Incidentolomas - Evaluation and Management of Incidental Liver Lesions - PowerPoint Presentation

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Incidentolomas - Evaluation and Management of Incidental Liver Lesions

Patrick M. Horne, MSN, ARNP, FNP-BC

Assistant Director of

Hepatology

Clinical Research

Division of Gastroenterology,

Hepatology

and Nutrition

University of Florida Health

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Disclosures

Financial relationships to disclose within the past 12 months:

Grant support with Bayer/Onyx

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Objectives

Discuss natural history of benign liver lesions.

Discuss Evaluation and management of FNH,

Hemangioma

, Liver Cyst

, Adenoma

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Background

Causes of focal liver lesions are diverse and can range widely.

Typically are clinically silent and detected incidentally while undergoing evaluation for unrelated symptoms.

Understanding the clinical circumstances surrounding the presence of liver lesions aids in better diagnosis.

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Differential diagnosis

Common benign liver lesions include:

Hepatic

hemangioma

Focal nodular hyperplasia (FNH)

Hepatic adenoma

Hepatic cyst

Idiopathic

noncirrhotic

portal hypertensionFocal nodular hyperplasiaRegenerative nodules

Bonder A &

Afdhal

N.

Clin

. Liver Dis. 2012

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Case 1

40 year old Caucasian female presents to her PCP’s office intermittent nonspecific abdominal pain and nausea.

Physical exam negative but abdominal ultrasound ordered which notes a possible lesion.

Follow up imaging obtained

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Case 1

Persistent enhancement throughout imaging phases

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Hemangioma

Most common benign hepatic tumor

60-80% diagnosed in people between the ages of 30-50.

Ratio of occurrence in women to men, 3:1.

More common in young women

Choi BY & Nguyen MH. J

Clin

Gastroenterol

. 2005

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Hemangioma-Diagnosis

On ultrasound appear well

-defined, lobulated, homogeneous

hyperechoic

mass.

The

accuracy of US is reported to be 70% to 80%

.

CT and/or MRI was best optionsWith MRI having sensitivity and specificity around 85-95%.

Descottes

B

et

al

. Surg.

Endosc

. 2003.

Unai

O et al.

Clin

Imaging. 2002.

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Hemangioma-Management

Treatment is usually not indicated in the setting of no symptoms with a firm diagnosis and confirmed stability on imaging at least 6 months apart.

Lesions less than 5 cm

Larger lesions may require closer monitoring and if symptoms develop may need to treatment.

Blecker

E et al. Z.

Gastroenterol

. 2003

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Hemangioma-Management

Treatment options include

Surgery

Resection

Hepatic irradiation or

transarterial

catheter chemoembolization

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Case 2

25 year old

H

ispanic female undergoing work up for elevated liver function tests (LFTs).

Noted to have multiple liver lesions on abdominal ultrasound, the largest measuring 13 cm in diameter.

Follow up imaging including CT and MRI completed.

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Case 2-Imaging

CT scan

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Case 2-Imaging

MRI

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Focal Nodular Hyperplasia (FNH)

Second most common liver tumor

Incidence is on the rise due to better imaging.

Can occur in both men and women

80-95% of cases seen in women, ratio 5:1

Bartolotta

TV et al. La

Radiologia

Medica. 2013.

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FNH-features

Class findings include:

Presence of a “central scar” on contrast enhanced imaging

Present in about 1/3 of patients

Lesions typically become

hyperdense

during arterial phase imaging.

Due to arterial origin of the blood supply

Isodense

during portal venous phaseThough central scar may be hyperdense

Bartolotta

TV et al. La

Radiologia

Medica

. 2013.

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FNH-Diagnosis

Sulfur colloid scanning

Due to prevalence of

Kupffer

cells, 80% of FNHs will show active uptake

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FNH-Management

Typically conservative.

Typically stable lesions and do not change over time

No evidence to suggest malignant transformation

Enlargement and/or development in the setting of OCP?

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Case 3

30 year old Caucasian female presents with chronic abdominal pain.

Has been on oral contraception therapy for 5 years

Otherwise healthy, no significant medical history.

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Case 3

MRI

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Hepatic adenoma

Uncommon lesions

Mostly in young women (22-40)

Commonly in the right lobe of the liver

Grazioli

L.

Radiographics

. 2001

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Hepatic adenoma

Strong association with:

Oral

contraceptives and hormones

Anabolic steroids

Glycogen storage disease

Less common association:

Pregnancy

Diabetes mellitus

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Farges

O. Gut. 2011

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Hepatic adenoma

Prognosis not well established

There is an association with:

Malignant transformation

Spontaneous hemorrhage

Rupture

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Hepatic adenoma-Diagnosis

Typically made clinically with imaging.

Biopsy of the lesion is not indicated or recommended due to risk of bleeding.

Imaging techniques:

US-limited

CT and/or MRI

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Hepatic adenoma-Diagnosis

CT: Well demarcated and have low attenuation or are

isodense

on

noncontrast

imaging and show peripheral enhancement early with

centipedal

flow during portal

venous.

MRI: usually well demarcated and typically hyperintense on T1. Enhancement on T2 images

that enhance further with gadolinium administration is highly

suggestive.

Grazioli

L.

Radiographics

. 2001

Chung. KY AJR. 1995

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Hepatic adenoma-Management

Dependent on size of lesion and symptoms

If asymptomatic and lesion is small (less than 5 cm)

Stop OCP if taking

Can monitor with imaging and possibly AFP

If symptomatic and/or lesion is large (greater than 5 cm)

Surgical resection is recommended.

Liver transplantation rare

Dokmak

S. et al. Gastroenterology. 2009

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Case 4

60 year old female presents to a local ER with severe abdominal pain with a palpable mass on physical examination.

No known history of liver disease or GI symptoms

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Case 4

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Hepatic cyst-Differential

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Hepatic cyst-Prevalence

Dependent on origin

Simple:

More common in right lobe.

More in women, ratio of 1.5:1.

Distinction between simple and other types of cysts is difficult to make but very important for management.

Huge cysts found often in women over age 50.

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Hepatic cyst-Diagnosis

Ultrasound:

Good at distinguishing between simple and other cystic lesions

CT scan:

Well demarcated lesion with no enhancement after administration of IV contrast.

MRI:

No enhancement with contrast.

T1-weighted images the cyst shows a low signal, whereas a very high intensity signal is shown on T2-weighted

images.

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Simple cyst

Cystic

echinococcosis

Alveolar

Echinococcosis

Cystadenoma

And

cystadenocarinoma

Border

Sharp

and smooth

Laminated

Irregular

Irregular

Shape

Spherical or oval

Round or oval

Irregular

Round

or oval

Echo pattern

Anechoic

Anechoic or atypical

Hyperechogenic

outer ring and

hypoechogenic

center

Hypoechogenic

with

hyperechogenic

septations

Appearance

No septa

multiseptated

multivesicular

Septated

and/or sold structures

Wall

Strong

posterior wall echoes

Wall enhancement

Posterior

acoustic feature

Relative accentuation of echoes

Dorsal

shadowing (calcified areas)

Doral shadowing (calcified areas)

Lantinga

MA. 2013. World Journal of Gastro.

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Hepatic cyst-Management

Symptoms and type of cyst drive the management

Majority do not require intervention (if simple).

Would consider monitoring large cysts over 4 cm with interval imaging.

Minor and major surgical options available for large cysts and/or symptoms

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Hepatic cyst-Management

Interventions:

Needle aspiration (though associated with high failure rate and rapid recurrence)

Deroofing

Liver resection

If infectious, treat appropriately.

Yasawry

MI. World J

Gastroenterol

. 2011

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Conclusion

Liver lesions are common and proper diagnosis is important.

A combination of medical history as well as appropriate imaging is essential.

Most liver lesions are benign but in certain situations must be addressed or treated.

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Thank you