in Children May seen even in Children

16. Hepatic Primary Malignancies Malignant Liver Tumors Risk Factor of HCC n Cirrhosis due to : HCV,HBV,Hemochromatosis n Alcoholic & Postnecrotic Cirrhosis n Aflatoxin Longstanding Toxemia n Parasite Infestation of Clonorchis (ICCA)

17. Malignant Liver Tumors Pathology of HCC Malignant Liver Tumors Pathology of HCC n Hepatocellular Ca –Hepatocytes n Hepatoblastoma –Immature Hepatocyte n Fibrolamellar Ca –Eosinophili Hepatocyte n n Small HCC (< 2 Cm) n Unifocal Expansive n Infiltrating n Multifocal n Vascular Invasion

18. Malignant Liver Tumors Diagnosis of HCC Malignant Liver Tumors Diagnosis of HCC n Ultrasonography n Serial Alpha _ Fetoprotein n Alkaline phosphatase n Hepatic Arteriography n Liver Isotope Scan n CT & MRI

19. Malignant Liver Tumors Clinical Presentation of HCC Malignant Liver Tumors Clinical Presentation of HCC n Weight loss & Weakness 80 % n Abdominal Pain & Fullness 50% n Portal Hypertension n Jaundice 20-50 % n Hypoglycemic Interval n Ascites

20. Malignant Liver Tumors Fibrolamellar Carcinoma Malignant Liver Tumors Fibrolamellar Carcinoma n Occur in Western Hemisphere n Younger Age 20 to 35 years n More common in Lt Lobe n Occur in Normal Liver n Better prognosis than HCC n Better Response to Surgery

21. Malignant Liver Tumors IntraHepatic CholangioCarcinoma n Rare Tumour n Normal underlying Liver n May seen in Caroli & PSC n May be local or diffuse n Have a poor Prognosis

22. Malignant Liver Tumors AngioSarcoma n Most frequent Sarcoma of the liver n 1% of All Primary Malignancy of Liver n Involved Entire liver n An Association with( Anabolic Steroids,Estrogens,OCP ) n Male to Female 3/1 n Age Time Of Diagnosis 50_ 70 n May Progress to Haemangioendothelioma n Poor Prognosis

23. Malignant Liver Tumors Treatment Options of HCC n Liver Resection n Liver Transplantation n Systemic Chemotherapy ? n TransArterial Embolization ( Lipiodol) n Percutaneous Ethanol Injection n CryoSurgery ( liquid Nitrogen ) n Radiation Therapy ? n RF I.T. T

24. Hepatic Metastatic Neoplasms B. Nakhaei, M.D n Most Common Malignancy of the Liver n 1/20 Primary to Secondary n Liver is Second only to Regional lymph nodes n 25%_ 50% of dying patients have Liver Metastasis n Mitotic count of Metastasis is 5 times greater than Primary Lesion

25. Routes of Metastasis to the Liver n Portal Circulation n Lymphatic spread n Hepatic Arterial System n Direct Extension

26. Liver Metastasis Clinical Manifestations : n Hepatic pain n Ascites n Jaundice n Anorexia n Weight loss n Hepatic nodularity n Audible friction rub n Portal hypertension n Flushing Syndrome

27. Liver Metastasis Timing of Appearance n Precocious ( Carcinoid of the Ileum) n Synchronous ( Most GI Cancers ) n Metachronous ( Ocular Melanoma)

28. Liver Metastasis Surgical treatment if : n Control of primary tumor n No systemic or intra- abdominal Metastases n Good patient,s condition n Extent of hepatic involvement n No more than 4 metastases n Primaries in Colon & Rectum & Wilms, n Debulking for other tumor ( ovary, stomach, breast, cervix,.... )

29. References n HepatoBiliary & Pancreatic Surgery –James Garden 2th Edition 2001 n Principles of Surgery –Schwartz 7th Edition 1999 n ACS Surgery 2001 n Text Book of Surgery –Sabiston 16Th Edition 2001 n B, Nakhaei, M.D.