in the name of god l iver masses general overview behzad nakhai, m.d.,fics fellowship in...
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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
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LiverLiver Masses In Masses In GeneralGeneral
LiverLiver Cystic Cystic Masses Masses LiverLiver BenignBenign Masses Masses LiverLiver MetastaticMetastatic Masses Masses LiverLiver Malignant Malignant Masses Masses
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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)
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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
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Types ofTypes of LiverLiver CellsCells
HepatocytesHepatocytes– { Parenchymal { Parenchymal
cells }cells } MacrophagesMacrophages
– { Kupffer cells }{ Kupffer cells }
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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)
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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
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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
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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
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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
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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
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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
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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
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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
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RoutesRoutes of Metastasis to theof Metastasis to the LiverLiver
Portal CirculationPortal Circulation Lymphatic spreadLymphatic spread Hepatic Arterial SystemHepatic Arterial System Direct ExtensionDirect Extension
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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
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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)
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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 ,.... )
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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.