Liver tumors & Liver TransplantationProf.C.P.Ganesh Babu

Common liver lesions

Classification of benign

liver lesions

CLASSIFICATIONhistological classification of tumor-like primary hepatic space-

occupying lesionsHepatocellular lesions:1. Focal nodular hyperplasia2. Nodular regenerative hyperplasia3. Partial nodular transformation 4. Adenomatoid hyperplasia5. Compensatory lobar hyperplasia6.Focal fatty change7. Accessory lobe

Bile duct lesions:1. Biliary microhamartoma2. Cyst and polycystic liver3. Ciliated foregut cyst4. Epidermoid cyst5. Intrahepatic peribiliary gland cyst6. Mesothelial cyst7. Cystic echinococcosis8.Biloma

Miscellaneous lesions:1. Mesenchymal hamartoma2. Inflammatory pseudotumor 3. Pseudolymphoma4. Solitary necrotic nodule5. Peliosis hepatis6. Hereditary hem. Telangiectasia 7. Sarcoidosis8. Nodular extramed. Hematopoiesis9. Abscess10. Tuberculoma11. Botryomycosis12. Malacoplakia/ adrenal rest tumor13. Granulomas

Classification

• Hemangioma• Focal nodular

hyperplasia• Adenoma• Liver cysts

1. Primary liver cancers• Hepatocellular

carcinoma• Fibrolamellar carcinoma• Hepatoblastoma

2. Metastases

Benign Malignant

Benign Liver Lesions

1. Hemangioma2. Focal nodular hyperplasia3. Adenoma4. Cysts

HemangiomaClinical Features

The commonest liver tumor5% of autopsiesUsually single smallWell demarcated capsuleUsually asymptomatic

HemangiomaDiagnosis and Management

Diagnosis• US: echogenic spot, well demarcated• CT: venous enhancement from periphery to

center• MRI: high intensity area• No need for FNAC or Biopsy

Treatment• No need for treatment

Focal Nodular Hyperplasia (FNH)Clinical Features

• Benign nodule formation of normal liver tissue• Central stellate scar• More common in young and middle age women• No relation with sex hormones• Usually asymptomatic• May cause minimal pain

Focal Nodular Hyperplasia (FNH)Diagnosis and Management

Diagnosis:• US: Nodule with varying echogenicity• CT: Hypervascular mass with central scar• MRI: iso or hypo intense • FNA: Normal hepatocytes and Kupffer cells with

central core.

Treatment:• No treatment necessary• Pregnancy and hormones OK

Hepatic AdenomaClinical features

• Benign neoplasm composed of normal hepatocytes no portal tract, central veins, or bile ducts

• More common in women• Associated with contraceptive hormones• Usually asymptomatic but may have RUQ

pain• presents with rupture, hemorrhage, or

malignant transformation (very rare)

Hepatic AdenomaDiagnosis and Management

DXUS: filling defectCT: Diffuse arterial enhancementMRI: hypo or hyper intense lesionFNA : may be needed

TxStop hormonesObserve every 6m for 2 yIf no regression then surgical excision

HemangiomaClinical Features

The commonest liver tumor5% of autopsiesUsually single smallWell demarcated capsuleUsually asymptomatic

Focal Nodular Hyperplasia (FNH)Clinical Features

• Benign nodule formation of normal liver tissue• Central stellate scar• More common in young and middle age women• No relation with sex hormones• Usually asymptomatic• May cause minimal pain

Hepatic AdenomaClinical features

• Benign neoplasm composed of normal hepatocytes no portal tract, central veins, or bile ducts

• More common in women• Associated with contraceptive hormones• Usually asymptomatic but may have RUQ

pain• presents with rupture, hemorrhage, or

malignant transformation (very rare)

Malignant Liver Tumors1. Hepatocellular carcinoma (HCC)2. Fibro-lamellar carcinoma of the liver3. Hepatoblastoma4. Intrahepatic cholangiocarcinoma5. Others

HCC: Incidence

• The most common primary liver cancer• The most common tumor in Saudi men• Increasing in US and all the world

HCC: Risk Factors

The most important risk factor is cirrhosis from any cause:

1. Hepatitis B (integrates in DNA)2. Hepatitis C3. Alcohol4. Aflatoxin5. Other

HCC: Clinical Features

Wt loss and RUQ pain (most common)AsymptomaticWorsening of pre-existing chronic liver disAcute liver failure

O/E:Signs of cirrhosisHard enlarged mass

HCC: Metastases

• Rest of the liver• Portal vein• Lymph nodes• Lung• Bone• Brain

HCC: Systemic Features

HypercalcemiaHypoglycemiaHyperlipidemiaHyperthyroidism

HCC: labs

• Labs of liver cirrhosis

AFP (Alfa feto protein)• Is an HCC tumor marker• Values more than 100ng/ml are highly

suggestive of HCC• Elevation seen in more than 70% of pt

HCC: Diagnosis

• Clinical presentation• Elevated AFP• US• Triphasic CT scan: very early arterial

perfusion• MRI• Biopsy

US: HCC

CT: Venous Phase

CT: Arterial Phase

HCC: Prognosis

• Tumor size• Extrahepatic spread• Underlying liver disease• Pt performance status

HCC: Liver Transplantation

• Best available treatment• Removes tumor and liver• Only maximum 3 tumors with largest less

than 6 cm of total size less than 8Recurrence rate is low

• Not widely available• costly

HCC: Resection

Feasible for small tumors with preserved liver function (no jaundice or portal HTN)Recurrence rate is high

HCC: Local Ablation

• For non resectable pt• For pt with advanced liver cirrhosis• Alcohol injection• Radiofrequency ablation• Temporary measure only

Radio Frequency Ablation

Ethanol Injection

HCC: Chemoembolization

• Inject chemotherapy selectively in hepatic artery

• Then inject an embolic agent• Only in pt with early cirrhosis• No role for systemic chemotherapy

Chemoembolization

Fibro-Lamellar Carcinoma

Presents in young pt (5-35)Not related to cirrhosisAFP is normalCT shows typical stellate scar with radial septa showing persistant enhancement

Secondary Liver Metastases

• The most common site for blood born metastases

• Common primaries : colon, breast, lung, stomach, pancreases, and melanoma

• Mild cholestatic picture (ALP, LDH) with preserved liver function

• Dx imaging or FNA• Treatment depends on the primary cancer• Incase of metastasis from intestinal cancer or

neuroendocrine cancer. Surgery can offer cure.

Summary

• Hemangioma• Focal nodular

hyperplasia• Adenoma• Liver cysts

1. Primary liver cancers

• Hepatocellular carcinoma

• Fibrolamellar carcinoma• Hepatoblastoma

2. Metastases

Benign Malignant

I am a non-complainer I can't and won't tell you I'm in trouble

untilI'm almost at the end of my rope... and

yours.

Your….. Liver

If…..the functioning of liver is inadequate to meet the

requirement of body

© 2007 Thomson - Wadsworth

What Happens When Liver Fails

Causes of Liver Cirrhosis• Acute Liver Failure• Alcoholic cirrhosis

– Represents the most common cause of cirrhosis5

• HCV– HCV is the most frequent diagnosis in patients

undergoing liver transplantation1

– Viral recurrence is nearly universal, with up to 30% of patients progressing to cirrhosis1,2

• HBV• HCC

– Accounts for 90% of all liver cancers3

– Causes 50% to 70% of liver-related mortality among patients with cirrhosis4

– Incidence and mortality is rising4

Viral hepatitis (40%)

Alcoholic hepatitis (32%)

Primary biliary cirrhosis (10%)

Unknown (7%)

Viral + alcoholic hepatitis (5%)

Autoimmune hepatitis (4%) Other causes

(2%)

Causes of cirrhosis

Source: CDC. Slide 45. ftp://ftp.cdc.gov/pub/infectious_diseases/hepatitis/slides/technote.

txt.

HCV = hepatitis C virus; HCC = hepatocellular carcinoma; HBV = hepatitis B virus1. Berenguer M, et al. Hepatology. 2002;36:202–10; 2. Berenguer M, et al. J Hepatol. 2001;35:666–78; 3. Jelic S, Sotiropoulos GC. Ann Oncol. 2010;21 (Suppl 5):v59–64; 4. Varela M, et al. Liver Transpl. 2006;12:1028–36; 5. Murray KF, Carithers RL. Hepatology. 2005;41:1407–32 41

Treatment of liver failure

Liver Transplant

1967 : 1st successful Liver Transplant

1989 : 1st successful LDLT ( Adult to child )

1998 : 1st successful LDLT ( Adult to Adult )

• Chronic Liver Disease - One of top ten cause of death in India

• About 2,00,000 Indians die of liver failure every year.

• 25,000 liver transplants need to be done every year in India.

• Only 1,100 transplants performed in India every year

Indian Scenario

Determine the need for transplant

Confirm all effective treatments have been

exhausted

Assess whether patient is an appropriate candidate

When to Consider Transplantation?

Liver transplant surgery carries a risk of significant complications, including:

• Bile duct complications, including bile duct leaks or shrinking of the bile ducts

• Bleeding• Blood clots• Failure of donated liver• Infection• Memory and thinking problems• Rejection of donated liver

What risks are involved?

• Most liver transplant recipients are able to return to a normal and healthy lifestyle

• Most report that they feel re-energized, have an improved quality of life and enjoy everyday activities once more

• Liver transplant recipients are able to participate in normal exercise after their recuperation and women are able to conceive and have normal post-transplant pregnancies and deliveries

QOL after tx

Right hepatectomy complex surgery

Bile leak well recognized complication

Wound pain quite common

Psychological trauma in case of recipient death

Overall risk -0.1-0.2%

The risk to living liver donor

Don’t drown me in alcohol

Watch those drugs, can harm me. No medications without consulting doctor

Don’t eat too much of fatty food.Get Shots against

Hepatitis A and B

Don’t have unsafe sex, don’t share needles/syringes, personal items like razors.

Pledge your organs

Save a life

Don’t Take me to heaven, no one needs me there!