Hepatobiliary—Liver Mass
Concept
Usually found during an exploratory laparotomy per- formed for colon cancer, GI bleed, or other unrelated rea- sons. May also be diagnosed incidentally on CT or U/S performed on a patient with abdominal pain. Make sure to differentiate solid from cystic lesions here. Hemangioma is most common benign tumor. Half of adenomas present with spontaneous bleeding.
Way Question May be Asked?
“A 37 y/o female is evaluated in the ED for abdominal pain and the CT scan shows a 3 cm mass deep in the right lobe of the liver. What do you want to do?” May be in the sce- nario of doing an ex lap and finding an incidental lesion in the periphery of the liver or patient may present hypoten- sive with abdominal pain.
How to Answer?
History
Hepatitis
Previous malignancy (colon CA) OCP use
Weight loss/anorexia
Race (Africa/Southeast Asia associated with HCC) Abdominal pain
Physical Exam
Full physical especially abdominal exam (liver enlarge- ment, tenderness)
Diagnostic Tests
Hepatitis panel/LFTs +/− AFP (if suspect HCC)
+/− CEA if suspect colorectal recurrence CBC
Ultrasound RUQ (used to r/o solid lesion from cyst/abscess—different scenario)
CT scan abdomen/pelvis (central scar associated with FNH)
MRI
+/− Tagged RBC technetium scan (r/o hemangioma) +/− Angiography—helpful in evaluating primary malig-
nancies
DDx
Hemangioma FNH
Adenoma
Malignancy (primary or metastatic)
Surgical Treatment
(1) FNA under CT guidance—helpful if diagnoses malignancy (don’t do if suspect hepatocellular can- cer (elevated AFP, hepatitis B positive, cirrhosis) (2) If FNA negative, need core needle bx by
laparoscopy or open surgery (3) Treatment
(a) FNH—observation unless becomes sympto- matic
(b) adenoma—stop BCP and observe for 6 months, resect if:
becomes symptomatic
increases in size during observation period pt intends on becoming pregnant
(c) malignancy—
(1) Can resect metastatic disease if colon or neuroendocrine malignancy as long as pri- mary site controlled
(5 yr survival ~30% from metastectomy for colorectal ancer if < 5 mets and less than 5 cm in size)
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(2) Hepatocellular—be prepared to describe liver resection
(d) hemangioma—dx by CT, MRI, or tagged RBC scan
observe unless very large or symptomatic can cause pain, hemolysis, CHF
spontaneous rupture rare (1–2%) embolization 1st choice if symptomatic often surgically treated by enucleation (4) Incidental Liver Lesion
biopsy necessary
FNA to make sure not cystic or hemangioma Consider intra-op U/S
Can perform wedge resection if small and peripheral
Common Curveballs
Pt will have history of malignancy
Being asked when you will perform resection for metastatic disease
Liver nodule found during exploratory laparotomy—
“what would you do?”
Change scenario and pt will have cystic rather than solid lesion in the liver
Adenoma/hemangioma will bleed spontaneously dur- ing your observation period and pt will present in hemorrhagic shock
FNA will be negative but pt. has bleeding when doing open biopsy
You get into bleeding during open biopsy (change scenario)
Strikeouts
Not ruling out a cystic lesion
Not knowing treatment for FNH or hepatoma Sticking needle into hemangioma
Not knowing how to describe your liver resection Not trying to biopsy a liver lesion found during an
exploratory laparotomy
Not performing CT scan with contrast
Performing metastatectomy for breast, stomach cancer Performing FNA on hepatocellular cancer
Performing liver resection laparoscopically
Getting lost in a discussion about angiographic embolization when pt clearly needs to go to OR (resuscitate/check coags first)
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