Benign Liver Tumors. Cameron Schlegel PGY-1 3/6/2013

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1 Benign Liver Tumors Cameron Schlegel PGY-1 3/6/2013

2 Outline Benign Liver Tumors are, in general. Asymptomatic Diagnosed: imaging Treatment: Do no harm Unless Malignant potential Causing symptoms

3 Differential Benign Cavernous Hemangioma Focal Nodular Hyperplasia Hepatocellular Adenoma Cystic Tumors Paraganglioma Inflammatory Pseudotumor Peliosis Hepatis Angiomyolipoma/Lipoma Biliary Papillomatosis Caroli Disease Peribiliary Cysts Von Meyenburg Complexes Biliary cystadenomas Malignant Hepatocellular Carcinoma Intrahepatic Cholangiocarcinoma Metastases

4 Differential Benign Cavernous Hemangioma Focal Nodular Hyperplasia Hepatocellular Adenoma Cystic Tumors Paraganglioma Inflammatory Pseudotumor Peliosis Hepatis Angiomyolipoma/Lipoma Biliary Papillomatosis Caroli Disease Peribiliary Cysts Von Meyenburg Complexes Biliary cystadenomas Malignant Hepatocellular Carcinoma Intrahepatic Cholangiocarcinoma Metastases

5 Cavernous Hemangioma Presentation: Most common benign liver tumor Female, 40, usually <5cm and solitary Asymptomatic Syndromes: Kasabach-Merritt, Osler-Rendu-Weber, VHL Symptomatic in children, 70% mortality Pathogenesis: Endothelial lining of blood vessels Diagnosis: Imaging CT: peripheral centripital MRI: T1 hypointensity; T2hyperintensity

6 Focal Nodular Hyperplasia Presentation Second most common benign liver tumor Females, 40s, solitary lesions Not stimulated by hormones Asymptomatic Pathogenesis: Hepatocellular hyperplasia 2/2 vascular malformation High concentration Kupffer cells Well circumscribed, unencapsulated, central fibrous scar Benign hepatocytes in nodules, separated by fibrous septa that originate from central scar Diagnosis: Imaging CT: hypoattenuating on early phase images MRI: arterial enhancement

7 Hepatocellular Adenoma Presentation Females (90%), 20-40s, solitary (80%) OCP/Androgen use Iron overload B-thalassemia, type 1 or 3 glycogen storage, diabetes mellitus Asymptomatic Intraperitoneal hemorrhage (30-50%) Malignant transformation 10% Pathogenesis Well differentiated hepatocytes lacking bile ducts/portal triads Diagnosis: Imaging CT: hypo- to isoattenuating MR: T1 hyper-isointense; T2 hyper

8 Imaging Characteristics of Benign Liver Tumors Kane et al. Benign Hepatic Tumors and Iatrogenic Pseudotumors. Radiographics. 2009

9 Imaging Characteristics of Benign Liver Tumors

10 Imaging Characteristics of Benign Liver Tumors

11 Compare/Contrast Tumors Malignant? CT MRI T1 T2 Treatment Cavernous Hemangio ma No Peripheral central, hyperintense on delayed Nothing If symptoms: enucleation or resection FNH No rapid enhancement during arterial phase - Hypointense central scar Nothing If symptoms: resection - Sulfur Colloid Scan HC adenoma Yes hypervascular lesion arterial phase Resection

12 Compare/Contrast Tumors Malignant? CT MRI T1 T2 Treatment Cavernous Hemangio ma No Peripheral central, hyperintense on delayed Nothing If symptoms: enucleation or resection FNH No rapid enhancement during arterial phase - Hypointense central scar Nothing If symptoms: resection - Sulfur Colloid Scan HC adenoma Yes hypervascular lesion arterial phase Resection

13 Cystic Tumors Simple Multiple Cystadenomas Echinoccocal

14 Cystic Tumors Simple cysts: Asymptomatic Pathogenesis: Embryonal development of intrahepatic biliary duct Single layer columnar/cuboidal epitheliuam, straw-colored serous fluid Diagnosis: imaging Treatment: Injection or enucleation if symptomatic

15 Cystic Tumors Multiple Cysts: Asymptomatic Polycystic liver disease autosomal dominant Hepatic parenchyma and function preserved Pathogenesis: histo same as simple cysts Diagnosis: Imaging Treatment: resection or transplant if symptomatic

16 Cystic Tumors Cystadenomas Presentation: Benign w malignant potential Slow growing, Pathogenesis Multilocular, single layer cuboidal/columnar epithelium Dx: Imaging Treatment: Resection

17 Echinococcal/Hydatid Cysts Presentation: Travel SW US, Scotland, Greece, Europe Asymptomatic, +/- fever, abdominal pain Pathogenesis Echinococcus humans intermediary hosts Diagnosis: Imaging Treatment: Albendezole, enucleation Cystic Tumors

18 Questions?