Benign and malignant liver neoplasms

Number 1 benign lesion of the liver

Hemangioma

Hemangioma is associated with

Focal nodular hyperplasia and Kasabach-Merritt syndrome

Hemangiomas are more common in ___________

Women

Hemangioma

Usually found in the right lobe

Solitary <3cm diameter

Subcapsular masses

Cat scan is helpful in determining the type of tissue in the hyperechoic mass identified on US

Contrast US is very accurate in evaluation of suspected hemangioma

Hemangioma labs

Normal LFTs

• Asymptomatic

Hemangioma can increase in size with

Pregnancy and estrogen therapy

If a suspected hemangioma is accompanied by abnormal LFTs, clinical symptoms of liver disease, or an atypical sonographic appearance, it should…

Be further evaluated with contrast US, CT, MRI or NucMed to eliminate possibility of malignancy

________ ultrasound is very accurate in evaluation of suspected hemangiomas

Contrast

Contrast exam

Demonstrates enhancement of hemangioma throughout the arterial

Benign nodules demonstrate isovascular enhancement

Malignant tumors demonstrate hypervascular enhancement

USA hemangioma

Focal concentration of blood vessels

Homogeneous, hyperechoic, well defined borders, posterior enhancement

Some have areas of degeneration, necrosis, and fibrosis which are demonstrated as hypoechoic

Has mass effect on surrounding structures - Compress and displace

May appear hypoechoic in a fatty liver

Color is not useful, blood flow is too slow

Hemangioma

Kasabach-Merritt syndrome is also called

Hemangioma thrombocytopenia syndrome

Kasabach-Merritt syndrome

Seen in infants with large hemangiomas

Sequestration and destruction of platelets within the larger cavernous hemangioma causes significant thrombocytopenia

Visible cutaneous blue or reddish lesions on extremities

Hepatomegaly or jaundice can also be identified

If the skin lesions are present with significant thrombocytopenia, the ____ and spleen should be evaluated for __________ formation

Liver; Hemangioma

Most common benign vascular liver tumor in INFANCY

Infantile hemangioma

Infantile hemangioma

Normally occurs within the first 6 months of life

Usually presents with cardiac failure early in life due to the AV malformation within the tumor

Spontaneously regresses in most patients before age 2

2nd most common benign liver mass

Focal nodular hyperplasia

Focal nodular hyperplasia (FNH)

Contains all normal parenchyma components, except normal portal venous structures

MOST COMMON IN WOMEN of childbearing years

Not encapsulated

Asymptomatic, Normal LFTS

Sulfur colloid imaging

FNH is associated with

Oral contraceptive use

Sulfur colloid imaging

Nuclear medicine exam used to detect FNH

In most pts, the FNH mass will absorb the sulfur colloid at the same rate as the normal liver tissue = warm nodule

In some pts, FNH mass will absorb the sulfur colloid at a higher rate than normal liver tissue = hot nodule

USA FNH

Variable in appearance, can be isoechoic to liver

Stealth lesion b/c it is difficult to differentiate from liver

Solitary mass <5cm

CENTRAL SCAR with radial vascularity

SPOKE WHEEL with color

May distort liver contour

Not able to diagnose on US

Contrast US demonstrates enhancement of FNH throughout arterial and portal phases

Contrast first fills central lesion and moves peripherally

Focal nodular hyperplasia

Focal nodular hyperplasia

Liver cell adenoma

Uncommon tumor

Atypical hepatocyte formation

Bile ducts and Kupffer cells are absent or few in number

Encapsulated mass

More common in women

Asymptomatic or RUQ pain

Normal LFTs

Cold nodule on sulfur imaging

Surgical intervention is recommended

Liver cell adenoma is associated with

Oral contraceptives, glycogen storage disease

USA liver cell adenoma

Hypervascular mass, with/without hemorrhage, solid and well defined

Varying echogenicity, usually hypoechoic

Increased vascularity with possible internal hemorrhage

HYPOECHOIC RIM

Cannot be differentiated from FNH on US

Contrast first pools peripherally then moves centrally

Liver cell adenoma

Liver cell adenoma

Hepatic lipoma

Very rare

Associated with tuberous sclerosis

Hyperechoic mass

May see propagation speed artifact due to difference in speed of sound in liver tissue and fat → broken diaphragm posterior to lesion

CT is helpful to determine type of tissue

HCC is the __th leading cause of cancer death

5

Most common primary malignancy of liver in adults

HCC

Most common risk factor for HCC

• 80% of pts already have this

Cirrhosis

HCC

Primary tumor of parenchymal cells that interferes with hepatocyte function

Leads to hepatoma formation

Related to formation of multiple nodules but can be solitary or diffuse

Invades vasculature causing an obstruction

3-4 month survival after detection

HCC is also assocaited with

Chronic hepatitis

70% of cases with HCC have moderate levels of ____ in blood → sign of malignancy

70

Symptoms of HCC

Fever, hepatomegaly, palpable mass, ascites, weight loss

HCC is more common in _______

Males

Lab testing for HCC

Increased AST, ALT and ALP

HCC most commonly invades what vessel

MPV

USA HCC

Single large mass or multiple masses with diffuse infiltration of cancer cells

Solid nodules <5cm

Varying echogenicity with Central Scar

Fibrosis and necrosis causes heterogenicity

HALO EFFECT → hypoechoic ring

Hypervascular

Venous invasion

Low resistance waveforms

Contrast demonstrates enhancement during arterial phase

Patient Hx of a primary cancer in the body + liver mass with halo =

Liver mets

Patient Hx of chronic liver disease and liver mass with halo =

HCC

HCC

Fibrolamellar carcinoma

Subtype of HCC found in ADOLESCENTS and young adults with NO coexisting liver disease

AFP is normal

Solitary mass that can grow large (6-22cm)

Mass is well differentiated, and usually encapsulated by fibrous tissue

Punctate calcs and a central echogenic scar help to differentiate it from hepatoma

Number 1 PEDIATRIC primary liver malignancy

Hepatoblastoma

Hepatoblastoma

Genetic

Associated with Beckwith-Wiedemann syndrome or familial adenomatous polyposis

Abdominal enlargement, hepatomegaly, palpable mass

Lab testing: Abnormal LFTs, INCREASED AFP

USA Hepatoblastoma

Solid echogenic mass

May have cystic portions/septations

May contain calcs

Has tendency to invade hepatic and portal veins

Hepatoblastoma

Liver is the #__ site for mets

1

Most common solid mass of the liver

Mets

Mets is ___x more common than primary liver cancer

20

__% of primary cancers that metastasize to liver are carried to the liver by the portal vein

50

Liver Mets

RUQ pain, weight loss, ascites, jaundice, palpable mass, N/V

Labs: Increased LFTs, Alk phos, AFP, direct bilirubin

Contrast US = rapid contrast washout in the portal venous phase

Liver Mets USA

Multiple masses that vary in size

Necrosis at the center of the lesion as the blood supply is outgrown

Hypoechoic rim USUALLY METS

Hyperechoic → GI tract primary or HCC
Hyperechoic with hypervascularity → RCC

Hypoechoic → Lymphoma, lung or breast primary

BULLS-EYE

Calcified

Abnormal lymph nodes in surrounding area

Liver mets

Kaposi Sarcoma

Malignancy of connective tissues in body

May also involve skin, lungs, GI tract and other organs

Most common liver malignancy seen with HIV/AIDS

Kaposi sarcoma

Lymphoma

Associated with HIV/AIDS

Malignancy of the lymphatic system

Solid tumor

Single or multiple

Hypoechoic and/or complex appearance

• Hodgkins

• Nonhodgkins

Non-Hodgkin lymphoma

Most common bloodborne chronic infection in US

Hepatitis C

A bulge in the liver capsule indicates __________, while an indented liver capsule indicates ________________

Intrahepatic; Extrahepatic

All the following describe a hemangioma except:

Most common benign mass of liver

Decreases in size with pregnancy

Most commonly seen in right lobe

Isovascular contrast enhancement

Decreases in size with pregnancy

Kasabach-merritt syndrome is associated with the formation of what benign liver mass?

Hemangioma

What benign liver masses are associated with use of oral contraceptives?

FNH and adenoma

FNH is demonstrated by US as:

Solid mass with central scar with radial vascularity

A liver adenoma is typically:

Hypoechoic

Hypervascular

Surgically removed

All of the above

All of the above

The presence of which blood testing indicated HCC is present in cases of cirrhosis?

AFP

Which of the following sonographic characteristics of a liver mass should cause a strong suspicion of malignancy?

Posterior enhancement

Hypervascularity

Calcificatinos

Hypoechoic halo

Hypoechoic halo

Focal fatty sparing vs. Hepatoma

Fatty sparing has no mass effect on the vasculature, while a hepatoma will invade vasculature

What is a sign of fibrolamellar carcinoma (FLC), but is not seen with other types of HCC?

FLC demonstrates punctate calcifications and a central echogenic scar

No coexisting liver disease

A liver mass with a target or bulls eye appearance is most likely

Liver mets

If liver mets is suspected after an upper abdominal US, the entire abdomen should be evaluated for associated:

Lymphadenopathy

What two liver malignancies are most commonly seen with AIDS?

Lymphoma and Kaposi tumor