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LIVER TUMOURS
143
Fig. 3.44 Investigation of a mass in the liver.
Isolated
hepatic mass
Potentially
resectable
Unresectable
technically
Laparoscopy
No-extrahepatic
disease
Biopsy
through sheath
Resect
Renal primary
neuroendocrine
Colonic primary
See colorectal
metastases
See GEP–NET
management
See treatment of
non-colorectal
non-neuroendocrine
metastases
Other primary
Metastatic
Chemotherapy
• US
• CT
• MRI
• Tumour markers-CEA, Alpha FP,
CA19.9
• Gastroscopy
• Colonoscopy
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144
Benign tumours ( Table 3.1 and Fig. 3.45 )
Patients with benign tumours either present with symptoms or with an inci-
dentally found lesion on ultrasound or CT or at laparotomy. Significant symp-
toms of pain or pressure may justify resection but with incidental tumours
thorough investigation is essential in order to be certain they are not meta-
static. Usually a 3–6-month period of observation is reasonable to assess any
change. If stable they are less likely to be part of a malignant process (Ichikawa
et al ., 2000 ; Nino-Murcia et al ., 2000 ; Horita et al ., 2002 ; Danet et al ., 2003 ;
Kim et al ., 2004 ; Cherqui, 2008 ).
If doubt exists about the nature of the lesions, laparoscopic Tru-cut biopsy
will provide useful information. This often needs to be combined with intra-
operative ultrasound and will be impossible for many tumours in Segments
VII, VIII, and I. A policy of close observation will show if size or contour is
changing. If this is the case, resection is the safest option.
Biopsy of liver lesions
Lesions found within the liver that are likely to be malignant will need resec-
tion. If surgery is possible, then percutaneous FNA or Tru-cut biopsy should
not be performed. There is a risk of needle track seeding or peritoneal spread
particularly with hepatocellular cancer (Kosugi et al ., 2004 ; Thompson et al .,
1985 ). It does not alter the clinical management, as positive results still
require resection and negative results as in all clinical situations can never be
relied upon completely, and removal may still be necessary (Silva et al ., 2008 ).
If the lesion or lesions are irresectable then biopsy confirmation prior to
chemotherapy is acceptable.
Hepatic cystadenomas and cystadenocarcinomas ( Fig. 3.46 )
Hepatic cystadenomas are rare tumours of the liver which have malignant
potential and a strong tendency to recur. They are often very large at presenta-
tion (10–20cm), loculated on examination, and contain mucinous fluid. Of
the two types, cystadenomas with mesenchymal (ovarian-like) stroma occur
only in females and those without mesenchymal stroma predominate in men
(Ishak et al ., 1977 ). Cystadenomas are often multilocular, septated, non-calcified,
and surrounded by compressed liver tissue (Teoh et al ., 2006 ). As the mesen-
chymal variant is the more common, the majority of patients with hepatic
cystadenomas are female.
Most patients are asymptomatic but when problems do occur these are
usually upper abdominal pain due to the size of the lesion and an abdomi-
nal mass. These tumours are slow growing with a mean duration between
onset of symptoms and treatment being 29.3 months (Barthet et al ., 1992 ;
LIVER TUMOURS
145
Table 3.1 CT, MRI, and red cell scan appearances of common benign liver tumours
and suggested management
Adenoma Focal nodular
hyperplasia (FNH)
Haemangioma
CT
Should be
homogeneous in
appearance
May have central scar Late blush on portal
phase
MRI
Appearances vary:
generally hyperintense
on T1-weighted images.
Occasional hyperintense
pseudocapsule like
a hepatocellular
carcinoma.
Hypervascular with
enhancement during
the arterial dominant
phase of IV contrast
injection. Occasional
central scar. Small
adenomas with no
central scar difficult to
differentiate from FNH
Central fibrous scar
common. Isointense
or slightly hypointense
compared with normal
liver on T1-weighted
images. Displaces
normal hepatic
vasculature. Early
arterial peak
enhancement
with dynamic
administration of IV
contrast
Hyperintense on
T2-weighted images,
peripheral nodular
enhancement with
‘filling in’ after
gadolinium
administration. Giant
haemangiomata may
show variable signal
intensity. Small
haemangiomata may
‘flash fill’and appear
hypervascular.
Distinguished by T2
characteristics
Red cell scan
Cold nodule Cold nodule Usually ‘hot’ on
scanning
Asymptomatic
Remove if resection
straightforward.
Histology can be
confirmed
preoperatively with
biopsy
Observe. Repeat CT
scan at 12 months.
Biopsy may be useful
when any doubt
about diagnosis
Observe. Annual
scanning initially if
large
Symptomatic
Symptoms very
uncommon and
generally excised
because of malignant
potential. Low risk
< 3cm. Avoid
contraceptive pill and
pregnancy. Bleeding
during pregnancy has
significant morbidity
and mortality
If imaging
characteristics and/or
biopsy confirm the
diagnosis then
observation unless
size produces
mechanical symptoms
(unusual).
Small
haemangiomata
with typical
appearances
need surveillance
only. Large lesions
occasionally
produce pressure
symptoms or
very rarely high
output failure in
cavernous lesions
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146
Fig. 3.45 Management of a benign liver tumour.
Symptomatic
Asymptomatic
Mass effect
• Resection if feasible
• If not, gastric bypass
Capsular pain
Regional blockade, surgery
rarely necessary
Embolization/surgery
Bleeding
Observe
Haemangioma
Adenoma
FNH
Other
Observation
No treatment unless
symptoms develop
Stop oral contraceptives
Large
Resection if
patient fit
Multiple Observe
Consider ablation
Awkward
position
Percutaneous
drainage
Consider
secondary
surgery
Surgery only for very large
lesions or high output failure
Necrosis/
infection
Liver tumour benign
on investigation/
biopsy
LIVER TUMOURS
147
Fig. 3.46 Management of cystic liver lesions.
Single
Cystic liver
lesion
Asymptomatic
Symptomatic
Symptomatic
Multiple
Laproscopic
deroofing
Observation
Pain/distension
Dominant cyst
Laproscopic
deroof or debulk
Multiple
widespread
Assess for
surgical
resection
Resection/
bypass
Mechanical
symptoms
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148
Cadranel et al ., 1994 ). Biliary cystadenocarcinomas account for 0.4% of malig-
nant epithelial hepatic lesions (Ishak et al ., 1977 ; Iemoto et al ., 1983 ; Kokubo
et al ., 1988 ).
The malignant potential of cystadenomas, and their tendency to recur
(Lewis et al ., 1988 ) if inadequately excised makes it vital to distinguish them
from simple hepatic cysts (which are fortunately about 1000 times more com-
mon), polycystic liver disease, hydatid cysts, and complex non-neoplastic
cystic lesions (Ishak et al ., 1977 ; Choi et al ., 1989 ; Korobkin et al ., 1989 ).
Routine blood tests and amylase are part of the workup of a liver cyst. Serum
CA 19.9 levels may be elevated in cases of cystadenoma with mesenchymal
stroma but CEA is not a useful marker. Cyst fluid CA 19.9 may be raised
to almost any level and CEA (unlike serum levels) can also be elevated. Cyst
fluid cytology is variable but is always worth examining (Yamaguchi et al .,
1999 ).
Ultrasound may demonstrate an anechoic mass with internal septations. CT
scanning generally demonstrates the multilocular and raised nature of the
lesions with internal septations. In the contrast phase, the wall of the cyst
enhances and nodules may be seen. MRI findings are also of septations and a
hyperintense signal on T2-weighted images.
Because of the risk of recurrence and the potential for malignant transfor-
mation, complete anatomical resection is favoured. It is important to sample
fluid from all cysts in these patients as multiple cystadenomas are described.
Unfortunately the 3-year survival after resection is only 55% (Barthet et al .,
1992 ). If the lesions are technically irresectable, or cannot be separated from
major venous or arterial structures, then liver transplantation may be
required.
Malignant tumours
Primary hepatocellular carcinoma ( Figs. 3.47 and 3.48 )
Hepatocellular carcinoma (HCC) is very common worldwide and is believed
to be the most common fatal solid organ malignancy (Parkin et al ., 2001 ;
Bosch et al ., 2004 ; Gomaa et al ., 2008 ). Hepatocellular carcinoma can appear
within a previously damaged liver (hepatitis B, hepatitis C, alcoholic cirrhosis,
etc.) or de novo in an otherwise normal liver.
Within a diffusely damaged liver it must be viewed as a multifocal process.
Treatment can therefore be directed at each outbreak of HCC or a view taken
that if no dissemination is present and there are fewer than three lesions (each
smaller than 5cm) then transplantation is an option (Sala et al ., 2004 ). The
argument for transplantation will depend on the patient’s general health, social
LIVER TUMOURS
149
Fig. 3.47 Investigation of a suspected hepatocellular carcinoma.
Mass in liver
cirrhosis increase
alpha FP
>2cm
1−2cm
CT & MRI
Non-diagnostic
Fit
Unfit
Diagnostic
Benign
Malignant
Treat as HCC
Surveillance
6-monthly
scans
Laproscopy with
intraoperative
ulttrasound ±
biopsy
Increase in
size
6-monthly
scans
Stable
CT & MRI
Appearance
diagnostic
Atypical
appearance
Repeat US at 3
months
<1cm
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150
Fig. 3.48 Treatment of hepatocellular carcinoma.
Non-metastatic
Metastatic
Biopsy
Large lesion Laparoscopy
Inoperable due to
co-morbidity or
liver disease
Unresectable due
to local factors
Consider
transplantation
<3 lesion/<5cm
No Biopsy
needed
Alpha FP positive
Alpha FP low or
negative
Potentially
resectable/
operable mass
ChemotherapyHCC
Chemotherapy/
Embolization
• Radiolipiodol
Resection
If inoperable
consider ablation
if safe
Liver mass suspicious
for HCC or
histologically
confirmed
LIVER TUMOURS
151
supports, geographic location, and supply of donor organs. Currently the vast
majority of hepatocellular cancers are managed by resection or ablation rather
than by liver transplantation (Belghiti et al ., 2002 ; Bruix et al ., 2004 ; Lin et al .,
2004 ; Lencioni et al ., 2005 ).
Ablation HCC is a multifocal disease and ablation of small lesions with alco-
hol, radiofrequency, or microwave seems reasonable in the clear knowledge
that subsequent ablations may be required for local recurrences (at the treated
site) or new disease elsewhere in the liver (Lin SM et al ., 2004 ; Lencioni et al .,
2005 ; Lau and Lai, 2009 ).
Surgery Prior to considering surgery, the general condition of the patient
needs careful assessment. Child class A patients are the only realistic candi-
dates for resection unless the situation is unusual (small peripherally placed
tumour). Some units will offer surgery to Child class B patients but irrespec-
tive of the grade or position of the tumour there must be no evidence of
dissemination on either CT or bone scan.
Laparoscopy is part of our routine preoperative assessment with biopsy of
the non-HCC liver as well as the HCC deposits to confirm the diagnosis. If the
patient has difficulty tolerating even an uncomplicated laparoscopy then a
liver resection is unlikely to succeed. In the cirrhotic liver, the principle of liv-
er-conserving surgery is vital. Advanced cirrhosis leaves the liver stiff, non-
compliant, and difficult to dissect. Intraoperative ultrasound may be useless in
distinguishing between regenerative nodules and HCC. Close correlation MRI
or CT scan with or without lipiodol may be the only way to determine the site
of the tumour (Burrel et al ., 2003 ; Bruix and Sherman, 2005 ). Given the risks
associated with liver resection in the cirrhotic patient, positive histology should
always been obtained either at surgery or from the preoperative laparoscopy.
There is a risk of dissemination with percutaneous biopsy and this technique
should never be used in the potentially operable patient. At laparoscopy, the
conditions are more controlled. The needle must be used with a sheath and
watched carefully as it is removed. The biopsy site must then be immediately
controlled by argon or diathermy to prevent bleeding and seal and sterilize the
site. The resection must be adequate to clear all tumour but should preserve
the maximum possible residual volume of liver. Biopsy of the non-involved
liver helps guide the degree of aggression possible in the proposed resection
(Yang et al ., 2009 ). No chemotherapy is effective in the long term for controlling
HCC and the only treatment where any response can be demonstrated is tran-
sarterial chemoembolization (Llovet et al ., 2003 ), and radiolabelled lipiodol
has also been utilized in the postresection as well as in inoperable patients
(Launois and Maddern, 2002 ; Kanhere et al ., 2008 ) to sterilize the remaining
LIVER
152
liver (Raoul et al ., 1997 ; Brans et al ., 2003 ). Fortunately, however, many cir-
rhotic patients seem to have an indolent course despite evidence from cross-
sectional imaging and alpha-fetoprotein estimations demonstrating the
development of an HCC.
Metastatic colorectal carcinoma ( Figs. 3.49 and 3.50 )
Assessment of metastatic colorectal carcinoma within the liver requires a dili-
gent search for extrahepatic dissemination and distant metastases. We rou-
tinely perform CEA (for ongoing follow-up for recurrence if elevated), CT
chest and abdomen, MRI of the abdomen, and, in selected patients, a PET scan
(Lai et al ., 1996 ; Ogunbiyi et al . 1997 ; Maldonado et al . 2007 ). Bone scans are
only rarely requested and always to investigate a specific symptom such as back
or limb pain and occasionally neurological symptoms. If all investigations
indicate tumour localized to the liver, then resection is planned if technically
possible.
Technical feasibility will depend on a strategy being available that removes
all known tumours and allows sufficient liver for the patient’s survival. If syn-
chronous tumours are not resected at the time of initial colon surgery then the
patient should be allowed to recover from the procedure and the options for
treatment of their liver metastases assessed. The options are to proceed to a
planned liver resection 6–8 weeks later or to commence a course of chemo-
therapy with the aim of reassessing the situation with repeated imaging (CT
and MRI) at 3 months and performing the surgery at that time. Frequently the
decision is simplified by the existence of a trial which is recruiting patients, but
in the absence of this, consideration must be given to the extent of the liver
metastases. If operability is borderline, and especially where minimal progres-
sion would render the patient inoperable, then as 10–20% will fail to respond
to chemotherapy then we prefer to operate as soon as the patient is fit enough
(Goldberg et al ., 2004 ; Tournigand et al ., 2004 ; Colucci et al ., 2005 ). With less
extensive liver involvement, initial chemotherapy, followed by surgery is pre-
ferred by many. The potential drawback of this approach is that paradoxically
the patient may respond very well to chemotherapy and subsequently the
metastases become difficult or impossible to see on cross-sectional imaging. In
the patients who are resected without chemotherapy the converse can poten-
tially occur with the rapid appearance of new lesions. There is then a dilemma
in respect of the extent of the planned resection and whether it should include
areas that were previously known to contain tumour that may now be sterile.
The best management of these patients remains controversial and differ-
ent approaches are taken in different units and for different patients in the
same unit. It is our policy generally to proceed to resection as soon as possible