evaluation of the incidental solitary liver...
TRANSCRIPT
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Lewis R. Roberts, PhD, FAASLD
Evaluation of the Incidental
Solitary Liver Lesion
Postgraduate Course:
Challenges in Management of Common Liver Diseases
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© 2016 AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES
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Questions for Reviewers:
1. Is it ok to leave out simple cyst
and abscess slides – 23,24,25?
2. Are LIRADS slides needed –
30,31?
3. Any other suggested changes?
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A 39 year old female with a 2 cm solitary lesion
on ultrasound and normal liver chemistries
Key Questions/Content Focus:
• Present an algorithm for investigation of
incidental solitary solid liver lesions.
• How does one differentiate a benign from a
malignant lesion?
• Do adenomas and focal nodular hyperplasia
need to be followed and if so, how? © 2016 AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES
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Case
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Objectives
• Clinical classification of liver masses
• Evaluation of liver mass lesions
• Common benign mass lesions • Clinical features • Imaging characteristics • Optimal management
• Common malignant mass lesions • Hepatocellular Carcinoma • Cholangiocarcinoma • Metastases from other Primary Sites
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Three Categories of Liver Masses
1. Benign lesions usually requiring no further intervention
2. Benign lesions requiring further investigation and therapy
3. Malignant lesions requiring appropriate management
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1. Benign lesions usually requiring no further intervention
• Cavernous hemangioma
• Focal nodular hyperplasia
• Simple cyst
• Focal fatty change or sparing
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2. Benign lesions requiring further
investigation and therapy
• Hepatic adenoma and adenomatosis
• Biliary cystadenoma
• Hepatic abscess – pyogenic or amebic
• Echinococcal cyst
• Granulomatous inflammation
• Inflammatory pseudotumor
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3. Malignant lesions requiring appropriate
management
• Metastases from other primary sites
• Hepatocellular carcinoma
• Cholangiocarcinoma
• Biliary cystadenocarcinoma
• Lymphoma
• Hepatic angiosarcoma
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Clinical Approach to Liver Mass Lesions
• Symptoms
• Physical examination
• Laboratory studies
• Imaging characteristics: Ultrasound, CT,
MRI (especially with newer hepatobiliary
contrast agents)
• Need for biopsy
• Optimal management 355
Cavernous Hemangioma: Histology
Large hemangiomas
may have areas of
thrombosis, scarring,
and calcification
Network of vascular spaces separated by thin, fibrous stroma
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Pre-contrast
Arterial phase
Venous phase
Peripheral nodular arterial phase enhancement,
with fill-in to the center in the venous phase
45 y o F with a Liver Mass
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Focal Nodular Hyperplasia: Histology
• Benign reaction to congenital arterial malformation
• Vascular stellate scar and septal fibrosis
• Polyclonal hepatocytes and functioning bile ductules
• Aspirates indistinguishable from adenoma 361
Sodium Gadoxetate MRI for
Distinguishing FNH from Adenoma
• Brightly enhancing in arterial phase
• Homogeneous enhancement with central scar
• Isointense in portal venous phase
• Retained intensity in the hepatobiliary phase supports the diagnosis of FNH
Arterial Portal Venous Hepatobiliary
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Histopathology of Adenoma
Monoclonal hepatocytes
Prominent “naked” arteries
No normal portal tracts or bile ducts
Adenoma
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β-catenin Exon 3 Mutated Adenomas
have Higher Risk of Malignancy
Normal Membrane
Staining
Positive Nuclear
Staining 365
Gadobenate Dimeglumine MRI for
Distinguishing FNH from Adenoma
• Heterogeneous arterially enhancing mass • Isointense in portal venous phase • Decreased intensity in the hepatobiliary
phase suggests HNF1A mutated adenoma • Inflammatory and β-catenin mutated
adenomas may retain contrast
Arterial Portal Venous Hepatobiliary
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Management of Hepatic Adenomas
• Follow up 6 mo, q 1 yr x 5 yrs, then q 2 yrs
• High Risk: Resect
• Lesions ≥ 5 cm (or increasing size)
• Hemorrhage
• Male Gender (increased malignant risk)
• β-Catenin mutated adenomas
• Older females with no history of OCP use
• Low Risk: Stop OCPs, lose weight
• Young Females, lesions < 5 cm on OCP
• Follow w US q 6-12 weeks during pregnancy
• Alternatives to Resection: RFA, embolization 368
Imaging Characteristics of Liver Cysts
Ultrasound
• Best test
• No internal echoes
• No flow on color flow
or duplex Doppler
• Through transmission
• Well-defined posterior
walls
• May have thin
echogenic septa 369
Symptomatic Cyst in a 72 y o F with Painless Jaundice and Leg Edema
Presentation
1 year after cyst aspiration
& EtOH sclerosis 2 years later
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Pyogenic Liver Abscess
• Rupture or leak of
bile duct or bowel
• Biliary stenting,
instrumentation, or
chemoembolization
• Increased risk in
diabetes mellitus
• Biliary: enteric gram
-ves & enterococci
• Other sites: mixed
aerobic & anaerobic
41 yo F with new diagnosis of type 1 diabetes mellitus with ketoacidosis and liver mass
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Imaging Characteristics of Focal Fat:
65 y o Woman Referred for Presumed
Gallbladder Adenocarcinoma
Ultrasound Hyperechoic
T1 Weighted In & Out of Phase
3 Month Follow-Up
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• Epidemiology:
• Fatty liver is increasingly common
• Focal fatty infiltration looks like a mass
• Also focal sparing in diffuse fatty infiltration
• Associations:
• Obesity
• Diabetes mellitus
• High alcohol consumption
• Altered metabolism due to chemotherapy
Focal Fat or Fat Sparing
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Non-Invasive Diagnosis: Arterial Enhancement, Venous Washout, Capsule and Threshold Growth
Arterial
Portal
Late venous phase 375
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Lesion
Characteristics
LIRADS System for HCC Diagnosis
Schema
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20 year old F with Long History of Vague Symptoms and Large Liver Mass
Fibrolamellar Subtype of HCC
Arterial phase Portal phase
• Young females
• Lymph node metastases
• Aggressive surgery recommended
• DNAJB1-PRKACA Chimeric Transcripts 378
Intrahepatic CCA
Perihilar CCA
Distal CCA
Image Courtesy of Dr. Gregory Gores
Gall bladder
Cystic duct
Pancreas
Cholangiocarcinoma (CCA)
Small
intestine
Liver
Bile duct
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Imaging and Pathology of CCA
Intrahepatic Cholangiocarcinoma
Histopathology Peripheral
Enhancement
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Case
A 39 year old female with a 2 cm solitary lesion
on ultrasound and normal liver chemistries
Key Questions/Content Focus:
• Present an algorithm for investigation of
incidental solitary solid liver lesions.
• How does one differentiate a benign from a
malignant lesion? Imaging and/or biopsy
• Do adenomas and focal nodular hyperplasia
need to be followed and if so, how? Follow
adenomas – 6 mo, q 1 yr x 5 yrs, then q 2 yr 382
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Summary
• History, physical, and laboratory tests are important in the evaluation of liver masses
• Imaging techniques allow distinction between most benign and malignant liver masses
• Repeat imaging after an interval or biopsy when the diagnosis remains uncertain
• The commonest conundrum is the distinction between FNH and adenoma
• Focal fat or sparing in a fatty liver frequently masquerade as a mass
• HCCs show distinct differences from adenocarcinomas such as cholangiocarcinoma
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Thank You for Your Attention!
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