Liver Mass Domingo, Elizabeth Guzman, Alexander Joseph Hipolito, April Lorraine.
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Transcript of Liver Mass Domingo, Elizabeth Guzman, Alexander Joseph Hipolito, April Lorraine.
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Liver Mass
Domingo, Elizabeth
Guzman, Alexander Joseph
Hipolito, April Lorraine
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Case 1b
General Data: – 35 year old, male– Nonsmoker, non-alcoholic– elevated AFP (400 ng/ml) on routine tests– Asymptomatic– No history of Hepa B infection– No history of blood transfusion– PE is essentially unremarkable
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Differential Diagnosis For elevated AFP: 400ng/ml (N= < 10ng/ml) Also consider laboratory error and ask for repeat A
FP level determination
1. Hepatoma
- primary malignant tumor of the liver
- may present w/ hepatosplenomegaly, pain, hypoglycemia, weight loss or anorexia, ascites, portal hypertension, jaundice
2. Hepatocellular Carcinoma
- has elevated AFP in 60-75% of the cases, commonly presents w/ enlarged liver on palpation, with sufficient irregularity or nodularity to permit differentiation from cirrhosis
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Differential Diagnosis
3. Alcoholic Cirrhosis
- may be clinically silent and in many cases(10-40%) are discovered incidentally at laparotomy or autopsy
4. Testicular tumor
- malignant teratoma, embryonal cancer, yolk sac tumor.
- unlikely in our case, px is already 35 y/o
5. Chronic hapatitis
- unlikely in our case, no hx of hepatitis infection nor blood transfusions
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Probable Diagnosis Fibrolamellar Hepatocellular
Carcinoma- a distinctive clinical and pathologic subtype of hepatocellular carcinoma (HCC)- occurs in young adults (20-40 y/o) without underlying parenchymal liver disease- alpha-fetoprotein level are usually not elavated- non-encapsulated but well circumscribed and contains fibrous lamellae- slowly growing tumor
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AFP levels
1° Liver CA
Malignant teratomas
Hepatitis and cirrhosis
CA of pancreas/stomach/biliary tract
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Diagnostic Evaluation
Abdominal CT scan is the preferred test for the detection, diagnosis, staging, and postoperative follow-up of HCC
MRI is useful in detecting & characterizing primary tumors. It is more sensitive in detecting multiple intrahepatic recurrent lesions but less sensitive in detecting extrahepatic disease.
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Ultrasound can be used intra-operatively as well as monitoring the progression of known intrahepatic lesions.
Radionucleotide sulfur-colloid scans are ocassionally useful in the differentiation of fibrolamellar carcinoma from other tumors.
Percutaneous biopsy with ultrasound guidance may be necessary for a definitive pre-operative diagnosis of fibrolamellar HCC.
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Lab Studies AFP levels may be elevated since this p
rotein is commonly produced by HCC. However, this is not a sensitive parameter since AFP levels may be normal in more than one-third of the patients.
Normal adult levels of AFP are below 10 ng/mL
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Follow-up Fibrolamellar carcinoma is an aggressive tum
or that progresses to recurrent liver masses and metastatic lymph node metastases in most patients.
Recurrent lesions often develop 6-18 months after attempted curative resection and may progress rapidly; therefore, follow-up imaging is recommended at 2- to 4-month intervals for at least 12-18 months after resection of the primary tumor.
The early detection of metastatic disease is important because surgical resection of metastases improves patient survival rates.
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Management
Medical Care Surgical Care
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Medical Care Patt et al reported a phase II clinical trial of sy
stemic, continuous 5-fluorouracil and thrice-weekly subcutaneous recombinant interferon alfa-2b for liver cancers.
demonstrated that this regimen was an effective treatment for patients with FLC, suggesting that neoadjuvant chemoimmunotherapy may play a previously unappreciated role in treatment of FLC
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Surgical Care
Hepatic Resection Liver Transplantation
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Hepatic Resection problems:
– presents of advanced-stage disease – direct invasion of adjacent organs– lymphadenopathy– limited metastais– presence of extensive liver involvement
contraindication:– involvement of the main portal vein or hep
atic artery
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Liver Transplantation problems:
– limited donor availability with attendant waiting lists
– high cost– sustained morbidity
contraindications:– presence of extrahepatic disease– comorbid factors– presence of vascular invasion– poorly differentiated histologic grade
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Prognosis
48% resectability rate 32 months average survival time 63% 5-year survival time prognosis better than usual type of hepa
tocellular carcinoma