In the Name of GOD L iver Masses General Overview

1. In the Name of GODLiver Masses General Overview Behzad Nakhai, M.D.,FICS Fellowship in HepatoBiliarySurgery Asso Professor Iran University of Medical Sciences Tehran , Islamic Republic of Iran

2. Liver Masses In General • LiverCystic Masses • LiverBenign Masses • LiverMetastatic Masses • LiverMalignant Masses

3. LiverinGeneral • 1/50 of total body weight • Its Size reflects complexity of its Function • 8 Segments through (Cantlie Line) • 75% Portal vein & 25% Hepatic artery • 80% Removal = Normal life • Total Hepatic Blood Flow: • (1500cc / Min / 1.73 m2 of body surface)

4. Metabolic Functions of theLiver • Glucose production & storage • Urea formation (amino acid metabolism) • Synthesis of proteins & clotting factors • Detoxification of drugs & other substance • Bile acid & Bilirubin production

5. Types ofLiverCells • Hepatocytes • { Parenchymal cells } • Macrophages • { Kupffer cells }

6. Benign Lesions of the LiverIntroduction • Are Common • Diagnostic Difficulty with Malignancy • Unknown Etiology ( May be Congenital ) • Necrosis,Thrombosis,Haemorrhage,Rupture • L.F.T are Normal • US & CT Scan are Diagnostic • Biopsy rarely indicated • Diagnostic Laparascopy is now available • Lesions may be Cystic or Solid

7. Degenerative Cyst Dermoid Cyst Lymphatic Cyst Endothelial Cyst Retention Cyst Proliferative cyst Cystadenomas Parasitic Cysts Hydatid Cyst Amebic Cyst Benign Lesions of the LiverLiver Cysts

8. Hamartoma Adenoma Focal Nodular Hyperplasia Hemangioma Benign Lesions of the LiverBenign Liver Tumors

9. Benign Liver TumorsHamartoma • Composed from normal Liver tissues • Mesenchymal Hamatomas may berapidly growing in children • Firm, Nodular & Surface location • May be Solitary or Multiple • Malignant Transformation do not occur

10. Benign Liver TumorsAdenoma • Is seen with Oral Contraceptive • 60-80% with Mestranol • May developed during Pregnancy • Adenomatosis may seen • Severe Pain or Mass effect may occur • Malignant Transformation occur • Liver Resection / Liver Transplantation is indicated

11. Benign Liver TumorsFocal Nodular Hyperplasia • Occurs in Women in Reproductive age • HyperVascular Pattern in Angiogram • Patients are Asymptomatic • Possible precursor to HCC • Resection is indicated only for Symptomatic FNH

12. Benign Liver TumorsHemangioma • Most common benign tumor of Liver • Is seen in the 3rd to 5rd decades • Are less than 5 cm in diameter • May be Single or Multiple • Usually are Asymptomatic • Complications are rare • May be Cavernous & Lobulated • Malignant transformation do not occur • Liver Resection rarely indicate

13. Malignant Liver TumorsOrigin • From liver Cells:HCC, Fibrolamellar Ca • From Biliary Cells : ICCA • From Mesodermal Cells:Angiosarcoma,Sarcoma

14. Malignant Liver TumorsHepatocelluler Carcinoma( HCC ) • 90% of all Primary Liver Malignancy • 4Th Malignancy in the world • Common in Asia & Africa • More common in Males • May seen even in Children

15. Hepatic Primary MalignanciesMalignant Liver TumorsRisk Factor of HCC • Cirrhosis due to : HCV,HBV,Hemochromatosis • Alcoholic & Postnecrotic Cirrhosis • Aflatoxin Longstanding Toxemia • Parasite Infestation of Clonorchis (ICCA)

16. Hepatocellular Ca Hepatocytes Hepatoblastoma Immature Hepatocyte Fibrolamellar Ca Eosinophili Hepatocyte Small HCC (< 2 Cm) Unifocal Expansive Infiltrating Multifocal Vascular Invasion Malignant Liver TumorsPathology of HCC

17. Malignant Liver TumorsDiagnosis of HCC • Ultrasonography • Serial Alpha _ Fetoprotein • Alkaline phosphatase • Hepatic Arteriography • Liver Isotope Scan • CT & MRI

18. Malignant Liver TumorsClinical Presentation of HCC • Weight loss & Weakness 80 % • Abdominal Pain & Fullness 50% • Portal Hypertension • Jaundice 20-50 % • Hypoglycemic Interval • Ascites

19. Malignant Liver TumorsFibrolamellar Carcinoma • Occur in Western Hemisphere • Younger Age 20 to 35 years • More common in Lt Lobe • Occur in Normal Liver • Better prognosis than HCC • Better Response to Surgery

20. Malignant Liver TumorsIntraHepatic CholangioCarcinoma • Rare Tumour • Normal underlying Liver • May seen in Caroli & PSC • May be local or diffuse • Have a poor Prognosis

21. Malignant Liver TumorsAngioSarcoma • Most frequent Sarcoma of the liver • 1% of All Primary Malignancy of Liver • Involved Entire liver • An Association with(Anabolic Steroids,Estrogens,OCP) • Male to Female 3/1 • Age Time Of Diagnosis 50_ 70 • May Progress to Haemangioendothelioma • Poor Prognosis

22. Malignant Liver TumorsTreatment Options of HCC • Liver Resection • Liver Transplantation • Systemic Chemotherapy ? • TransArterial Embolization ( Lipiodol) • Percutaneous Ethanol Injection • CryoSurgery ( liquid Nitrogen ) • Radiation Therapy ? • RF I .T. T

23. Hepatic Metastatic NeoplasmsB. Nakhaei, M.D • Most Common Malignancy of the Liver • 1/20 Primary to Secondary • Liver is Second only to Regional lymph nodes • 25%_ 50% of dying patients have Liver Metastasis • Mitotic count of Metastasis is 5 times greater than Primary Lesion

24. Routesof Metastasis to theLiver • Portal Circulation • Lymphatic spread • Hepatic Arterial System • Direct Extension

25. Hepatic pain Ascites Jaundice Anorexia Weight loss Hepatic nodularity Audible friction rub Portal hypertension Flushing Syndrome LiverMetastasisClinical Manifestations :

26. Liver MetastasisTiming of Appearance • Precocious ( Carcinoid of the Ileum) • Synchronous( Most GI Cancers ) • Metachronous( Ocular Melanoma)

27. LiverMetastasisSurgical treatment if : • Control of primary tumor • No systemic or intra- abdominal Metastases • Good patient,s condition • Extent of hepatic involvement • No more than 4 metastases • Primaries in Colon & Rectum & Wilms, • Debulking for other tumor ( ovary , stomach, breast , cervix ,.... )

28. References • HepatoBiliary & Pancreatic Surgery • James Garden 2th Edition 2001 • Principles of Surgery • Schwartz 7th Edition 1999 • ACS Surgery 2001 • Text Book of Surgery • Sabiston 16Th Edition 2001 • B, Nakhaei, M.D.