Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 473 - файл
.pdf
88
Benign Liver Lesions
A. H. Sohail et al.
Pathology
Characteristics
Radiologic
features
Hepatic adenoma Hepatic hemangiomas
Yellow-tan, well-circumscribed,
round lesions
Absence of bile ducts
90% are females; 15–45years old
Associated with high-estrogen states
(pregnancy, OCPs)
Chronic androgen and anabolic
steroid use
Risk factors: Congenital disorders
(such as glycogen storage
disorders), familial adenomatous
polyposis, obesity, metabolic
syndrome
Arterial enhancement
Do not typically demonstrate
delayed washout
Well-circumscribed,
compressible, dark-colored
lesions
Supplied by branches of
hepatic artery
Most common between 30
and 50years of age
Often found incidentally in
asymptomatic patients
Most common benign liver
lesion
Rare complications:
Consumptive coagulopathy
(Kasabach-Merritt syndrome)
and CHF➔seen in children
Peripheral nodular
enhancement on arterial
phase, followed by
progressive centripetal
enhancement on portal
venous phase
Focal nodular
hyperplasia
Non-encapsulated,
lobulated slightly lighter
color than the surrounding
liver
Has Kupffer cells
Female predilection (8:1)
Usually in the third to fth
decades of life
Has Kupffer cells➔take
up sulfur colloid
Arterial enhancement on
arterial phase, except for a
hypoattenuating central
scar (central scar due to an
overt feeding artery)
a
3 Liver
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
89
CT ndings
Hepatic adenoma Hepatic hemangiomas
Axial abdominal CT image with IV
contrast demonstrates active
hemorrhage (black arrow) in a
hepatic segment 6 adenoma (white
arrow).
b
c
Axial CT urogram (A)
non-contrast, (B) IV
contrast-enhanced
nephrogenic phase, and (C)
and IV contrast-enhanced
excretory phase images
demonstrate a peripherally
discontinuous progressively
enhancing mass (arrow), a
hepatic hemangioma
Focal nodular
hyperplasia
Axial abdominal CT image
with IV contrast
demonstrates a hepatic
segment 8 peripherally
enhancing liver mass with a
hypoenhancing center
(arrow), most consistent
with focal nodular
hyperplasia. Note the
characteristic central
brous scar
T1: Variable; mostly hyperintense,
but can also be iso or hypointense
MRI ndings
T2: Hyperintense
T1 (Gadolinium contrast): Early
arterial enhancement; isointense on
delayed images
T1: Hypointense
T2: Hyperintense
T1 (Gadolinium contrast):
Centripetal progression of
enhancement on delayed
images
T1: Iso to hypointense;
hypointense central scar
T2: Iso to hyperintense;
hyperintense central scar
T1 (Gadolinium contrast):
Early arterial enhancement,
isointense to liver on portal
venous phase; contrastenhanced central scar on
delayed images
90
A. H. Sohail et al.
Hepatic adenoma Hepatic hemangiomas
Discontinuation of OCPs/
Management
androgens➔tumor regression
(observe every 6months for
2years)
Do not need to be resected, unless
>5cm, or unable to rule out
malignancy
Concern for malignant degeneration
or spontaneous rupture (seen with
tumors on the surface of liver;
sudden upper abdominal
pain+hypovolemic shock)
If rupture➔angioembolization
rst➔surgery
Resection if symptomatic or
>10cm
Cystic lesions of liver
Types
Simple (solitary) cyst Thin wall and no internal septations Nonoperative
Parasitic
(echinococcal) cyst
See section on “Hepatic infections”
Characteristics
Unroong of the cyst if symptomatic
Focal nodular
hyperplasia
Surgical resection if
symptomatic or if a
denitive diagnosis cannot
be made
Annual ultrasound for
2–3years if continuing
OCPs
Management
Primary neoplastic
Metastatic neoplasm
(ovary, pancreas,
colon, kidney)
False cysts
Mucinous cystic neoplasms (previously
Cystadenomas)➔heterogeneous septations,
irregular papillary growths, and thickened
cyst wall
Hyperintense on MRI T2 weighting
Uncommonly presents with an isolated cystic
lesion
Caused by intrahepatic hematoma after
trauma/surgery or intrahepatic biloma
Do not have an epithelial lining
Premalignant lesions that can progress to
biliary cystadenocarcinoma➔resection
with clear margins or enucleation at the
level of the pseudocapsule
Anatomic resection is not required
Nonoperative management if asymptomatic
Consider deroong/alcohol sclerosis if
symptomatic
3 Liver
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Malignant Liver Masses
Malignant liver masses
Can be primary liver neoplasms (hepatocellular carcinoma and cholangiocarcinoma) or secondary
metastases from distant primary malignancies
Characteristics
Secondary malignant neoplasms are more common than primary tumors of the liver
Most common secondary malignant neoplasm➔colorectal cancer (up to 50% of patients develop
liver metastases)
91
Diagnosis
In diagnosing liver masses➔consider patient risk factors such as cirrhosis, hepatitis infection,
extrahepatic malignancy, trauma, recent travel, and use of OCPs
• Triphasic abdominal CT scan➔rst diagnostic step
• Liver mass+cirrhotic liver➔HCC until proven otherwise
• HCC needs to be differentiated from a regenerative nodule or cholangiocarcinoma➔CT or
MRI, AFP levels, and biopsy
Imaging characteristics of liver lesions on computed tomography
Imaging
HCC
Type
characteristic
Heterogenous
Poorly circumscribed
mass
Enhances on arterial
phase
Washes out in the portal
venous and delayed
phases with possible
pseudocapsule
Imaging
Axial abdominal CT (A) arterial phase and (B) portal
venous phase IV contrast-enhanced images demonstrate an
ill-dened area of arterial enhancement with rapid washout
during the venous phase (arrow)
92
ab
Imaging characteristics of liver lesions on computed tomography
Imaging
Type
Hepatic adenomas
Cholangiocarcinoma
characteristic
CT appearance that
overlaps with that of HCC
Enhance on arterial phase
Do not typically
demonstrate delayed
washout
Low-attenuation mass
with minor peripheral
enhancement that
becomes stronger in
venous phase
Capsular retraction
Dilation of bile ducts
distal to the mass
Imaging
A. H. Sohail et al.
Metastases from NET
or RCC
Arterially enhancing liver
lesions
May be confused with
HCC
(A) Axial and (B) coronal abdominal CT images with IV
contrast demonstrate multiple peripheral enhancing liver
nodules and masses measuring up to 2.4cm (arrows), as
well as a 5.8cm exophytic mass arising from the lower pole
of the left kidney (star). Findings are most consistent with
renal cell carcinoma with metastatic disease to the liver
3 Liver
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Imaging characteristics of liver lesions on computed tomography
Imaging
Type
Metastases
characteristic
Hypodense compared to
surrounding tissue
May enhance minimally
during arterial phase
Metastatic lesions can be
either high or low
attenuating lesions
depending on the site of
origin
Adenocarcinomas from
the colon, pancreas, or
stomach➔low
attenuating
Neuroendocrine, breast,
melanoma, thyroid, and
renal cell
carcinoma➔enhanced
compared to surrounding
parenchyma
Axial abdominal CT image with IV contrast demonstrated
a segment 7 calcied metastasis (solid arrow), and a
segment 2 metastasis (outlined arrow)
Imaging
93
MRI ndings of malignant liver masses
HCC T1: Variable; mostly isointense or hypointense
T1 with contrast (Gadolinium): Arterial enhancement with rapid washout to hypointensity
T1 with contrast (Eovist/Primovist): Arterial hyperenhancement
T2: Hyperintense
DWI: Hyperintense
T1: Hypointense
Metastases
T2: Moderately hyperintense
Gadolinium creates lesion or perilesional enhancement, while gadoxetate (Eovist) shows metastatic
lesions as “holes” in the liver in the delayed phase
The presence of uid-uid levels is typically seen in neuroendocrine metastases
Hepatocellular Cancer
Hepatocellular cancer (HCC)
Hepatitis B, hepatitis C, ethanol, hemochromatosis, alpha-1-antitrypsin deciency, primary
Risk factors
Pathophysiology
sclerosing cholangitis, aatoxins, hepatic adenoma
Chronic viral hepatitis is responsible for the majority of HCC cases
Inammation, necrosis, brosis➔ongoing regeneration➔HCC development
94
A. H. Sohail et al.
Hepatocellular cancer (HCC)
Characteristics Inammation, necrosis, brosis, and ongoing regeneration characterizing the cirrhotic liver
contribute to HCC development in chronic hepatitis
HBV: HCC can develop in livers that frankly are not cirrhotic
HCV: HCC invariably presents in the setting of cirrhosis
> 75% of primary malignant liver tumors are HCC
100× risk of HCC in individuals with chronic viral hepatitis
In the USA, 16% of HCC cases are attributed to HBV and 48% to HCV
Screening
Diagnosis AFP correlates with tumor size
Management
For high risk patients➔ultrasound every 6months to monitor
Obtain CT or MRI➔specic imaging characteristic➔if diagnosis uncertain➔biopsy
Assess tumor size, location, extrahepatic metastasis, liver function, performance status
(Barcelona Clinic Liver Cancer system)
Surgery if early stage with preserved liver function
Liver-directed therapies with advanced disease or poor performance status
Localized disease and ineligible for resection or transplant, no macrovascular
invasion➔liver- directed approaches (radiofrequency/microwave ablation, embolization,
external beam radiation) or systemic therapy
Liver directed approaches are superior to systemic therapy
Transarterial chemoembolization (TACE) if preserved liver function and no vascular
involvement
Best results with radiofrequency and microwave ablation are with one or two tumors <4cm
Resection Liver-directed therapy Systemic therapy
Types Right hepatectomy
Left hepatectomy
Extended right
Extended left
Thermal ablation
TAC E
Radioembolization
Chemotherapy
(sorafenib and
immunotherapy)
Indications
Contraindications
Localized disease
(removal of lesion is
achievable while
leaving an adequate
FLR)
Metastatic disease
Child C/advanced
Child B cirrhosis
Multifocal disease
(inadequate FLR
post-resection)
Macroscopic vascular
invasion in portal
vein branches/hepatic
veins
Main bile duct
involvement
Downstage tumor and permit
resection/transplantation
Patients who do not quality for
operative management
Advanced HCC
3 Liver
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Hepatocellular cancer (HCC)
Milan criteria used to assess the suitability liver transplant
Indications for liver
transplantation
One lesion <5cm in size
2–3 lesions <3cm
No macroscopic vascular invasion
No extrahepatic disease
95
Transplantation in
HCC
Deceased donor liver allocation (for adults and children) based upon MELD score
MELD score predicts survival in cirrhotics
MELD criteria are of limited utility in individuals with HCC (do not predict survival with
chronic liver disease+HCC)
Clinical scenarios for HCC management
Clinical scenario Best management
Solitary tumor+good performance status+preserved liver
function
Solitary tumor+good performance status+preserved liver
function+portal hypertension
Solitary tumor+poor performance status Liver-directed therapies with curative intent
Multifocal HCC+good performance status+active alcohol
abuse
Liver resection
Orthotopic liver transplantation
Transarterial chemoembolization as palliative
treatment
Research
Reference Findings
European Association for the Study of the Liver;
European Organisation for Research and Treatment
of Cancer. EASL-EORTC clinical practice
guidelines: Management of hepatocellular
carcinoma J Hepatol. 2012;56(4):908–43
New nodules on ultrasound require further investigation.
Nodules smaller than 1cm should have a repeat ultrasound
in approximately 4months to determine growth. Evaluate
lesions 1cm or larger with a 4-phase dynamic CT scan or
an MRI.Biopsy, if scans not denitive
Llovet JM, Ricci S, Mazzaferro V, Hilgard P, Gane
E, Blanc JF, De Oliveira AC, Santoro A, Raoul JL,
Forner A, Schwartz M.Sorafenib in advanced
hepatocellular carcinoma. New England J Med.
2008;359(4):378–90
Tanaka S, Kaibori M, Ueno M, etal. Surgical
outcomes for the ruptured hepatocellular
carcinoma: Multicenter analysis with a casecontrolled study. J Gastrointest Surg.
2016;20(12):2021–34
Sorafenib signicantly prolongs survival over supportive
care alone in patients with advanced HCC Sharp Trial
Rupture of HCC does not worsen long-term survival
96
A. H. Sohail et al.
Cholangiocarcinoma
Denition Bile duct cancer in intrahepatic, perihilar, or distal extrahepatic biliary tree
Presentation Painless jaundice, weight loss
Surgery with cholangiocarcinoma and adequate FLR
Management
Contraindications: Portal vein or common hepatic artery invasion, metastatic disease
Diagnostic laparoscopy➔to rule out extrahepatic involvement or locally advanced
disease
Metastatic Liver Tumors
Metastatic liver tumors
Most common malignant tumors of the liver
General characteristics
Generally, of gastrointestinal origin (metastasis via portal system)
Categorized
into three groups: Colorectal, neuroendocrine, and noncolorectal–nonneuroendocrine
Diagnosis
Prognosis Symptomatic advanced malignant disease is generally a poor prognostic indicator
MRI has greater sensitivity than CT for detection of liver metastases
Biopsy➔not required unless the primary site is unknown
Biopsy can provide tissue for pathologic, immunohistochemical, and molecular
testing
Colon cancer metastases to the liver
General characteristics Most common site of metastasis for colon cancer
Metastases conned to liver in 70–80%
Metachronous liver lesions (>6months after primary site) have less aggressive
biology
Diagnosis
Management Surgical resection is the most effective treatment for liver metastasis
Increasing CEA levels+new liver lesion on imaging➔diagnostic of metastatic
colorectal cancer
5–10% of patients are candidates for upfront resection
Isolated colon cancer metastasis to liver➔resect (provided adequate FLR)
If not candidate for resection➔multimodal approach (makes 20% amenable to
resection)
3 Liver
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Colon cancer metastases to the liver
97
Management of colorectal
cancer with liver metastasis
Risk factors for poor
outcomes
Simple
Concomitant CRC and liver
metastases resection
Extrahepatic metastases, lymph node involvement, CEA>200ng/mL,
synchronous presentation, multiple tumors, bilobar involvement, largest lesion
CRC with liver metastases
Colon
Obstruction
NO
Resectability
Borderline Unresectable
Tr ial chemotherapy first
followed by resection or
resect liver desease first (as
might become unresectable)
YES
Systemic or hepatic arterial
infusion chemotherapy to
downstage liver metastases,
transarterial embolization
chemotherapy or radiation
beads or stereotactic body
>5cm, positive histologic margins
Recurrence
Recurrence in 75% after resection➔re-resect if isolated to liver and adequate FLR
Survival 50% 3-year, 35% 5-year, 20% 10-year survival after resection
Resect
obstructed bowel
with or without
radiation therapy
Neuroendocrine metastases to the liver
Characteristics 40–95% gastroenteropancreatic neuroendocrine tumors have metastasized before diagnosis
Most common site: liver
Management Surgery is the only curative option
Prognosis Liver metastasis is the most important prognostic indicator
Survival 50–75% 5-year survival rate after liver resection if >90% cytoreduction is achieved
Research
Reference Findings
Fretland ÅA, Dagenborg VJ, Bjørnelv GMW,
etal. Laparoscopic versus open resection for
colorectal liver metastases: The OSLO-COMET
randomized controlled trial. Ann Surg.
2018;267(2):199–207
Nordlinger B, Sorbye H, Glimelius B, etal.
Perioperative FOLFOX4 chemotherapy and
surgery versus surgery alone for resectable liver
metastases from colorectal cancer (EORTC
40983): Long-term results of a randomised,
controlled, phase 3 trial. Lancet Oncol.
2013;14(12):1208–15
Lower complication rate after laparoscopic liver resection
vs. open resection (19% vs 31%) for colorectal metastasis,
without an increase in operating room time (123min vs
120min)
Investigated the effect of systemic perioperative
chemotherapy for resectable colorectal metastases to
liver➔patients randomized to receive FOLFOX
chemotherapy before and after surgery or surgery alone. No
difference in long-term survival, but improvement in
progression- free survival with perioperative chemotherapy
Соседние файлы в папке @xirurgi_2025