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.

In the Name of GODIn the Name of GOD

LLiver Masses General iver Masses General OverviewOverview

Behzad Nakhai, M.D.,FICSBehzad Nakhai, M.D.,FICSFellowship in Fellowship in HepatoBiliaryHepatoBiliary SurgerySurgery

Asso Professor Iran University of Medical Asso Professor Iran University of Medical Sciences Sciences

Tehran , Islamic Republic of IranTehran , Islamic Republic of Iran

LiverLiver Masses In Masses In GeneralGeneral

LiverLiver Cystic Cystic Masses Masses LiverLiver BenignBenign Masses Masses LiverLiver MetastaticMetastatic Masses Masses LiverLiver Malignant Malignant Masses Masses

LiverLiver inin GeneralGeneral

1/50 of total body weight1/50 of total body weight Its Size reflects complexity of its Its Size reflects complexity of its

FunctionFunction 8 Segments through (Cantlie Line)8 Segments through (Cantlie Line) 75% Portal vein & 25% Hepatic artery75% Portal vein & 25% Hepatic artery 80% Removal = Normal life 80% Removal = Normal life Total Hepatic Blood Flow:Total Hepatic Blood Flow:

– (1500cc / Min / 1.73 m2 of body (1500cc / Min / 1.73 m2 of body surface)surface)

Metabolic Functions of theMetabolic Functions of the LiverLiver

Glucose production & storageGlucose production & storage Urea formation Urea formation ((amino acid metabolismamino acid metabolism)) Synthesis of proteins & clotting factorsSynthesis of proteins & clotting factors Detoxification of drugs & other Detoxification of drugs & other

substancesubstance Bile acid & Bilirubin productionBile acid & Bilirubin production

Types ofTypes of LiverLiver CellsCells

HepatocytesHepatocytes– { Parenchymal { Parenchymal

cells }cells } MacrophagesMacrophages

– { Kupffer cells }{ Kupffer cells }

Benign Lesions of the LiverBenign Lesions of the Liver

IIntroduction Are CommonAre Common Diagnostic Difficulty with MalignancyDiagnostic Difficulty with Malignancy Unknown Etiology ( May be Congenital )Unknown Etiology ( May be Congenital ) Necrosis,Thrombosis,Haemorrhage,RuptureNecrosis,Thrombosis,Haemorrhage,Rupture L.F.T are NormalL.F.T are Normal US & CT Scan are DiagnosticUS & CT Scan are Diagnostic Biopsy rarely indicatedBiopsy rarely indicated Diagnostic Laparascopy is now availableDiagnostic Laparascopy is now available Lesions may be Cystic or SolidLesions may be Cystic or Solid

Benign Lesions of the LiverBenign Lesions of the Liver

Liver CystsLiver Cysts

Degenerative Degenerative CystCyst

Dermoid CystDermoid Cyst Lymphatic Cyst Lymphatic Cyst Endothelial Cyst Endothelial Cyst Retention Cyst Retention Cyst Proliferative cystProliferative cyst

– CystadenomasCystadenomas

Parasitic Cysts Parasitic Cysts – Hydatid Cyst Hydatid Cyst – Amebic CystAmebic Cyst

Benign Lesions of the LiverBenign Lesions of the Liver

Benign Benign Liver TumorsLiver Tumors

Hamartoma Hamartoma Adenoma Adenoma

Focal Nodular Hyperplasia Focal Nodular Hyperplasia HemangiomaHemangioma

Benign Benign Liver TumorsLiver Tumors

HamartomaHamartoma

Composed from normal Liver tissuesComposed from normal Liver tissues Mesenchymal Hamatomas may beMesenchymal Hamatomas may be

rapidly growing in childrenrapidly growing in children Firm, Nodular & Surface locationFirm, Nodular & Surface location May be Solitary or MultipleMay be Solitary or Multiple Malignant Transformation do not Malignant Transformation do not

occuroccur

Benign Benign Liver TumorsLiver Tumors

AdenomaAdenoma Is seen with Oral ContraceptiveIs seen with Oral Contraceptive 60-80% with Mestranol60-80% with Mestranol May developed during PregnancyMay developed during Pregnancy Adenomatosis may seenAdenomatosis may seen Severe Pain or Mass effect may occurSevere Pain or Mass effect may occur Malignant Transformation occurMalignant Transformation occur Liver Resection / Liver Liver Resection / Liver

Transplantation is indicatedTransplantation is indicated

Benign Benign Liver TumorsLiver Tumors

Focal Nodular HyperplasiaFocal Nodular Hyperplasia

Occurs in Women in Reproductive ageOccurs in Women in Reproductive age HyperVascular Pattern in AngiogramHyperVascular Pattern in Angiogram Patients are AsymptomaticPatients are Asymptomatic Possible precursor to HCCPossible precursor to HCC Resection is indicated only for Resection is indicated only for

Symptomatic FNHSymptomatic FNH

Benign Benign Liver TumorsLiver Tumors

HemangiomaHemangioma Most common benign tumor of LiverMost common benign tumor of Liver Is seen in the 3rd to 5rd decadesIs seen in the 3rd to 5rd decades Are less than 5 cm in diameterAre less than 5 cm in diameter May be Single or MultipleMay be Single or Multiple Usually are AsymptomaticUsually are Asymptomatic Complications are rareComplications are rare May be Cavernous & LobulatedMay be Cavernous & Lobulated Malignant transformation do not occurMalignant transformation do not occur Liver Resection rarely indicateLiver Resection rarely indicate

Malignant Liver TumorsMalignant Liver Tumors

OriginOrigin

From liver Cells:From liver Cells:HCC, Fibrolamellar CaHCC, Fibrolamellar Ca From Biliary Cells : From Biliary Cells : ICCAICCA From Mesodermal Cells:From Mesodermal Cells:Angiosarcoma,SarcomaAngiosarcoma,Sarcoma

Malignant Liver TumorsMalignant Liver Tumors

Hepatocelluler Carcinoma( HCC )Hepatocelluler Carcinoma( HCC )

90% of all Primary Liver Malignancy90% of all Primary Liver Malignancy 4Th Malignancy in the world4Th Malignancy in the world Common in Asia & AfricaCommon in Asia & Africa More common in MalesMore common in Males May seen even in ChildrenMay seen even in Children

Hepatic Primary MalignanciesHepatic Primary Malignancies

Malignant Liver TumorsMalignant Liver Tumors

Risk Factor of HCCRisk Factor of HCC

Cirrhosis due to : Cirrhosis due to : HCV,HBV,HemochromatosisHCV,HBV,Hemochromatosis

Alcoholic & Postnecrotic CirrhosisAlcoholic & Postnecrotic Cirrhosis Aflatoxin Longstanding Toxemia Aflatoxin Longstanding Toxemia Parasite Infestation of Clonorchis (ICCA)Parasite Infestation of Clonorchis (ICCA)

Malignant Liver TumorsMalignant Liver Tumors

Pathology of Pathology of HCCHCC

Hepatocellular CaHepatocellular Ca– HepatocytesHepatocytes

HepatoblastomaHepatoblastoma– Immature Immature

HepatocyteHepatocyte Fibrolamellar CaFibrolamellar Ca

– Eosinophili Eosinophili HepatocyteHepatocyte

Small HCC (< 2 Small HCC (< 2 Cm)Cm)

Unifocal ExpansiveUnifocal Expansive InfiltratingInfiltrating MultifocalMultifocal Vascular InvasionVascular Invasion

Malignant Liver TumorsMalignant Liver Tumors

Diagnosis of HCCDiagnosis of HCC

UltrasonographyUltrasonography Serial Alpha _ Serial Alpha _

Fetoprotein Fetoprotein Alkaline phosphataseAlkaline phosphatase Hepatic ArteriographyHepatic Arteriography

Liver Isotope ScanLiver Isotope Scan CT & MRICT & MRI

Malignant Liver TumorsMalignant Liver Tumors

Clinical Presentation of HCCClinical Presentation of HCC

Weight loss & Weakness 80 %Weight loss & Weakness 80 % Abdominal Pain & Fullness 50%Abdominal Pain & Fullness 50% Portal HypertensionPortal Hypertension Jaundice 20-50 %Jaundice 20-50 % Hypoglycemic IntervalHypoglycemic Interval AscitesAscites

Malignant Liver TumorsMalignant Liver Tumors

Fibrolamellar CarcinomaFibrolamellar Carcinoma

Occur in Western HemisphereOccur in Western Hemisphere Younger Age 20 to 35 yearsYounger Age 20 to 35 years More common in Lt LobeMore common in Lt Lobe Occur in Normal LiverOccur in Normal Liver Better prognosis than HCCBetter prognosis than HCC Better Response to Surgery Better Response to Surgery

Malignant Liver TumorsMalignant Liver Tumors

IIntraHepatic ntraHepatic CCholangioholangioCaCarcinomarcinoma

Rare TumourRare Tumour Normal underlying LiverNormal underlying Liver May seen in Caroli & PSCMay seen in Caroli & PSC May be local or diffuseMay be local or diffuse Have a poor PrognosisHave a poor Prognosis

Malignant Liver TumorsMalignant Liver Tumors

AngioSarcomaAngioSarcoma

Most frequent Sarcoma of the liverMost frequent Sarcoma of the liver 1% of All Primary Malignancy of Liver1% of All Primary Malignancy of Liver Involved Entire liverInvolved Entire liver An Association with(An Association with(Anabolic Steroids,Estrogens,OCPAnabolic Steroids,Estrogens,OCP)) Male to Female 3/1Male to Female 3/1 Age Time Of Diagnosis 50_ 70 Age Time Of Diagnosis 50_ 70 May Progress to HaemangioendotheliomaMay Progress to Haemangioendothelioma Poor Prognosis Poor Prognosis

Malignant Liver TumorsMalignant Liver Tumors

Treatment Options of HCCTreatment Options of HCC

Liver ResectionLiver Resection Liver TransplantationLiver Transplantation Systemic Chemotherapy ?Systemic Chemotherapy ? TransArterial Embolization TransArterial Embolization

( Lipiodol)( Lipiodol) Percutaneous Ethanol InjectionPercutaneous Ethanol Injection CryoSurgery ( liquid Nitrogen )CryoSurgery ( liquid Nitrogen ) Radiation Therapy ?Radiation Therapy ? RF I .T. TRF I .T. T

Hepatic Metastatic NeoplasmsHepatic Metastatic Neoplasms

B. Nakhaei, M.DB. Nakhaei, M.D

Most Common Malignancy of the LiverMost Common Malignancy of the Liver 1/201/20 Primary to Secondary Primary to Secondary Liver is Second only to Regional lymph nodesLiver is Second only to Regional lymph nodes 25%_ 50%25%_ 50% of dying patients have Liver of dying patients have Liver

MetastasisMetastasis Mitotic count of Metastasis is Mitotic count of Metastasis is 55 times times

greater than Primary Lesiongreater than Primary Lesion

RoutesRoutes of Metastasis to theof Metastasis to the LiverLiver

Portal CirculationPortal Circulation Lymphatic spreadLymphatic spread Hepatic Arterial SystemHepatic Arterial System Direct ExtensionDirect Extension

LiverLiver MetastasisMetastasis Clinical Clinical Manifestations :Manifestations :

Hepatic pain Hepatic pain Ascites Ascites Jaundice Jaundice AnorexiaAnorexia Weight lossWeight loss

Hepatic nodularity Hepatic nodularity Audible friction rubAudible friction rub Portal Portal

hypertension hypertension Flushing Flushing

SyndromeSyndrome

Liver Liver Metastasis Metastasis Timing of AppearanceTiming of Appearance

Precocious Precocious ( Carcinoid of the Ileum)( Carcinoid of the Ileum) SynchronousSynchronous ( Most GI Cancers )( Most GI Cancers ) MetachronousMetachronous ( Ocular Melanoma)( Ocular Melanoma)

LiverLiver MetastasisMetastasis Surgical treatment if :Surgical treatment if :

Control of primary tumor Control of primary tumor No systemic or intra- abdominal MetastasesNo systemic or intra- abdominal Metastases Good patient,s condition Good patient,s condition Extent of hepatic involvement Extent of hepatic involvement No more than 4 metastases No more than 4 metastases Primaries in Colon & Rectum & Wilms, Primaries in Colon & Rectum & Wilms, Debulking for other tumor ( ovary , Debulking for other tumor ( ovary ,

stomach, breast , cervix ,.... )stomach, breast , cervix ,.... )

ReferencesReferences

HepatoBiliary & Pancreatic SurgeryHepatoBiliary & Pancreatic Surgery– James Garden 2th Edition 2001James Garden 2th Edition 2001

Principles of SurgeryPrinciples of Surgery– Schwartz 7th Edition 1999Schwartz 7th Edition 1999

ACS Surgery 2001ACS Surgery 2001 Text Book of SurgeryText Book of Surgery

– Sabiston 16Th Edition 2001Sabiston 16Th Edition 2001

B, Nakhaei, M.D.B, Nakhaei, M.D.