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🏥 LIVER TUMORS - Key Points

BENIGN TUMORS

1. HEMANGIOMA

• Most common benign liver tumor
• Types: Capillary (multiple, asymptomatic) vs Cavernous (solitary, large, symptomatic)
• Diagnosed incidentally on USG; confirmed by triphasic CT
• CT finding: asymmetrical peripheral enhancement (arterial phase) → centripetal enhancement (venous phase)
• Biopsy is CONTRAINDICATED - risk of fatal haemorrhage
• Treatment: Asymptomatic = no treatment; Symptomatic/mass effect = resection

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2. HEPATIC ADENOMA

• Rare benign tumor, associated with OCP (oral contraceptive pills) - synthetic estrogen/progesterone
• Seen in young women (20-40 years)
• Histology: hepatocytes with glycogen, no portal triads, no Kupffer cells, no bile duct cells, separated by a capsule
• Presents with: mass, intraperitoneal bleeding, pain; rupture risk during pregnancy
• Diagnosis: Triphasic CT (similar to HCC but less vascular); biopsy for confirmation
• Treatment: Resection (pre-malignant + rupture risk); small asymptomatic lesions regress with stopping OCP

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3. FOCAL NODULAR HYPERPLASIA (FNH)

• Benign, common in women of childbearing age, NOT associated with OCP
• Reaction to injury, not a true neoplasm
• CT: homogenous enhancement on arterial phase, central scar (better seen on MRI)
• Key differentiator from adenoma: Technetium sulphur colloid scan - FNH takes up tracer (has Kupffer cells); adenoma does NOT
• No malignant potential - asymptomatic lesions need no treatment

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MALIGNANT TUMORS

4. HEPATOCELLULAR CARCINOMA (HCC) ⭐

• Most common primary liver malignancy - accounts for 80% of primary liver cancers
• In Pakistan: 80% associated with Hepatitis C-related cirrhosis

• 40% asymptomatic at diagnosis
• Weakness, weight loss (85%), mass in right hypochondrium, anemia, jaundice
• Age: 40-50 years

• AFP raised in 35-75%; level >400 ng/ml (normal: 20 ng/ml) is highly suggestive
• Triphasic CT (liver dynamic scan): diagnostic in >90% - no biopsy needed in most cases
• Biopsy needed in <5% when CT findings are atypical

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HCC Treatment:

• Resection only if: early cirrhosis (Child A), no portal hypertension, peripheral tumor, normal/mildly elevated WHVP

• Solitary lesion < 6.5 cm
• Up to 3 nodules, each < 4.5 cm, total diameter < 8 cm
• No vascular invasion, no extrahepatic disease

• Percutaneous ethanol injection - ultrasound guided, for small lesions (2-3 cm)
• RFA (Radiofrequency Ablation) - thermal waves, good for lesions ≤4 cm; NOT for subcapsular or near major vessels
• TACE - chemotherapy (doxorubicin) via hepatic artery then blocked with gel foam; median survival increased to 20 months for intermediate-stage HCC

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5. METASTATIC NEOPLASMS OF LIVER

• 20x more common than primary liver carcinoma
• Common primaries: GIT (colorectal) > Breast > Lung > Pancreas > Kidney
• Presentation: fatigue, anorexia, weight loss, palpable mass
• CEA > 5 ng/ml = highly suggestive of colorectal primary
• Investigations: USG/CT/MRI + Colonoscopy + PET scan
• Surgery: 5-year survival 37-53% for colorectal liver metastasis

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6. SIMPLE LIVER CYST

• Common incidental finding on USG
• Criteria: thin-walled, unilocular, no density variation
• Asymptomatic = no treatment; large symptomatic cyst → laparoscopic deroofing
• Aspiration alone = associated with recurrence

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7. POLYCYSTIC LIVER DISEASE

• Congenital, autosomal dominant; associated with kidney/pancreas cysts
• Usually asymptomatic; does not affect liver function
• Large cyst → abdominal discomfort; severe pain = haemorrhage in cyst
• Treatment: asymptomatic = none; large symptomatic cysts = fenestrated laparoscopically

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8. PYOGENIC LIVER ABSCESS

• Incidence: 0.016% - most common liver abscess in USA
• Amoebic liver abscess more common worldwide

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Quick memory hooks:

• Hemangioma = NO biopsy
• Adenoma = OCP + young women + resect
• FNH = Technetium positive (Kupffer cells present)
• HCC AFP >400 = highly suggestive
• UCSF criteria: single <6.5cm or ≤3 nodules <4.5cm each
• Sorafenib = only systemic chemo for HCC
• Metastasis 20x > primary; colorectal most common