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Incidentolomas - Evaluation and Management of Incidental Liver Lesions
Patrick M. Horne, MSN, ARNP, FNP-BCAssistant Director of Hepatology Clinical Research
Division of Gastroenterology, Hepatology and Nutrition
University of Florida Health
Disclosures• Financial relationships to disclose within
the past 12 months:
• Grant support with Bayer/Onyx
Objectives• Discuss natural history of benign liver
lesions.• Discuss Evaluation and management of
FNH, Hemangioma, Liver Cyst, Adenoma
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.
Differential diagnosis• Common benign liver lesions include:– Hepatic hemangioma– Focal nodular hyperplasia (FNH)– Hepatic adenoma– Hepatic cyst– Idiopathic noncirrhotic portal hypertension• Focal nodular hyperplasia
– Regenerative nodules
Bonder A & Afdhal N. Clin. Liver Dis. 2012
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
Case 1
Persistent enhancement throughout imaging phases
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
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 options– With MRI having sensitivity and specificity
around 85-95%.
Descottes B et al. Surg. Endosc. 2003.
Unai O et al. Clin Imaging. 2002.
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
Hemangioma-Management• Treatment options include– Surgery• Resection
– Hepatic irradiation or transarterial catheter chemoembolization
Case 2• 25 year old Hispanic 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.
Case 2-Imaging• CT scan
Case 2-Imaging• MRI
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.
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 phase• Though central scar may be hyperdense
Bartolotta TV et al. La Radiologia Medica. 2013.
FNH-Diagnosis• Sulfur colloid scanning– Due to prevalence of Kupffer cells, 80% of FNHs
will show active uptake
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?
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.
Case 3
MRI
Hepatic adenoma• Uncommon lesions• Mostly in young women (22-40)• Commonly in the right lobe of the liver
Grazioli L. Radiographics. 2001
Hepatic adenoma• Strong association with:– Oral contraceptives and hormones– Anabolic steroids– Glycogen storage disease
• Less common association:– Pregnancy– Diabetes mellitus
Farges O. Gut. 2011
Hepatic adenoma• Prognosis not well established• There is an association with:– Malignant transformation– Spontaneous hemorrhage– Rupture
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
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
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
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
Case 4
Hepatic cyst-Differential
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.
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.
Simple cyst Cystic echinococcosis
AlveolarEchinococcosis
CystadenomaAnd 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.
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
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
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.
Thank you