Benign Liver Tumors...Differential Benign • Cavernous Hemangioma • Focal Nodular Hyperplasia •...

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Benign Liver Tumors Cameron Schlegel PGY-1 3/6/2013

Transcript of Benign Liver Tumors...Differential Benign • Cavernous Hemangioma • Focal Nodular Hyperplasia •...

Page 1: Benign Liver Tumors...Differential Benign • Cavernous Hemangioma • Focal Nodular Hyperplasia • Hepatocellular Adenoma • Cystic Tumors • Paraganglioma • Inflammatory Pseudotumor

Benign Liver Tumors

Cameron Schlegel PGY-1

3/6/2013

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Outline

Benign Liver Tumors are, in general…. • Asymptomatic • Diagnosed: imaging • Treatment: Do no harm

– Unless… • Malignant potential • Causing symptoms

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Differential

Benign • Cavernous Hemangioma • Focal Nodular Hyperplasia • Hepatocellular Adenoma • Cystic Tumors • Paraganglioma • Inflammatory Pseudotumor • Peliosis Hepatis • Angiomyolipoma/Lipoma • Biliary Papillomatosis • Caroli Disease • Peribiliary Cysts • Von Meyenburg Complexes • Biliary cystadenomas

Malignant • Hepatocellular Carcinoma • Intrahepatic

Cholangiocarcinoma • Metastases

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Differential

Benign • Cavernous Hemangioma • Focal Nodular Hyperplasia • Hepatocellular Adenoma • Cystic Tumors • Paraganglioma • Inflammatory Pseudotumor • Peliosis Hepatis • Angiomyolipoma/Lipoma • Biliary Papillomatosis • Caroli Disease • Peribiliary Cysts • Von Meyenburg Complexes • Biliary cystadenomas

Malignant • Hepatocellular Carcinoma • Intrahepatic

Cholangiocarcinoma • Metastases

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Cavernous Hemangioma

• Presentation: – Most common benign liver tumor – Female, 40, usually <5cm and

solitary – Asymptomatic – Syndromes: Kasabach-Merritt,

Osler-Rendu-Weber, VHL – Symptomatic in children, 70%

mortality • Pathogenesis:

– Endothelial lining of blood vessels • Diagnosis: Imaging

– CT: peripheralcentripital – MRI: T1 hypointensity;

T2hyperintensity

Presenter
Presentation Notes
compression adjacent structures/hemorrhage/alter coagulation/inflammation gross: red/blue flat lesions; micro cavernous vascular spaces with fibrous septa CT: peripheral followed by centripetal enhancement – pathognomonic for hemangiomas Delayed scans, entire lesion enhances MRI: hypointense on T1, hyperintense on T2 Avoid biopsy T2: 100% sensitive, 92% specific for diff hemangiomas vs malignancies of the liver Contrast-enhanced computed tomography (CT) scan. These images reveal the pathognomonic features of a hemangioma, namely, peripheral nodular enhancement and progressive centripetal fill-in (arrow). The smaller, peripheral lesion (circled) shows homogeneous enhancement.
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Focal Nodular Hyperplasia • Presentation

– Second most common benign liver tumor

– Females, 40s, solitary lesions – Not stimulated by hormones – Asymptomatic

• Pathogenesis: – Hepatocellular hyperplasia 2/2 vascular

malformation – High concentration Kupffer cells – Well circumscribed, unencapsulated,

central fibrous scar – Benign hepatocytes in nodules,

separated by fibrous septa that originate from central scar

• Diagnosis: Imaging – CT: hypoattenuating on early phase images – MRI: arterial enhancement

Presenter
Presentation Notes
pedunculated torsion/pain Larger lesions symptomatic b/c pressure on adjacent organs. Pedunculated lesions can torse on pedicle acute episode of pain Solitary, 20-30% multiple , possible due to reaction to arterial malformation that leads to hyperperfusion; CT 70% sensitivity differentiating FNH from other central scar containing lesions including hemangiomas/HCC
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Hepatocellular Adenoma • Presentation

– Females (90%), 20-40s, solitary (80%) – OCP/Androgen use – Iron overload B-thalassemia, type 1 or

3 glycogen storage, diabetes mellitus – Asymptomatic – Intraperitoneal hemorrhage (30-50%) – Malignant transformation 10%

• Pathogenesis – Well differentiated hepatocytes lacking bile

ducts/portal triads

• Diagnosis: Imaging – CT: hypo- to isoattenuating – MR: T1 hyper-isointense; T2 hyper

Presenter
Presentation Notes
0.1/100,000 in non OCP users, 3-4/100,000 in OCP 10-30% multiple – pain/impaired liver function; high risk of rupture (hep artery embolization/radiofrequency ablation + resection)
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Imaging Characteristics of Benign Liver Tumors

Kane et al. Benign Hepatic Tumors and Iatrogenic Pseudotumors. Radiographics. 2009

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Imaging Characteristics of Benign Liver Tumors

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Imaging Characteristics of Benign Liver Tumors

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Compare/Contrast Tumors Malignant? CT MRI

T1 T2 Treatment

Cavernous Hemangioma

No Peripheral central, hyperintense on delayed

Nothing If symptoms: enucleation or resection

FNH No rapid enhancement during arterial phase - Hypointense central

scar

- Sulfur Colloid Scan

Nothing If symptoms: resection

HC adenoma

Yes hypervascular lesion arterial phase

Resection

Presenter
Presentation Notes
No treatment if asymptomatic and no evidence of malignant potential (ch, FNH, cysts) Aspiration/injection sclerosing agent vs unroofing: cyst >5cm, symptomatic/ Enucleation: cavernous hemangioma Resection: FNH (large veins surround lesion); hepatocellular adenoma (unless <3cm dc OCP, serial image and alphafetoprotein levels) Liver transplantion: cavernous hemangioma, PC liver disease if fail fenestration/resection
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Compare/Contrast Tumors Malignant? CT MRI

T1 T2 Treatment

Cavernous Hemangioma

No Peripheral central, hyperintense on delayed

Nothing If symptoms: enucleation or resection

FNH No rapid enhancement during arterial phase - Hypointense central

scar

- Sulfur Colloid Scan

Nothing If symptoms: resection

HC adenoma

Yes hypervascular lesion arterial phase

Resection

Presenter
Presentation Notes
No treatment if asymptomatic and no evidence of malignant potential (ch, FNH, cysts) Aspiration/injection sclerosing agent vs unroofing: cyst >5cm, symptomatic/ Enucleation: cavernous hemangioma Resection: FNH (large veins surround lesion); hepatocellular adenoma (unless <3cm dc OCP, serial image and alphafetoprotein levels) Liver transplantion: cavernous hemangioma, PC liver disease if fail fenestration/resection
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Cystic Tumors

• Simple • Multiple • Cystadenomas • Echinoccocal

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Cystic Tumors

Simple cysts: • Asymptomatic • Pathogenesis:

• Embryonal development of intrahepatic biliary duct

• Single layer columnar/cuboidal epitheliuam, straw-colored serous fluid

• Diagnosis: imaging • Treatment: Injection or

enucleation if symptomatic

Presenter
Presentation Notes
Simple: RUQ pain, early satiety, upper abd fullness >8cm (ultrasound, not enhance CT/MRI, no internal septations/masses)
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Cystic Tumors

Multiple Cysts: • Asymptomatic • Polycystic liver disease –

autosomal dominant • Hepatic parenchyma and

function preserved • Pathogenesis:

• histo same as simple cysts • Diagnosis: Imaging • Treatment: resection or

transplant if symptomatic

Presenter
Presentation Notes
Simple: RUQ pain, early satiety, upper abd fullness >8cm (ultrasound, not enhance CT/MRI, no internal septations/masses)
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Cystic Tumors

Cystadenomas • Presentation:

• Benign w malignant potential

• Slow growing, • Pathogenesis

• Multilocular, single layer cuboidal/columnar epithelium

• Dx: Imaging • Treatment: Resection

Presenter
Presentation Notes
CT/MRI – internal septations, irregular borders, calcifications Host ingests parasite egg liver/lung/brain/kidney CT/MRI echin: thick walled cysts w calcification containing debris, complete enucleation not drainage 2/2 risk anaphylaxis
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Cystic Tumors Echinococcal/Hydatid Cysts • Presentation:

• Travel SW US, Scotland, Greece, Europe

• Asymptomatic, +/- fever, abdominal pain

• Pathogenesis • Echinococcus – humans

intermediary hosts • Diagnosis: Imaging • Treatment: Albendezole,

enucleation

Presenter
Presentation Notes
CT/MRI – internal septations, irregular borders, calcifications Host ingests parasite egg liver/lung/brain/kidney CT/MRI echin: thick walled cysts w calcification containing debris, complete enucleation not drainage 2/2 risk anaphylaxis
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Questions?