liver mass - how to investigate?
DESCRIPTION
Liver space occupying lesion, Liver lesion- how to investigate and how to manage.TRANSCRIPT
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Dr Harshal Rajekar MS MRCS DNBHPB, GI and Transplant Surgeon
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Dr Harshal Rajekar MS MRCS DNB
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HISTOLOGICAL CLASSIFICATION OF TUMOR-LIKE PRIMARY HEPATIC SPACE-OCCUPYING LESIONS
Hepatocellular 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 hamartoma
2. Inflammatory pseudotumor
3. Pseudolymphoma
4. Solitary necrotic nodule
5. Peliosis hepatis
6. Hereditary hem. Telangiectasia
7. Sarcoidosis
8. Nodular extramed. Hematopoiesis
9. Abscess
10. Tuberculoma
11. Botryomycosis
12. Malacoplakia/ adrenal rest tumor
13. Granulomas
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History Clinical examination Lab – Hemogram, LFT, Albumin,INR Serology – ALA , Hydatid Tumor markers – AFP,CEA, CA 19-9
Dr Harshal Rajekar MS MRCS DNB
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Asymptomatic Nodule on screening in cirrhotic patients Presenting with pain and fever SOL in a known patient of extrahepatic
malignancy
Dr Harshal Rajekar MS MRCS DNB
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Algorithm for Solitary SOL of Liver on USG
Dr Harshal Rajekar MS MRCS DNB
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Algorithm for Solid lesions on USG
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Algorithm for Multiple Liver SOLs on USG
Dr Harshal Rajekar MS MRCS DNB
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Symptomatic lesions – no response to treatment
Alterations in LFT
Underlying liver disease
Dr Harshal Rajekar MS MRCS DNB
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When to do MRI ----- HCC vs regenerating nodule vs dysplastic nodule atypical lesions
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Usually not required
Diagnostic uncertainty
Dr Harshal Rajekar MS MRCS DNB
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Screening strategy
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27 year old male vague abdominl discomfort. significant loss of apetite. no history of liver disease. ?W eight loss over the past 4 months.
Dr Harshal Rajekar MS MRCS DNB
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Went to local doctor, had an abdominal ultrasound.
USG found a liver mass occupying most of right lobe.
What next?
Dr Harshal Rajekar MS MRCS DNB
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Imaging? CT scan.
Dr Harshal Rajekar MS MRCS DNB
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Bloods: Normal liver function tests, apart from a rai
sed Alkaline Phosphotase. Alpha Feto protein - >1,600,000 ng/dL
Dr Harshal Rajekar MS MRCS DNB
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30 female. unmarried, no other medical or
surgical disease. No jaundice. Vague abdominal pain. Post-prandial discomfort.
Dr Harshal Rajekar MS MRCS DNB
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went to GP, had an US scan. Large 15 cm cystic lesion in the
central part of the liver, reaching the hilum, with +/- septations.
Dr Harshal Rajekar MS MRCS DNB
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what next? Imaging? Blood tests? FNA?
Dr Harshal Rajekar MS MRCS DNB
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patients GP did all three. Blood tests:
- Alk Phosp.- >800, rest normal.- CECT - .....
Dr Harshal Rajekar MS MRCS DNB
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Did a US guided FNA of cyst fluid. Cytology showed dysplastic cells,
degenrate hepatocytes.
Dr Harshal Rajekar MS MRCS DNB
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Dr Harshal Rajekar MS MRCS DNB
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63 male. moderate alcohol intake. no co-morbidities. vague symptoms, weakness and abdominal
discomfort. episode of diarrhoeal illness.
Dr Harshal Rajekar MS MRCS DNB
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Investigated: - HBsAg +ve- USG abdomen deteccted a 4.5cm lesion in liver , seg 5/8, altered liver architechtexture.
What next?
Dr Harshal Rajekar MS MRCS DNB
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CECT - 4.5cm lesion in right lobe occupying seg 5/8, with another satellite ?8mm lesion in segment 8.
The liver had a nodular outline, no ascites, spleen size normal.
AFP -181 ng/mL
Dr Harshal Rajekar MS MRCS DNB
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Childs A status.- No jaundice.- No ascites.- INR 1.1- Noencephalopathy.- Albumin 3.6 g/dL
What next?
Dr Harshal Rajekar MS MRCS DNB
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Patient was offered TACE (chemo-embolization).
HBV treatment was commenced with tenofovir. Patient continued to do well, performance
status remained well. Repeat CT scan 8 months later showed an
increase in the size of the sae lesion to 10.5cm in diameter and the satellite lesion was around the same size at 1.2cm.
There were no new lesions. Liver function – Childs A. No PHT. What next?
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Offered repeat TACE. Tolerated procedure well. 1 month post TACE – patient himself got
a CT scan, showed a slight increase in size to 13.1 cm.
No new lesions.
What does this mean?
Dr Harshal Rajekar MS MRCS DNB
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3 months later. Repeat CT scan – multiple liver and lung
mets.
Dr Harshal Rajekar MS MRCS DNB
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54 yrs gentleman, no comorbidities Change in bowel habit incomplete evacuation No other GI symptoms
USG abdomen – hypo echoic liver lesions
Lab - normal
Dr Harshal Rajekar MS MRCS DNB
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Ulcero proliferative lesion in sigmoid colon
No synchronous lesions/polyps
Biopsy - adenocarcinoma
Dr Harshal Rajekar MS MRCS DNB
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FOLFOX + bevaxizumab – 7 cycles
FOLFOX – 5 cycles
Dr Harshal Rajekar MS MRCS DNB
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PET CT
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Sigmoid colectomy + left lateral segmentectomy
+ metastectomy (seg 4b, seg 5, seg 7)
Dr Harshal Rajekar MS MRCS DNB
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THANK YOU