Gi 08: Neoplasias Of The Liver, Pancreas, Gallbladder, And Biliary Tract

Front 1

What are the types of liver lesions?

Back 1

Primary
- 3 Benign
- 2 Malignant

Metastatic (1)

3:2:1

Front 2

What are the types of Benign Primary liver lesions?

Back 2

- Hemangioma
- Focal Nodular Hyperplasia (FNH)
- Adenoma

Front 3

What are the types of Malignant Primary liver lesions?

Back 3

- Hepatocellular Carcinoma (HCC)
- Cholangiocarcinoma (CCA)

Front 4

If a patient tells you they are on oral contraceptives, what kind of liver lesion are you worried about?

Back 4

Hepatic Adenoma

Front 5

If a patient tells you they have a history of extra-hepatic malignancies, what kind of liver lesion are you worried about?

Back 5

Metastatic liver lesion

Front 6

If a patient tells you they have underlying liver disease, what kind of liver lesion are you worried about?

Back 6

Hepatocellular Carcinoma (HCC)

Front 7

If a patient tells you they have a history of primary sclerosing cholangitis (PSC), what kind of liver lesion are you worried about?

Back 7

Cholangiocarcinoma (CCA)

Front 8

In a non-cirrhotic liver, what are the most common causes of liver lesions?

Back 8

- 45% metastasize from GI tract
- 24% metastasize from lung
- 8% metastasize from urogenital tract
- 8% metastasize from breast

ONLY 3% originate in liver

Front 9

In a cirrhotic liver, what are the most common causes of liver lesions?

Back 9

77% originate in liver
- 10% metastasize from GI
- 7% metastasize from lung
- 3% metastasize from urogenital tract

Front 10

How does the presence of cirrhosis in the liver help you predict what type of cancer is in the liver?

Back 10

- Non-cirrhotic: most likely to be a metastases from elsewhere (only 3% originate in liver)

- Cirrhotic: most likely to be a primary lesion (77% originate in liver)

Front 11

What is the most common benign liver lesion?

Back 11

Hemangioma (found in 1% of all autopsies)

Front 12

Will you find cirrhosis with Hemangiomas?

Back 12

No - they are primarily found in non-cirrhotic livers

Front 13

What are Hemangiomas? Size?

Back 13

- Congenital vascular malformations (blood-filled cavities lined by endothelium)
- Range from 1-20 cm (>10 cm called a "giant hemangioma")

Front 14

When are most Hemangiomas diagnosed?

Back 14

- Majority during 3rd-5th decade

Front 15

Are Hemangiomas unitary lesions or do they present with multiple lesions?

Back 15

- Unitary in 70% of cases
- Multiple in 30% of cases

Front 16

What is the risk for malignancy with a Hemangioma?

Back 16

NO malignant potential!

Front 17

What symptoms are caused by Hemangiomas?

Back 17

Mostly asymptomatic unless they are at the surface of the liver and stretch the capsule

Front 18

What kind of liver lesion is this?

Back 18

Focal Nodular Hyperplasia (FNH) - benign

Front 19

What is the second most common benign liver lesion?

Back 19

Focal Nodular Hyperplasia (FNH)

Front 20

Will you find cirrhosis in patients with Focal Nodular Hyperplasia (FNH)?

Back 20

No - FNH is found in non-cirrhotic livers

Front 21

What causes Focal Nodular Hyperplasia (FNH)?

Back 21

- Reaction to intra-hepatic anomolous artery leading to hyper-perfusion
- Hyper-perfused area enlarges until it outgrows it's blood supply

Front 22

Who is most commonly affected by Focal Nodular Hyperplasia (FNH)?

Back 22

- Women
- Ages 20-50

Front 23

What is the size of Focal Nodular Hyperplasia (FNH)?

Back 23

Majority < 5 cm (rarely exceeds 10 cm)

Front 24

Does Focal Nodular Hyperplasia (FNH) present as a unitary lesion or does it present with multiple lesions?

Back 24

- Unitary in 80-90% of cases
- Multiple in 10-20%

Front 25

What risk for malignancy is there with Focal Nodular Hyperplasia (FNH)?

Back 25

NO malignant potential

Front 26

What is the third most common benign liver lesion?

Back 26

Hepatic Adenoma

Front 27

Is there cirrhosis in livers with Hepatic Adenoma?

Back 27

No - found in non-cirrhotic livers

Front 28

What is a Hepatic Adenoma?

Back 28

Benign proliferation of hepatocytes

Front 29

Who is primarily affected by Hepatic Adenoma?

Back 29

- Majority in women of child-bearing age
- Associated with contraceptive use
- Glycogen storage disease
- Diabetes Mellitus

Front 30

What is there a risk for in Hepatic Adenoma, unlike in Hemangiomas and Focal Nodular Hyperplasia (FNH)?

Back 30

- Hemorrhage
- Malignant transformation

Front 31

What type of liver lesion is associated with pregnancy? What can happen?

Back 31

Hepatic Adenoma - growth and rupture can occur during pregnancy

Front 32

How do you treat Hepatic Adenoma?

Back 32

- Contraceptives should be discontinued (associated w/ contraceptive use)
- Avoid pregnancy (this could lead to growth and rupture of adenoma)
- Surgical resection to avoid risk of cancer and tumor rupture

Front 33

Where is there higher incidence of Hepatocellular Carcinoma?

Back 33

- China
- Parts of Africa
- SE Asia

Front 34

How has the incidence and 5-year survival of Hepatocellular Carcinoma changed in the last 40 years?

Back 34

- Cases of HCC is increasing
- 5-year survival is increasing

Front 35

What ethnicity is HBV most frequent in? HCV?

Back 35

- HBV most frequent in Asians
- HCV most frequent in Non-Asians

Front 36

What are the most common viral causes of Hepatocellular Carcinoma?

Back 36

- HCV - 47% of cases
- HBV - 15% of cases

Front 37

What happens to the blood flow in Hepatocellular Carcinoma?

Back 37

- Normal: blood flow is 70% from portal vein and 30% hepatic artery blood flow

- HCC: switches so that 95% of blood flow supplied by arterial blood and only 5% from portal vein

Front 38

What happens in Hepatocellular Carcinoma when a radiologist infuses IV contract?

Back 38

- First 60 seconds is the arterial phase (where contrast goes first) - lights up the cancer
- Arterial blood flow disappears and venous blood flow goes away and now it is hard to see the lesion

Front 39

Which protein is elevated in 60-70% of patients with Hepatocellular Carcinoma? How much?

Back 39

Alpha Fetoprotein (AFP) - > 200 ng/mL

Front 40

Where is Alpha Fetoprotein (AFP) produced? When is it elevated?

Back 40

- Produced by fetal liver and placenta
- Elevated in 60-70% of patients w/ HCC

- Can be elevated w/ hepatic inflammation or cirrhosis in the absence of HCC

Front 41

What diagnostic features are consistent with a diagnosis of Hepatocellular Carcinoma?

Back 41

- Alpha Fetoprotein (AFP) > 200 ng/mL
- Liver lesion on imaging

Don't need to biopsy!!

Front 42

How do you prevent Hepatocellular Carcinoma?

Back 42

- HBV vaccination
- Treatment of viral hepatitis
- Coffee?

Front 43

What are the most common primary sites that metastasize to the liver?

Back 43

- GI: colon, pancreas, esophageal, gastric
- Lung
- Urogenital
- Breast
- Melanoma

Front 44

Why are pseudocysts not true cysts?

Back 44

- Lack of epithelial lining (fibrous and granulation tissue)
- No malignant potential

Front 45

How do you classify pancreatic cysts?

Back 45

Non-neoplastic, benign:
- True cysts
- Retention cysts
- Mucinous, non-neoplastic cysts
- Lymphoepithelial cysts