abdalla benign liver masses - excellence.creighton.edu · 8/21/2018 5 benign liver masses adapted...
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Benign Liver Masses
Adil Abdalla, MBBS
Creighton University-CHI Health
August 25, 2018
Financial Disclosure
Nothing to discloseFinancial Disclosure
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Objectives
To assess patients with benign liver tumors
To recognize the key radiologic findings
To understand indications of intervention
Case: A 41 yr old woman who is undergoing an US scan
for infertility evaluation is noted to have a 3cm hyperechoic mass in the Lt lobe of the liver. She is otherwise well and has no risk factor or physical exam findings to suggest chronic liver disease. LFTs and AFP levels are normal. What is the most appropriate next step in the care of this patient?
1. Hepatic artery embolization.
2. Contrast-enhanced MRI.
3. No further treatment or testing.
4. Radiology-guided biopsy of the mass
5. Surgical resection of the mass
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Primary Liver Lesions
Liver lesions
NeoplasmAbscessCyst
Benigntumors
Malignanttumors
Differential Diagnosis of Liver Mass?
Is it an incidentaloma?
Clinical circumstances
-Age.
-Sex.
-OCP.
Imaging characteristics:
-Modality. -Numbers, size, features
-Chronic liver disease.
-Travel
-Extrahepatic malignancies.
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You have a liver mass!!!
Having an answer:
-Benign Vs malignant?
-Primary Vs metastatic?
Avoid extensive testing.
Avoid unnecessary biopsy or surgery.
Are the symptoms connected to the presence of a liver mass?
Incidentalomas: Most Often Benign Benign lesion are common:
Incidence 7-9 %
Autopsy up to 20% of population
Concerns of benign masses:
Difficulty to differentiate form malignancy.
Few have the potential for complications
Important to recognize the features of the common benign liver tumors.
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Benign Liver Masses
Adapted from Bahirwani et al, Aliment pharmacol Ther 2008
Benign Tumors
Hepatocellular:AdenomaFocal nodular hyperplasiaNodular regenerative hyperplasiaRegenerating nodules
Mesenchymal:HemangiomaAngiolipomaLeiomyomaInfantile Hemangioendothelioma
Others:HamartomaTeratomaPancreatic restAdrenal rest
Cholangiocellular:Bile duct adenomaBiliary cystadenoma
Modified from http://acgmeetings.gi.org/pdfs/09pgcourse/ACG2009PG1042.PDF
Benign Liver Masses
Hemangioma 55%
FNH 21%
Adenoma 19%
Others 5%
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Accuracy of US, CT, MRI and Angiography in evaluating liver masses
Torzilli et al, hepatology 1999
Accuracy Specificity Positive predictive value
Negativepredictive value
Benign lesions
98.7% 100% 100% 98.6%
HCC 99.6% 98.9% 99.3% 100%
Metastatic lesion
99.1% 98.8% 96.9% 100%
Hemangioma
From: Tumors of the Liver and Intrahepatic Bile Ducts by Ishak
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Hemangioma Most common benign tumor of the liver.
Prevalence 3-20%.
Size 1—20 cm
Female: Male = 3-6:1, age 30-70.
Possible hormonal influence
Arise from endothelial lining, well demarcated capsule.
Symptoms very rare.
Bleeding: exceedingly rare even with large lesions.
No malignant transformation.
Gandolfi et al, Gut 1991Bahirwani et al, Aliment Pharmacol Ther 2008Choi et la, J Clin gatroentrol
Hemangioma, Radiological Findings
US: Well demarcated hyperechoic mass.
Unenhanced CT: Hypo-attenuated mass.
Contrast-enhanced CT: Sequential opacification (peripheral to centripetal fill-in).
Jay Heiken, Cancer Imaging 2007Choi et al, J Clin Gatroentrol 2005
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MRI T2: high intensity
Jay Heiken, Cancer Imaging 2007Choi et al, J Clin Gatroentrol 2005
MRI T1: early enhanced
MRI T1: delayed enhanced
Hemangioma, Treatment
Stop, leave it alone.
If treatment is needed (extremely rare):
-Enucleation.
-Resection.
-Embolization.
-Hepatic irradiation.
-Transplantation.
Nghiem et al, AJR Am J Roentgenol. 1997Bahirwani et al, Aliment Pharmacol Ther 2008Choi et al, J Clin Gatroentrol 2005
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Focal Nodular Hyperplasia
From: Tumors of the Liver and Intrahepatic Bile Ducts by Ishak
Focal Nodular Hyperplasia
Second most common benign tumor of the liver.
Prevalence 2.5-8%.
Mainly in women, 3rd-4th decades.
Female: Male = 8:1
Size: mostly 3-5 cm, near the surface.
Asymptomatic (only ~10% with symptoms).
Bahirwani et al, Aliment Pharmacol Ther 2008Choi et al, J Clin Gatroentrol 2005
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Focal Nodular Hyperplasia, cont.
Pathogenesis: focal congenital malformation of the hepatic vasculature.
-Increase local blood flow.
-Hyperplasia.
No clear association with OCP (may accelerate growth).
Complications:
-Bleeding: extremely rare.
-No malignant potential.Geders et al, Hepatology 1995Shortell et al, Surg Gynecol Obstet. 1991Fukukura et al, J Hepatol 1998
Pre: Homogenous and isoattenuating
Bahirwani et al, Aliment Pharmacol Ther 2008
Arterial: Bright with hypodense central scarring
Portal venous phase Delay phase
FNH CT
Characteristic (not present): radiating hypodense fibrous bands and septa that arise from the scar, seen in delayed films
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FNH MRI:
Jay Heiken, Cancer Imaging 2007
Gadolinium-enhanced: mass enhancement, hypointensescar and fibrous septa
T2: mass isointense, scar hyperintense
Unenhanced T1: isointense, hypointense central scar
Delayed postcontrast: mass isointense, scar hyperintense
Focal Nodular Hyperplasia, Treatment:
Asymptomatic patients, clear diagnosis:
-No further treatment is necessary.
-Close F/U during pregnancy.
Symptomatic Patients:
-Surgical resection.
-Transarterial embolization.
Choi et al, J Clin Gatroentrol 2005
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Hepatic Adenoma (HA)
From: Tumors of the Liver and Intrahepatic Bile Ducts by Ishak
Hepatic Adenoma (HA) Mostly in femals (>30 years), F: M=4:1
Mostly solitary, well circumscribed, round, uncapsulated (or pseudocapsule). Symptomatic in ~25-50% of patients.
Annual incidence:
-No OCP: 1-1.3 per million
-> 5 years OCP: 30-40 per millionSherlock S, Gut 1975Rooks et al, JAMA 1979Bahirwani et al, Aliment Pharmacol Ther 2008
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Etiologic Factors and Diseases Associated with Adenoma
Shrinks when OCP stoppedFrom: Tumors of the Liver and Intrahepatic Bile Ducts by Ishak
Hepatic Adenoma, Histology
Proliferation of hepatocytes
No portal tract or bile ductules.
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Hepatic Adenoma, Potential for Serious Complications
> 5 cm:
-Rupture, malignancy.
Increasing size:
-Rupture, malignancy.
If not decrease when OCP stopped
-Malignancy.
Risk of malignant transformation~ 10%.Mortele et al, Clin Liver Dis. 2002Bahirwani et al, Aliment Pharmacol Ther 2008Choi et al, J Clin Gatroentrol 2005
Adenoma, US and CT
US: variable and nonspecific:-Hypoechoic: simple-Hyperechoic: fat, hemorrhage-Mixed-echoic: fat, hemorrhage and necrosis.
CT: heterogeneous due to fat, hemorrhage, and necrosis.
-Contrast CT: enhancement, but less than FNH.-Portal phase: isodense.
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Adenoma, MRI with Gadobenate Dimeglumine
Roberts, Mayo GI Board Review, 3rd Ed
Arterial, hyperenhancement Venous, isoenhancement
Delayed hepatobiliary
Do We Need To Get Beta Catenin Staining for Adenoma?
Normal (negative) Staining Positive Staining
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Hepatic Adenoma, Treatment
If < 5cm, stop OCP and F/U US.
If has potential risk of complications or causing symptoms:
-Surgical enucleation
-Resection
-Transplantaion
-Arterial embolization.
Grazioli et al, Radiographics 2001Terkivatan et al, Arch Surg 2001Choi et al, J Clin Gatroentrol 2005
Adenoma: Multiple Lesion
Choi et al, J Clin Gatroentrol 2005
Multiple Hepatic Adenomas Liver Adenomatosis (>10)
Females > males Female =male
Prolonged OCP No OCP
GSD No GSD
Normal LFT Possible high AP, GGT
Treatment:-Stop any OCP, no pregnancy, US q 6 months.-Liver transplant: if risk factors present.
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Benign Masses with Atypical Imaging Features
Jay Heiken, Cancer Imaging 2007Bahirwani et al, Aliment Pharmacol Ther 2008Grazioli et al, Radiology 2005Choi et al, J Clin Gatroentrol 2005
Technetium-99m labeled RBC scintigraphy: defect in the early scan, prolonged and persistent uptake on delay scans diagnostic for hemangioma.
Scintigraphy with 99m TC-sulfur-colloid: high uptake by FNH, low or “absent” in adenoma.
MRI with Gadobenate Dimeglumine (Gd-GOPA): FNH enhances on delayed scans, adenoma does not.
When Do We Need Liver Biopsy?
Only in equivocal cases in which all imaging modalities fail to establish a firm diagnosis.
Issues with biopsies:
-Cost
-Morbidity
-Mortality
-Seeding
-Non-diagnostic
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Algorithm, Liver Mass, Asymptomatic patient
Modified from Choi et al, J Clin Gatroentrol 2005
LFTs, viral serology, AFP, CBC
Normal, nonspecific LFTs
US
Cystic Solid
Yes
Simple cystic structure
No
Observe Further evaluation
Abnormal
Evaluation R/O HCC, met
Dynamic CT or MRI
LFTs, viral serology, AFP, CBC
Normal, nonspecific LFTs
US
Cystic Solid
Simple cystic structure
No
Algorithm, Liver Mass, Asymptomatic patient
Modified from Choi et al, J Clin Gatroentrol 2005
Dynamic CT or MRI
Characteristic imaging of hemangioma
Yes
Observe
No
NoYes
Central scar on CT or MRI
No
Biopsy
99mTc scintigraphy
ObserveResectionBiopsy
Probable adenoma
Characteristic increased uptake
YesFocal nodular hyperplasia
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Conclusion
Hemangioma: Peripheral to centripetal fill-in.
FNH: Central scar.
Adenoma: Sometimes difficult to diagnose.
Risk for complications.
Most patients die with a benign liver lesion rather than from it
Case #1: A 41 yr old woman who is undergoing an US scan
for infertility evaluation is noted to have a 3cm hyperechoic mass in the Lt lobe of the liver. She is otherwise well and has no risk factor or physical exam findings to suggest chronic liver disease. LFTs and AFP levels are normal. What is the most appropriate next step in the care of this patient?
1. Hepatic artery embolization.
2. Contrast-enhanced MRI.
3. No further treatment or testing.
4. Radiology-guided biopsy of the mass
5. Surgical resection of the mass
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Case #2: A 35 yr old male bodybuilder was seen by PCP for
RUQ fullness and dyspepsia. US showed a 6 cm hepatic lesion. He does not have any liver disease and basic labs are normal. MRI ordered by GI demonstrated a large, sub-capsular, homogeneously-enhancing mass in segment 2. Biopsy of the lesion confirmed a hepatic adenoma. Your recommendation would be?
1. Repeat imaging in 6 months.
2. Refer to UNMC for liver transplant evaluation.
3. No further treatment or testing.
4. Refer for surgical resection.