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06-06-2008, 09:48 PM
m Benign Tumours (All are rare)
1. Haemangioma:
Ä Pathology: This is the comrnonest benign tumour of the liver and is usually of the cavernous type.
Ä Clinical picture: Most lesions are silent and are discovered accidentally during exploration. Although rupture is rare it causes serious bleeding. Large lesions may occur in children and may be diffuse. They may cause high output cardiac failure and a bruit may be heard over the mass.
Ä Diagnosis: CT scan and hepatic arteriography. Most cases of diffuse hepatic haemangioma are associated with cutaneous haemangiomata.
ÄTreatment: If the child survives the first year of life the hepatic and cutaneous lesions tend to regress. Resection if the lesion if localized. If the lesion is more diffuse ligation of the feeding vessel or hepatic artery may cause regression.
Irradiation of the liver may be useful
2. Adenomas and focal Nodular Hyperplasia:
Ä Aetiology and pathology:
Adenomas usually seen in children and postmenopausal women. They may be related to the use of contraceptive pills.
Focal nodular hyperplasia has no relation to the use of pills and may be related to injury of the liver parenchyma or anomalous blood supply. The condition is not premalignant.
Ä Diagnosis: is by ultrasound, CT scan and laparotomy.
Ä Treatment: An adenoma increasing rapidly in size should be excised, for fear of malignant change or rupture.
3. Hamartoma:
It is of congenital origin and has a pseudocapsule of compressed liver tissue. The tumour may be benign or may have a sarcomatous element. Local resection or lobectomy according to the size of the lesion may be needed.
4.Cholangioma
It is a rare benign tumour which arises from the bile duct epithelium.
5. Biliary cystadenoma
It is a rare tumour which may reach a large size, cystic degeneration is usually found.
m Malignant Tumours of the Liver
ÄAetiological factors:
1- Genetic and Racial:More common in Africans and Chinese.
2- Sex:Three times more common in males.
3- Chronic liver disease.Cirrhosis and chronic active hepatitis.There is no increased incidence with Bilharziasis.
4- Hepatitis B and C virusis the most important aetiological factor.

ÄPathology
Most primary tumours are large, with necrotic centres. 4 types are encountered:
(I) Hepatocellular carcinoma (HCC);
1. The common types is formed of cells which resemble normal polygonal hepatocytes. Basophilis and infiltration of lymphatics in the portal tracts give an indication of malignancy. Spread through the veins and lymphatics may give rise to multiple liver tumours. Blood-borne metastases in the lung are common.
2. The clear cell type is a rare type in which the cells are foamy and contain glycogen or lipid. They may be associated with hypoglycemia or hypercholestraemia.
(2)Fibrolamellar carcinoma, presents with abdominal pain and mass, affects young adults, equal in both sexes. Alpha-fetoprotein is not elevated as with HCC.
(3) Hepatocellular cholangiocarcinoma
Combines histological features of both types of tumours.
(4)Cystadenocarcinoma, is a large tumour formed of cystic spaces containing papillary projections.
m Sacrcorna of Liver
Sarcomas such as haemangioendothelioma and angiosarcoma are very rare tumours which arise from connective tissue components. They grow rapidly and may rupture and cause intraperitoneal haemorrhage.
m Hepatic tumours in children (Hepatoblastoma):
Hepatocellular carcinoma may occur in children and give rise to a big abdominal mass. Hepatoblastoma may develop usually by the third year. It consists of embryonic liver tissue and variable tissues such as bone, cartilage, striated muscles and connective tissue. The tumour produces high levels of Alpha­fetoprotein and some tumours produce gonadotrophins.
m Clinical Picture of Hepatoma:
Primary tumours of the liver may give rise to:
(I) General features
Common general features include Athenia, anaemia and anorrhexia .
(2) Mass in the abdomenis the commonest presentation. It is usually firm or hard and is usually rapidly growing. A friction rub or a bruit may be heard over it (10%).
(3) Late features:Jaundice deepens when the tumour obstructs the bile ducts. Ascites is common and is sometimes blood stained.
m Diagnosis
1. Ultrasound scanning demonstrates the size and position.
2. CT scanning demonstrates the lesion and its relations to the major structures. The new spiral CT technique can give three dimensions pictures of the liver and tumours. A True cut needle biopsy can be performed relatively safely.
3. Arteriography may be needed in a cirrhotic patient, because with cirrhosis ultrasound and CT scanning may fail to demonstrate the lesion. It is essential if treatment plan involves liver resection.
4. Cavography is essential to exclude invasion of inferior vena cava.
5. Laboratory studies:
(a) Alpha-fetoprotein is elevated in one third of cases. It is useful as a marker after resection.
(b) Hepatitis B antigen should be looked for in all patients.
(c) Study of coagulation parameters is essential before hepatic resection.
m Treatment
(A) Surgical treatment
Few cases are fit for surgery. This may be in the form of wedge resection if tumour is superficial and localized, excision of a segment or left or right lobectomy (hemihepatectomy). In patients with chronic liver disease minimal resection reduce the incidence of postoperative liver cell failure. Hepatic transplantation is considered.
(B) Non surgical treatment
I- Chemotherapy. Response is minimal. It may cause reduction in the tumour size.
II- Radiotherapy. It may be used to palliate pain in some tumours, but its use is limited due to sensitivity of normal liver cells to irradiation.
III - Intra-arterial embolization. Hepatic artery and its branches supplying the tumour are embolized with gel foam. The granules may be mixed with a chemotheraputic agent. The procedure causes necrosis of the tumour cells.
m Secondary Liver Tumours:
Ä Source: The liver is the commonest organ to develop secondaries either by direct invasion from tumours of stomach, colon or pancreas or metastatic by the portal vein or hepatic artery.
Ä Gross picture: They are frequently multiple and umbilicated and are usually formed on the under surface near the lower border.
Ä Clinical picture: Secondaries in the liver may remain silent for a long time, but ultimately they cause pain in the abdomen and back, dyspepsia, nausia, cachexia, jaundice and ascites
Ä Treatment of liver metastases:
(1) Surgical treatment:In most cases no surgical treatment is possible. Rarely a solitary secondary can be resected with a margin of healthy liver tissue. Occasionally long survival is achieved especially in colorectal carcinoma.
(2) Irradiation of the liver: This has little value for gastrointestinal tumours.
(3) Chemotherapy:A complete course of chemotherapy is justifiable, and if there is response it may be repeated. Ligation and cannulation of the hepatic artery for continuous infusion or intermittent chemotherapy infusion, is now possible by the use of an implantable pump. It is rather expensive, carries the risk of inducing sclerosing cholangitis and only 50% of cases can survive for one year.
SOURCE: DR. AYMAN SALEM'S BOOK
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