SURGICAL TREATMENT OF FOCAL LIVER MASSES

Department of General and Transplant SurgeryMedical University of Lódź

P. HOGENDORF

HISTORICAL PERSPECTIVE 1654 Francis Glisson – anatomy of th blood vessels of

the liver 1716 Berta – first described partial hepatectomy (stab

wound, resection of portion of protruding liver) 1908 J. Hogarth Pringle – Pringle's manoeuvre 1957 – Couinaud - descriptions of the segmental

nature of liver anatomy 1950's operative mortality rate – 20 % ! 1980's operative mortality rate – less than 5 %

Prometheus and Caucasian Eagle

PYOGENIC ABSCESSPYOGENIC ABSCESS Incidence 22/100.000

hospital admissions 11 cases per million /

year male-to-female ratio

is approximately 1.5 to 1

Potential routes of hepatic exposure to

bacteria: biliary tree, portal vein, hepatic artery, nearby focus of

infection, trauma

¾ involve right lobe of the liver

½ of hepatic abscesses are solitary

10% to 20% are sterile abscesses

40 % are polymicrobial

Most common: E. coli & K. pneumoniae S. aureus, E. species, S. viridans, and Bacterioides species

Pathology and Microbiology:

Presenting symptoms of hepatic abscess:

fever, jaundice (25%), right upper quadrant pain and tenderness(40-

70%) hepatomegaly all of the above

presentation is present only 10% fever, chills, and abdominal pain are the most common

nonspecific symptoms (malaise, vomiting, diarrhea, cough, dyspnea, peritonitis secondary to rupture)

Leukocytosis 70% to 90%

Abnormalities of LFTs

Hypoalbuminemia mild elevations of

the prothrombin

ALP is mildly elevated in 80%

total bilirubin is elevated 20% to 50%

Transaminases are mildly elevated about 60%

The sensitivity of ultrasound in diagnosing hepatic abscess is 80% to 95%.

The sensitivity of CT in diagnosing hepatic abscess is 95% to 100%.

MRI does not appear to have any distinct advantage over CT in diagnosing hepatic abscess.

CT: necrtic mass with gas formation in right lobe liver

Differential Diagnosis

differentiating pyogenic abscess from other cystic infective diseases of the liver is important –

differences in intreatment

amebic abscess echinococcal cysts

simple cyst Polycystic Liver Disease

TREATMENT

percutaneous catheter drainage has become the treatment of choice for most patients

percutaneous aspiration without the placement of a drain

liver resection

broad-spectrum antibiotics covering gram-negative and gram-positive organisms and anaerobes:

ampicillin + an aminoglycoside + metronidazole

third-generation cephalosporin with metronidazole

carbapenems

mortality from 10% to 20%

Amebic Abscess WHO estimated that 40

to 50 million people suffer from amebic colitis or amebic liver abscess worldwide

40,000 to 100,000 deaths each year

E. histolytica other E. species -

nonpathogenic

Clinical Features

20 to 40 y old patient who has traveled to an endemic area

male-to-female ratio: > 10:1

fever, chills, anorexia,

right upper quadrant pain, and tenderness and

hepatomegaly.

1/3 patients have diarrhea despite an obligatory colonic infection.

jaundice is a rare presentation.

weight loss and myalgias

the abdominal pain is typically constant, dull, and localized to the right upper quadrant.

symptoms and tenderness may be epigastric or left sided if the abscess is located in the left

pleuritic or shoulder pain can occur if there is irritation of the diaphragm.

Laboratory tests

moderate leukocytosis anemia is common. mild abnormalities of

LFTs including albumin, prothrombin time, ALP, AST, and bilirubin levels are typical

antiamebic antibodies that are present in 90% to 95% of patients.

the EIA has a reported sensitivity of 99% and specificity greater than 90% in patients with hepatic abscess.

Radiologic studies

US has a reported accuracy of approximately 90% when combined with a typical historyand clinical presentation

CT is probably more sensitive than US, helpful in differentiating amebic from pyogenic abscess

Nuclear medicine studies such as gallium scanning or technetium-99m liver scans

Treatment

Metronidazole (750 mg orally 3x per day for 10 days)

curative in over 90%

clinical improvement is usually seen within 3 days

The mortality for all patients with amebic liver abscess is 2% to 4%When an abscess ruptures the mortality is reported to be from 6% to as high as 50%.

Differential diagnosis of amebic and pyogenic abscess

Hydatid Cyst zoonosis that occurs

primarily in sheep-grazing areas of the world

endemic in Mediterranean countries, the Middle East, the Far East, South America, Australia, New Zealand, and East Africa

the dog is a definitive host

no human-to-human transmission

E. granulosus E. multilocularis and E.

oligartus

¾ of hydatid cysts are located in the right liver

¾ are singular

Echinococcusalveolaris

Dogs are the definitive host of E. granulosus, in which the adult tapeworm is attached to the villi of the ileum.

Eggs are passed (up to thousands of ova daily) and deposited with the dog’s feces.

Sheep are the usual intermediate host, but humans are an accidental intermediate host. Humans are an end stage to theparasite. In the human duodenum, the parasitic embryo releases an oncosphere containing hooklets that penetrate the mucosa, allowing access to the bloodstream.

Inthe blood, the oncosphere reaches the liver (most commonly) or lungs, where the parasite develops its larval stage known as the hydatid cyst

The most common presenting symptoms are:

abdominal pain, dyspepsia, and vomiting. hepatomegaly is the most

frequent sign jaundice - 8% fever - 8%

rupture of the cyst into the biliary tree or bronchial tree or free rupture into the peritoneal, pleural, or pericardial cavities can occur. Free ruptures can result in disseminated echinococcosis and/or a potentially fatal anaphylactic reaction.

Treatment

primarily surgical albendazole or

mebendazole is effective in 20% to 30% of patients

but in elderly patients with small, asymptomatic, calcified cysts,conservative management is appropriate

chemotherapy should generally be considered for widely disseminated disease or patients with poor surgical risk

Recurrence rates after surgical treatment is less than 5 % in experienced centers

NEOPLASMS

Solid Benign Neoplasms Liver cell adenoma

(LCA) Hemangioma

Focal Nodular Hyperplasia

Other Benign Tumors

Liver Cell Adenoma predominantly found in

young women aged 20-40

relatively rare

chronic oral contraceptive use dramatically increases the incidence of this tumor

female-to-male ratio is approximately 11:1

usually singular (multiple in 12% to 30%)

AFP level is normal

upper abdominal pain is common

dramatic presentations with free intraperitoneal rupture and bleeding can occur

quantifying the risk of rupture is difficult but it has been estimated to be as high as 30% to 50% and may be related to size

malignant transformation into HCC

Liver Cell Adenoma

CT well-circumscribed heterogeneous mass.

MRI a well-demarcated mass containing fat or hemorrhage

primarily surgical treatment of symptomatic LCA (limited resections can be performed)

acute hemorrhage need emergent operation

Liver Cell Adenoma

Histology of hepatic adenoma arranged in plates that aretwo to three cells thick, separated by sinusoids

Macroscopic aspect of liver adenoma with large intralesionalhemorrhage

Focal nodular hyperplasia (FNH)

second most common benign tumor of the liver

FNH is usually a small (<5cm) nodular mass

central fibrous scar with radiating septa - 85 %

etiology is not known

physical examination is usually unrevealing, and mild abnormalities of LFT may be found.

AFP level is normal rupture, bleeding, and

infarction are exceedingly rare

No malignant transformations

Contrast medium–enhanced CTMRI

persistent symptomatic FNH or an enlarging mass should be considered for resection

Contrast medium–enhanced CT: A delayed scan showed a non-enhancing scar with subtle enhancement of the capsule of the tumor

MRI: on T2W image, mass appeared hypointense whereas the scar was hyperintense.

Focal nodular hyperplasia (FNH)

Focal nodular hyperplasia with characteristic central fibrousregion (arrow) and radiating fibrous cords

Histology of a central stellate scar in FNH demonstratingthick-walled vessels (arrow) of a large arterial malformation surroundedby fibrous tissue

Focal nodular hyperplasia (FNH)

Hemangioma

the most common benign tumor of the liver

Female-to-male 3:1 mean age of about 45 usually singular Usually less than 5 cm in

diameter occur equally in the right

and left liver > 5 cm are called arbitrarily

“giant” hemangioma

Large compressive masses may cause vague upper abdominal symptoms.

Spontaneous rupture of liver hemangiomas is exceedingly rare.

An associated syndrome of

thrombocytopenia and consumptive coagulopathy known as Kasabach-Merritt syndrome is rare but well described

LFTs and tumor markers are normal

Cut section of two large hepatic hemangiomas showingcentral fibrosis and hyalin changes (arrows)

Hemangioma

Post-contrast MR imaging of the liver demonstrating nodular peripheral enhancement of the right hepatic lobe lesion. First image demonstrates completely hypointense rounded lesion, which shows peripheral enhancement in the subsequent phases. This enhancement pattern is typical for liver venous malformations ("cavernous hemangiomas")

Radiological investigations:

# Single-photon emission computed tomography (SPECT)# MRI# CT scan of the liver# Hepatic angiogram

Hemangioma

Other Benign Tumors

Nodular regenerative hyperplasia (NRH)

Mesenchymal hamartomas (Mhs)

Lipomas Leiomyomas Myxomas Schwannomas Lymphangiomas Teratomas

Primary Solid Malignant Neoplasms

Hepatocellular Carcinoma most common primary

malignancy of the liver

over 1 million deaths annually worldwide

clearly related to the incidence of hepatitis B virus (HBV) infection

The highest incidence of disease (greater than 10 to 20 per 100,000) is found in Southeast Asia and tropical Africa

the lowest incidence (1–3 per 100,000) is found in Australia, North America, and Europe.

risk factors: HBV infection, HCV infection, cirrhosis, smoking, alcohol abuse, age,chronic exposure to carcinogens such as aflatoxin, nitrites, hydrocarbons, solvents, pesticides, and vinyl chloride etc.

inherited metabolic liver diseases such as hereditary hemochromatosis,

a1 -antitrypsin deficiency, Wilson’s disease

macronodular cirrhosis

CLINICAL PRESENTATION

right upper quadrant abdominal pain,

weight loss, a palpable mass nonspecific symptoms:

anorexia, nausea, lethargy hepatic decompensation

Usually men 50-60 years of age

Rare presentations: - rupture with the sudden onset of abdominal pain followed by hypovolemic shock secondary to intraperitoneal bleeding

- hepatic vein occlusion (Budd-Chiari syndrome)

- obstructive jaundice, hemobilia, or fever of unknown origin

- paraneoplastic syndrome, most commonly hypercalcemia, hypoglycemia, and erythrocytosis

HCC largely metastasizes to the lung, bone, and peritoneum,

Cut section of a liver from a patient with Budd-Chiari syndrome demonstrating thrombus formation in a large hepatic vein (arrow)

DIAGNOSIS

Radiologic investigation:

CT MRI US Contrast medium–

enhanced CT and MRI

Laboratory tests: AFP level greater than 20

ng/mL in 75 % of HCC

Other: percutaneous needle

biopsies only in non-resectable cases

Hepatocellular Carcinoma

Cut surface of a hepatocellular carcinoma without a capsule,infiltrating the liver parenchyma

Cut section of a HCC with a mosaic pattern containingfat, solid nodules, necroses, fibrosis and cystic areas

Hepatocellular Carcinoma

Histological aspect of a well-differentiated HCC showingbile production (arrows)

Grade 1 HCC may be difficult to distinguishfrom liver-cell adenomas and atypical hyperplastic nodules

Treatment

First step: to stage the tumor

Second step: assessment of liver function

Third step: treatment plan

Liver resection is considered the treatment of choice for HCC

Other successful treatments: - ablative techniques, - embolization techniques, - liver transplantExternal beam radiation

ChemotherapyHormonal therapyImmunotherapy

Treatment (2)

Patients with advanced cirrhosis (Child’s B and C) and early-stage HCC should be considered for transplant, whereas those

with Child’s A cirrhosis have similar results with transplant and resection and should probably undergo resection.

Problems: lack of organ donors and need for chronic immunosuppression

Long-term survival rates in recent years have ranged from 25% to 75%.

Cholangiocarcinoma

uncommon neoplasm 1 to 2 per 100,000 in the

United States can develop anywhere

along the biliary tree 40-60 % involve the

biliary confluence (Klatskin’s tumor)

risk factors: primary sclerosing

cholangitis, choledochal cyst

disease, recurrent pyogenic

cholangitis.

The clinical presentation of IHC is similar to that of HCC.

If completely resected, 3-year survival rates range from 16% to 61% and 5-year survival rates range from 24% to 44%.

Other Primary Malignant Neoplasms

Hepatoblastoma Sarcomas Non-Hodgkin’s

lymphoma Malignant germ cell

tumors Primary hepatic

lymphoma neuroendocrine tumors Epithelioid

hemangioendotheliomaHodgkin’s disease

Metastatic TumorsThe most common

malignant tumors of the liver are metastatic lesions:

colorectal cancer tumors of the lung, prostate, breast, pancreas, stomach, kidney, cervix and ovary

liver is a common site of metastases from gastrointestinal tumors

metastatic colorectal cancer isolated in the liver can be resected with the potential for potential for long-term survival and curelong-term survival and cure

Colorectal liver metastases

There are over 50,000 cases of colorectal liver metastases a year in the United States

Diagnosis imaging studies

(contrast-enhanced-CT, triphasic technique)

LFTs CEA levels Colonoscopy – rule out

local recurrence or metachronous lesions.

Hepatic resections for colorectal liver metastases

is still associated with significant morbidity rates of 30% to 50%

complications are most commonly bleeding, bile leak, abscess, and other generalized cardiorespiratory complications.

Adjuvant systemic chemotherapy after liver resection for metastatic colorectal cancer

hepatic arterial infusion (HAI) chemotherapy.

After resections five-year survival rates range from 25% to 37%, and mortality in experienced centers is consistently less than 5%

Incision

HEPATIC RESECTION

Nomenclature for Major Anatomic Hepatic Resection