Hepatic Tumors & Hepatocellular Carcinoma (HCC)😍

Hepatic Tumors

Benign

1. Hepatic adenoma.

2. Cavernous adenoma.

Malignant

1. Hepatocellular carcinoma (HCC).

2. Angiosarcoma.

Key Notes on Prevalence

• Most Common Liver Malignancy: 
• Metastasis.
• m/c liver metastasis: From Colon cancer.

• Primary Liver Malignancy: 
• Classical Hepatocellular Carcinoma (HCC).

• Variant: Fibrolamellar HCC.

• m/c hepatic tumor in children: Hepatoblastoma.

• m/c liver sarcoma: Angiosarcoma.

• m/c benign liver tumor: Cavernous hemangioma.

Cavernous Hemangioma/ Liver Hemangioma

Hepatic Adenoma

• Young female on OCPs → Only have a sheet (sheet of hepatocytes) and board (Bordeaux Classification) nothing else → Board has Cochin HaNeeFa pic in it
• Cochi (β Catenin) ellarkum cancer ()
• Haneefa (HNF 1α) young actor played multiple role → young pt, multiple lesions

• m/c affected group: Young females.

• Associated with Oral Contraceptive Pill (OCP) intake.

• Risk of malignant conversion: 10%.

• Female (F) >> Male (M).

• Associations:
• OCP
• Anabolic steroids (males).

• Clinical: 
• Mostly symptomatic (Right hypochondrium pain/lump),
• Hemoperitoneum (due to rupture).

• Investigations:
• IOC: CECT.

• Gross morphology:
• Well circumscribed, encapsulated tumor.
• m/c in the right lobe of liver.

• Histopathology (HPE):
• Sheets of hepatocytes,
• Monomorphic hepatocytes with no atypia.
• No ducts,
• No Kupffer cells.
• No vascular invasion (vascular invasion is present in HCC).

Bordeaux Classification:

• Inflammatory:
• Highest bleeding risk.

• β-catenin mutated:
• ↑ risk of cancer.

• HNF 1α mutated:
• Young patients, multiple lesions.

Management: 

• Resection
• Indications:
• Usually >5 cm
• If High risk >2 cm

Angiosarcoma

• Most Common Organ:
• Most commonly in the liver.

• Most common cause for malignant cancer of heart in adults

• Causes: VAT chemicals:
• V: Vinyl chloride (plastics, polyvinyl chloride).
• A: Arsenic (pesticides).
• T: Thorotrast (thorium-based contrast dye, old radiology use).
• Thorotrast,
• Thorotrast linked to
• HCC,
• cholangiocarcinoma &
• renal cell carcinoma.
• Angiosarcoma (VAT → Plastic)

• Histology:
• Anastomosing vascular channels.
• Highly pleomorphic cells.

• IHC markers:
• von Willebrand factor.
• Factor VIII.
• VEGF.
• CD31 (PCAM)

• Mnemonic: Plastic (Plastic industry) ittu Vaattan (VAT) poyapo Liveril blood cancer vannnu

Focal Nodular Hyperplasia (FNH):

• Etiology: ↓ blood supply.

• HPE:
• Hepatocytes,
• Bile duct structures,
• Kupffer cells → Hotspot on Tc99 scan

• IOC: CECT → Central stellate scar.

Stellate terms	Seen in
Stellate cells	• Cirrhosis • NAFLD • Chronic pancreatitis • Young stella → alcoholic → liver and pancreas
Stellate Keratin Precipitates	• Herpetic uveitis • Toxoplasmosis • Fuchs Heterochromia Iridocyclitis • Young stella → Fucked () by Toxic () Herpes () Guy
Stellate Granuloma	• Cat Scratch Disease • LGV • Leprosy • Syphillis • Stella granny → has a Cat, Lgtv, has leprosy and syphillis
Stellate scar	• Kidney → Oncocytoma, Chromophobe RCC • Liver → Focal Nodular Hyperplasia, Fibrolamellar Carcinoma • Pancreas → Serous Cystadenocarcinoma • Breast → Radial Scar: Premalignant

Sulphur colloid scan

Hepatocellular Carcinoma (HCC)

• M/c primary malignant tumour of liver: HCC.

• M/c malignant tumour of liver (overall): Metastasis.

Risk Factors for HCC:

• Alcohol, Obesity

• Hemochromatosis.

• Chronic hepatitis B & C.

• Aflatoxin,

• DM,

• NASH/NAFLD.

• Tyrosinemia 1 → HCC in a child
• Tyre Flat VAT

• Note: Colon cancer risk can be reduced by metformin

Features:

• Male (M) > Female (F).

• Most common (m/c) affected group: 60-70 years old males.

• M/c presentation: Hepatomegaly (Hard & nodular liver).

• Paraneoplastic Syndromes:
• Hypoglycemia (M/c),
• Hyperlipidemia (M/c biochemical),
• Cushing’s syndrome,
• Gynecomastia,
• Hypercalcemia.

Gross Morphology

• Multiple liver nodules.

Histology

• Hepatocytes arranged in cords/tubules.

• Vascular invasion.

• AFP (α-fetoprotein):
• Tumour marker for HCC.
• AFP is raised in:
• HCC.
• Yolk sac/endodermal sinus tumors.

• Biopsy: Confirms diagnosis.

• IHC markers:
• AFP.
• Arginase 3
• Hepar 1
• Glypican 3
• PIVKA
• OPN
• NOT NEUROTENSIN → Fibrolamellar
• Mnemonic: Hepatocellu → Karalil (Hepar 1) 6 (Arginase) Clip (Glypican) Ittu

Child-Turcotte-Pugh Score: 

MELD (Model for End-Stage Liver Disease):

• Creatinine, Serum bilirubin, INR.

• (CBI)

PELD (Pediatric End-Stage Liver Disease):

• Growth failure, Albumin, Age (<1 year), Total bilirubin, INR.

• (GAABI)

• Milan was young beautiful lady → good cushion (cushings) body, due to cholesterol (hyperlipidemia), but she was not panchara (hypoglycemia)

• She was a prostitute (Paraneoplastic), she did threesome (Triple phase CT), va nallapole thurakkum (thorocast)
• She is initially enhanced, but when done she goes out early
• (hyper enhanced →early washout)

• She had a child
• Young GAABI (PELD score)
• Grow up → CBI (MELD score)

• 53 yr old MiLan → Mi L → says
• “My Liver is good” → Good for transplant
• No mets
• <5cm
• <3cm
• So Dont Tacer me (TACE → Palliative)

Management:

Localised Disease:

• Good functional liver reserve/Child Pugh A:
• Resection.

• Poor functional liver reserve/Child Pugh B or C:
• Child BC Liver → Bad capacity liver
• Liver transplantation (DDLT/LDLT) if Milan Criteria met

Milan Criteria: 

• Single lesion ≤ 5cm,

• 1-3 lesions ≤ 3cm,

• No distant metastases.

UCSF Criteria

• Extended Milan

• Single tumor < 6.5 cm,

• 2-3 lesions < 4.5 cm,

• with total tumor diameter < 8 cm

Advanced Disease (Palliative):

• Multiple lesions in one lobe:
• TACE (Transarterial chemoembolization).

• Radiofrequency/Microwave ablation,

• Chemotherapy,

• Intralesional ethanol injection.

Barcelona Clinic Liver Cancer (BCLC) Staging & Treatment:

Prognostic Indicators for HCC:

• OKUDA (BATA)
• Bilirubin
• Ascites
• Tumor size
• Albumin