Benign and Malignant Liver Disorder

BENIGN AND MALIGNANT
LIVER DISORDER

ANATOMY OF LIVER
Site: in the upper part of the abdominal cavity occupying
the right hypochondrium, epigastrium and extending to
the left hypochonrium.
Size: It is the largest organ in the body with weight of ~ 1.5
kg
Shape: Wedge-shaped with it's base directed to the right
Fixation of the liver depends on :
 The attachment of the hepatic veins emerging from the
liver to the fixed IVC
 Peritoneal ligaments attaching the liver to the
diaphragm and abdominal walls

FUNCTION OF LIVER
The liver is a metabolically active organ
responsible for many vital life functions.
The primary functions of the liver are:
 Bile production and excretion
 Excretion of bilirubin, cholesterol,
hormones, and drugs
 Metabolism of fats, proteins, and
carbohydrates
 Enzyme activation
 Storage of glycogen, vitamins, and
minerals
 Synthesis of plasma proteins, such as
albumin, and clotting factors
 Blood detoxification and purification

Anatomical Lobes: morphologically, the liver is divided into
right and left lobes by :
 The attachment of falciform ligament on the anterior
and superior surface.
 The fissure for ligamnetum venosum on the posterior
surface
 The fissure for ligamentum teres on the interior surface
Surgical (Structural) lobes:
On the basis of intrahepatic distribution of hepatic artery,
portal vein and biliary duct, the liver is divided into 2
nearly equal lobes (right & left) by an antero-posterior
plane passing through the gallbladder fossa and grovefor
IVC.

SEGMENTAL ANATOMY
Divided into 8 segments based on hepatic and portal venous segments
(Couinaud System)
 Caudate lobe : segment I
 Left lobe : segment II - IV
 Right lobe : segment V - VIII

ANATOMIC LIVER SEGMENT
CAUDATE I
LATERAL SEGMENT LEFT LOBE SUPERIOR II
LATERAL SEGMENT LEFT LOBE INFERIOR III
MEDIAL SEGMENT LEFT LOBE IV
ANTERIOR SEGMENT RIGHT LOBE
INFERIOR
V
POSTERIOR SEGMENT RIGHT LOBE
INFERIOR
VI
POSTERIOR SEGMENT RIGHT LOBE
SUPERIOR
VII
ANTERIOR SEGMENT RIGHT LOBE
SUPERIOR
VIII

ANATOMY OF LIVER
Blood supply
 75% from portal vein
 25% from hepatic artery
 Blood of both vessels is
mixed in the liver sinusoids
 Blood is collected from
each hepatic lobule by a
central vein
 The central vein unite to
form 2-3 hepatic veins
which open into IVC.

HEPATIC PORTAL SYSTEM
 The hepatic portal system is the venous system
that returns blood from the digestive tract and
spleen to the liver (where raw nutrients in blood
are processed before the blood returns to the
heart).
 Essentially, it drains the structures supplied
ultimately by the celiac (except for the gonads),
anterior mesenteric, gastrosplenic, and posterior
mesenteric arteries.

HEPATIC PORTAL SYSTEM
 The main vessel of the hepatic portal system is the
hepatic portal vein.
 The hepatic portal vein is formed by the confluence of
three main vessels, the gastric, pancreaticomesenteric,
and lienomesenteric veins.
 They unite to form the hepatic portal vein near the
anterior tip of the dorsal lobe of the pancreas.
 The celiac artery splits into its branches very near this
point as well. Occasionally, the gastric and
lienomesenteric veins join to form a very short vessel
that then unites with the pancreaticomesenteric to
form the hepatic portal vein.

ANATOMY OF LIVER
Nerve supply
Liver receives nerve supply from the hepatic plexus
containing:
 Sympathetic fibres: derived from coeliac plexus
 Parasympathetic fibres: from the anterior and
posterior vagal trunks
Lymphatic Drainage
Mainly into hepatic lymph nodes in porta hepatitis.
Efferent vessels pass to celiac lymph nodes

CLASSIFICATION
BENIGN MALIGNANT
 Hemangioma
 Focal nodular
hyperplasia
 Adenoma
 Liver cysts
1. Primary liver
cancers
 Hepatocellul
ar
carcinoma
 Fibrolamellar
carcinoma
 Hepatoblastoma
2. Metastasis

HEMANGIOMA
A liver hemangioma is made up of a tangle of blood
vessels. Other terms for a liver hemangioma are
hepatic hemangioma and cavernous hemangioma.

HEMANGIOMA
CLINICAL FEATURES
 The commonest liver tumor 5% of autopsies
 Usually single small
 Well demarcated capsule
 Usually asymptomatic but may present
with:
 Pain in the right hypochondric area
 Feeling full after eating only a small amount of
food
 Nausea

HEMANGIOMA
Diagnosis
 US: echogenic spot, well demarcated
 CT: venous enhancement from periphery to
center
 MRI: high intensity area
 No need for FNAC or Biopsy
Treatment
No need for treatment

FOCAL NODULAR HYPERPLASIA (FNH)
Focal nodular hyperplasia (FNH) is a benign tumor of the liver
and is the second most common tumor of the liver after the
benign liver tumor known as hemangioma. FNH does not
turn into liver cancer and generally it does not grow in size,
spread or bleed.
 Central stellate scar
 More common in young and middle age women
 No relation with sex hormones
 Usually asymptomatic
 May cause minimal pain

CAUSES
It is thought that FNH is due to vascular accidents
such as hemorrhages or clots in tiny blood vessels in
the liver. Because FNH is more common in women it
is thought that estrogens may promote its
development. Inflammation in the liver may also play
a role in its development.

HEPATIC ADENOMA
 Rare benign hepatic neoplasm that develop in a normal liver.
 Occur mostly in women of child bearing-age
(20-40years old)
 Associated with contraceptive hormones
 Usually asymptomatic but may have RUQ pain
 May presents with rupture, hemorrhage, or malignant
transformation (very rare)

HEPATIC ADENOMA
DIAGNOSIS
 US: filling defect
 CT: Diffuse arterial enhancement
 MRI: hypo or hyper intense lesion
 Biopsy: may be needed for confirmation and characterization of nature of
the lesion
TREATMENT
 Stop hormones
 Observe every 6 month for 2 years
 If no regression surgical excision

LIVER CYST
 May be single (simple cyst disease) or multiple
(polycystic liver disease)
 Patients often asymptomatic
 No specific management required

LIVER CYST
DIAGNOSIS:
Ultrasound
 round or ovoid anechoic
lesion (may be
lobulated)
well-marginated with a
thin wall
may show posterior
acoustic enhancement, if
large enough

METASTATIC LIVER
DISEASE FROM
COLORECTAL ORIGIN

INTRODUCTION
 Colorectal cancer (CRC) is the 3rd most common
cancer worldwide, ranking as high as the 2nd
leading cause of cancer-related deaths in
developed countries.
 The liver is recognized as the most common site of
CRC metastasis because the majority of the
intestinal mesenteric drainage enters the hepatic
portal venous system.
 More than 50% of patients with CRC will develop
metastatic disease to their liver (CRLM) over the
course of their life, which ultimately results in
death for more than two third of these patients.

 Currently, hepatic resection
of colorectal cancer liver
metastasis in patients with
isolated liver metastasis
remains the only option for
potential cure.
 However, even when
resection is combined with
modern adjuvent systemic
regimens, it is curative in
only 20% of patients with
70% developing recurrence,
primarily in the liver.
 Detecting 1ry CRC and
CRLM at an early stage
results in better prognosis.

CLINICAL FEATURES
Many people with colon cancer don't have symptoms. That's why it is so
important to keep up with routine screening tests.
When the disease -- at any stage -- causes symptoms, they may include:
 Blood (usually dark red or black) in the stool
 Constipation and diarrhea. These can also be symptoms of other, less serious
conditions, such as a stomach virus. But if it doesn't stop quickly, see your
doctor.
 Long, thin, pencil-like stools. These are a sign that something is blocking your
colon. The blockage could be a tumor or something else.
 Fatigue and weakness.
 Abdominal pain or bloating. Colon tumors can cause a blockage that makes it
hard to fully empty your bowels. You can feel bloated and full as a result.
 Unexplained weight loss. A weight loss of 10 pounds or more, when you
haven't changed your diet and exercise habits, could be cancer, especially if
you also have other colon cancer symptoms.
 Nausea and vomiting

LIVER MANIFESTATION
 Loss of appetite or feeling full early
 Fatigue
 Fever
 Itching
 Pain in the abdomen
 Swelling in the legs
 Weight loss
 Yellowing of the skin or whites of the eyes, called
jaundice

DIAGNOSING COLON CANCER
 Colonoscopy
 Biopsy for cancer staging
 Chest X-ray.
An X-ray uses radiation in low doses to make images of structures
inside the body. A chest X-ray can help to see whether the cancer
has spread to the lungs.
 CT.
The CT scan can show whether the cancer has spread to the
lungs, liver, or other organs. Sometimes you'll get a special dye
before the scan, either through a vein or as a pill. This dye gives a
more detailed view of the cancer.

DIAGNOSING COLON CANCER
 MRI
This test can show where the cancer has spread
inside the abdomen or pelvis.
 Ultrasound.
It can show whether the cancer has spread inside the
pelvis or to the liver.

MANAGEMENT
Surgical
 Hepatectomy remains the standard of care for CLM. In the past, post-
operative mortality was high but nowadays it has decreased to around
1%, allowing more extended hepatic resections by more advanced
surgical techniques.
 Liver failure after hepatectomy remains the major concern for the
hepatobiliary surgeon. Resection, even partial, can result in a small
postoperative remnant liver function, hence increasing the risk of
postoperative liver failure and subsequent very high mortality.
Chemotheraphy
 For patients with resectable disease, “perioperative chemotherapy”
has become an attractive option, in order to reduce the incidence of
cancer relapse, occurring in up to 50%-70% of them after resection,
through the eradication of occult disease

Targeted Biological Treatment
Monoclonal antibodies targeting two different
mechanisms:
 Angiogenesis (bevacizumab)
 Epidermal growth factor receptors (EGFRs)
(cetuximab and pantumumab)

REFERENCE
 Malaysia Clinical Practice Guideline on Management of Colorectal Cancer
Liver Metastasis
 Multisciplinary management of patients with liver metastasis from
colorectal cancer
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4997640/]
 Colorectal Cancer Liver Metastasis [https://www.webmd.com/colorectal-
cancer/colon-cancer-liver-metastasis#1]
 Liver Metastasis from Colorectal Cancer - Medscape
 Liver Tumour Basic Guide Slideshare
[https://www.slideshare.net/bhavinvasavada/liver-tumors-a-basic-guide-
to-diagnose-and-treat-liver-tumors]
 Anatomy Hand-out Abdomen - Dr. Sameh Doss

Benign and Malignant Liver Disorder

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