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General Surgery
Benign and Malignant Primary Liver Neoplasms
Built from Maingot's Abdominal Operations
What’s inside
16 sections · 179 slides
Overview
- Scope of this topic
- Two families of primary liver tumour
Benign tumours of the liver
Common, usually harmless, and easy to mistake for cancer
- Frequency of benign liver tumours
- Benign tumours of the liver
- Reading the classification
- Behaviour decides treatment
- Imaging tests for a benign liver lesion
- Radiographic features of benign tumours of the liver
- Key contrasts in the imaging table
- Indications for and limitations of liver biopsy
- Indications for resection of a benign tumour
- Evidence that observation is safe
- Treatment algorithm for a presumed solitary benign liver tumour
- Surgical approaches for benign tumours
Hepatic hemangioma
A tangle of blood-filled spaces, and the commonest liver tumour of all
- Hemangioma: epidemiology
- Sex hormones and hemangioma
- Pathology of cavernous hemangioma
- Tumour-parenchymal interface patterns
- The four tumour-parenchyma interface patterns
- Biopsy of a suspected hemangioma
- CT appearance of hepatic hemangioma
- Five CT criteria diagnostic of hemangioma
- MRI features of hemangioma
- Other imaging tests for hemangioma
- Nonoperative management of hemangioma
- Observation data from a Dutch series
- Indications for resection of hemangioma
- Controversy over operating for symptom relief
- Selecting patients for surgery for symptoms
- Complications of hepatic hemangioma
- Kasabach-Merritt syndrome
- Enucleation versus formal resection
- Steps in enucleation of a hepatic hemangioma
- Technique of hemangioma enucleation
Focal nodular hyperplasia
Not a true tumour but an overgrowth around an abnormal artery
- Focal nodular hyperplasia: epidemiology
- Proposed pathogenesis of FNH
- Oral contraceptives and FNH
- Gross pathology of FNH
- Typical and atypical FNH
- Subtypes of atypical focal nodular hyperplasia
- CT appearance of FNH
- MRI in focal nodular hyperplasia
- MRI of a large left lateral section focal nodular hyperplasia
- Delayed-phase features of focal nodular hyperplasia
- Percutaneous biopsy in FNH
- Treatment of focal nodular hyperplasia
Hepatocellular adenoma
The benign lesion that bleeds, ruptures and can turn malignant
- Hepatocellular adenoma and the contraceptive pill
- Contraceptive use and adenoma complications
- Complications of hepatocellular adenoma
- Rupture risk in a multicentre series
- Malignant transformation of adenoma
- Pathology of hepatocellular adenoma
- Histology and the absence of bile ducts
- Ultrasound and CT of hepatocellular adenoma
- Contrast washout in adenoma
- CT of a hepatic adenoma of the right hemiliver
- MRI findings in hepatocellular adenoma
- Separating hepatocellular adenoma from focal nodular hyperplasia
- Treatment of hepatocellular adenoma
Uncommon benign liver lesions
Three rarities that turn up on scans and in the operating room
- Nodular regenerative hyperplasia
- Peliosis hepatis
- Bile duct adenoma
Hepatocellular carcinoma: causes and pathology
The commonest solid organ cancer in the world
- Primary malignant liver tumours
- Three reasons hepatocellular carcinoma is hard to treat
- Global burden of hepatocellular carcinoma
- Hepatitis B virus and hepatocellular carcinoma
- Hepatitis C virus and hepatocellular carcinoma
- Factors associated with the development of hepatocellular carcinoma
- Chemical carcinogens and alcohol
- Aflatoxin exposure
- Inherited and metabolic conditions
- Histologic grading and growth pattern
- Three growth patterns of hepatocellular carcinoma
- Growth pattern and resectability
- Hanging and pushing growth patterns of hepatocellular carcinoma
- Infiltrating growth pattern of hepatocellular carcinoma
- Fibrolamellar variant of hepatocellular carcinoma
- Standard hepatocellular carcinoma compared with the fibrolamellar variant
- Key numbers from the fibrolamellar comparison
How hepatocellular carcinoma presents
Silent when small, dramatic when large
- Late presentation of hepatocellular carcinoma
- Common symptoms and signs of HCC
- General and febrile presentations
- Hepatic decompensation as a presentation
- Gastrointestinal bleeding in HCC
- Rupture of a hepatocellular carcinoma
- CT of a ruptured hepatocellular carcinoma
- Jaundice in hepatocellular carcinoma
- Paraneoplastic syndromes in HCC
Diagnosis and assessment of liver reserve
Confirm the tumour, map its extent, and measure what the liver can survive
- Three aims of the diagnostic work-up
- Noninvasive diagnosis of hepatocellular carcinoma
- Role of percutaneous needle biopsy in HCC
- Biopsy in patients not fit for surgery
- Extent of disease evaluation
- Cross-sectional imaging of the liver in HCC
- Hepatic angiography and lipiodol
- Single laboratory measures of liver reserve
- Child-Turcotte-Pugh classification
- Child-Turcotte-Pugh grading system for cirrhosis
- Scoring the Child-Turcotte-Pugh criteria
- Dynamic tests of liver function
- Hepatic venous wedge pressure
Resection of hepatocellular carcinoma
The only potentially curative option, and how cirrhosis changes it
- The range of treatments for HCC
- Partial hepatectomy in a noncirrhotic liver
- Survival after hepatectomy for hepatocellular carcinoma
- Outcomes after liver resection for hepatocellular carcinoma
- Outcomes after liver resection for hepatocellular carcinoma (continued)
- Trends across the resection outcome series
- Why cirrhosis makes hepatectomy dangerous
- Mechanism of liver failure after resection in cirrhosis
- Mortality and patient selection in cirrhosis
- Inflow occlusion in the cirrhotic liver
- Anatomic versus nonanatomic resection
- Factors that no longer prevent resection
- Major intravascular tumour extension
- Staging systems and the prognostic nomogram
- Prognostic nomogram for survival after resection
Treatment before and after resection
Shrinking the tumour first, and attacking what surgery leaves behind
- Rationale for neoadjuvant therapy
- Neoadjuvant chemoembolization before resection
- Transarterial immunoembolization
- Randomised data on neoadjuvant treatment
- Preoperative portal vein embolization
- Adjuvant trials that failed
- Adjuvant trials that succeeded
- Sorafenib in advanced hepatocellular carcinoma
Transplantation and palliative treatment
Replacing the whole diseased liver, and what to do when nothing can be removed
- Rationale for total hepatectomy and transplantation
- Early experience with transplantation for HCC
- The Milan criteria
- Outcomes after liver transplantation for hepatocellular carcinoma
- Outcomes after liver transplantation for hepatocellular carcinoma (continued)
- Trends across the transplantation outcome series
- Comparing resection with transplantation
- Palliative treatment of hepatocellular carcinoma
Intrahepatic cholangiocarcinoma
Cancer of the bile duct lining, and the inflammatory diseases that cause it
- Bile duct cancer: incidence and age distribution
- Location, resectability and survival
- Chronic biliary inflammation as the common cause
- Primary sclerosing cholangitis
- Choledochal cysts and Caroli's disease
- Cycle of recurrent biliary infection and stone formation
- Pyogenic cholangiohepatitis and liver flukes
- Environmental toxins and cholangiocarcinoma
- Anatomic classification and operative planning
- Three anatomic groups of cholangiocarcinoma
- Presentation of intrahepatic cholangiocarcinoma
- Distinguishing intrahepatic cholangiocarcinoma
- Resection for intrahepatic cholangiocarcinoma
- Predictors of outcome after resection
- Transplantation for cholangiocarcinoma
- Chemotherapy for cholangiocarcinoma
Other primary liver malignancies
Hepatoblastoma, angiosarcoma and epithelioid hemangioendothelioma
- Hepatoblastoma
- Outcome and treatment of hepatoblastoma
- Angiosarcoma of the liver
- Outcome of hepatic angiosarcoma
- Other primary hepatic sarcomas
- Epithelioid hemangioendothelioma
- Treatment of epithelioid hemangioendothelioma
Technique of hepatic resection
Why liver surgery became safe, and how the inflow is controlled
- Improvement in perioperative outcome
- Segmental anatomy and parenchymal sparing
- Complications and mortality by number of hepatic segments resected
- Benefits of parenchymal-sparing resection
- Extrahepatic control of vascular inflow
- Intrahepatic pedicle ligation
- Posterior and anterior approaches to the pedicle
- Hepatotomy placement for pedicle ligation
- Steps of right pedicle ligation
- Stapling the isolated right portal pedicle
- Controlling the hepatic venous outflow
- Dividing the liver parenchyma
- Transection in a cirrhotic or fatty liver
Pulling it together
The decisions that matter most in primary liver tumours
- Take-home points on benign tumours
- Take-home points on hepatocellular carcinoma
- Take-home points on other primary liver cancers
- Take-home points on operative technique
- References
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- References (continued)
- Maingot's Abdominal Operations, 12th Edition