Tumors of the liver and subhepatic region

Tumors of the liver and subhepatic region are mainly connected by the proximity of their location, the resulting symptomatology and often unfavorable prognosis. Tumors of the subhepatic region include tumors of the bile ducts, gallbladder and the head of the pancreas.

Liver tumors
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Liver tumors are tumors


 * primary (benign and malignant) and
 * secondary (metastases - mainly from the GIT).

Pathological classification
According to the tissue from which the liver tumors originate, we divide them into epithelial, mesenchymal, mixed.


 * Epithelial tumors


 * hepatocellular - nodular transformation, focular nodular hyperplasia, hepatocellular adenoma,
 * cholangiocellular - gallbladder adenoma, biliary cystadenoma.


 * Mesenchymal tumors

This group includes tumors arising from the interstitium and perivascular tissues:


 * lipoma ,
 * myelolipoma,
 * angiolipoma,
 * leiomyoma.


 * Mixed tumors


 * mesenchymal hamartoma,
 * benign teratoma.

Focal nodulation of hyperplasia
It is difficult to distinguish from malignancy (macroscopically and microscopically). It consists of an accumulation of hepatocytes, Kupffer cells and small bile ducts with congested fibrous septa. It occurs 2-8 times more often in women, between 20-50. year. The probability of occurrence in puberty and pregnancy increases significantly. It is therefore associated with hormonal influences and the use of hormonal contraception.

Clinical picture


 * does not manifest itself, usually discovered accidentally,
 * 80% does not exceed 5 cm in size,
 * larger ones may manifest as other tumors.

Diagnostics


 * Ultrasound, CT and scintigraphy are used for diagnosis . Then a biopsy to confirm.

Therapy


 * in small tumors, treatment is conservative (monitored), with unclear diagnosis, resection of part of the liver is indicated.Hepatic adenoma.

Liver adenoma
Liver adenoma or hepatocellular adenoma is also associated with the use of oral contraceptives, mainly affecting women aged 30-40 years. 30% are perforated and hemorrhage occurs. It can be malignant, it is a precancerous disease (possibility of malignancy 10%)!

Therapy


 * removal is indicated because in spontaneous perforation with bleeding, the lethality is up to 20%.

Hemangioma
Microscopic image of cavernous hemangioma. Thanks to USG, we diagnose it much more often today, especially in people aged 30-60, more often in women. The size is between 4-30 cm. Ruptures are rare. He usually did not pose any problems to the wearer prior to detection. Biopsies are never performed, there is a risk of massive bleeding.

Therapy


 * hemangiomas are among the tumors that we usually only monitor,
 * if it leads to complications, we treat:
 * resection in tumors over 4 cm,
 * in minor embolizations of supply and drainage vessels (interventional radiology).

See the Hemangioma page for more information .

Malignant tumors
Video in English, definition, pathogenesis, symptoms, complications, treatment. We divide them into primary and secondary. These include hepatocellular carcinoma, fibrolamellar carcinoma, cholangiocarcinoma, hepatoblastoma, mesenchymal malignancies (angiosarcoma, fibrosarcoma) and others (carcinoid,…).

Hepatocellular carcinoma
Hepatocellular carcinoma (HCC) is the most common primary malignant liver tumor. Hepatocellular carcinoma is the fifth most common tumor in men and eighth in women worldwide. The development of this cancer occurs most often in patients with chronic liver disease, usually in the field of cirrhosis of various etiologies (alcohol abuse, chronic hepatitis B and hepatitis C ). Hepatocellular carcinoma is the third leading cause of death worldwide. In our population, tumors are among the less common with an incidence of 5-7 / 100,000 inhabitants. The only potentially curative therapy is surgical treatment (resection or transplantation).

For more information, see Hepatocellular carcinoma .

Fibrolamellar carcinoma
Highly differentiated hepatocellular carcinoma. It is difficult to distinguish from adenoma and nodular hyperplasia. He usually has cirrhosis. It is usually 75% resectable, so it has a better prognosis.

Cholangiogenic carcinoma
It affects the intrahepatic bile ducts. It rarely manifests as inflammation of the bile ducts. It is more common in primary sclerosing cholangitis. The main manifestation is jaundice. The prognosis is often poor, the tumor is usually detected when it is unresectable.

Liver metastases
CT of liver and spleen metastases Liver metastases of pancreatic cancer.

Metastases cause up to 90% of liver malignancies. In 20% they are metastases from gastric cancer, 25% from colons, in 50% they are metastases from pancreatic cancer. In solitary and innumerable (up to 3) there is an indication of anatomical and non-anatomical resection (mainly in colorectal cancer ).

Conservative
It is mainly used for metastases from colorectal cancer and breast cancer, unless cirrhosis is significant:


 * cholecystectomy (prophylaxis of toxic cholecystitis), gastroduodenal probing and catheter insertion,
 * discontinuation of contraception or estrogen preparations in adenoma if the adenoma does not subside → surgery,
 * multiple liver metastases are treated with local intraarterial CHT (via hepatic artery ) by subcutaneously implanted port system for 14 days, the treatment has only a minimal systemic effect.

Surgical
Surgical treatment is indicated for benign tumors (adenomas, bleeding tumors or large hemangiomas) and some malignancies. The tumor must be bounded to one lobe (T1 – T3).

Surgery is the only treatment option, only 20% of patients are curatively operable (late onset of symptoms). We use the following approaches:


 * transverse or medial laparotomy, or incision along the arch,
 * hemihepatectomy - is oriented in the line vena cava - gallbladder,
 * extended hemihepatectomy on the right - according to the ligamentum falciforme hepatis,
 * resection of the liver lobe on the left - left lobe up to the lig. falciforme,
 * peripheral resection.


 * Liver metastases

Peripheral resection without orientation according to anatomical structures. The ultima ratio indicates liver transplantation in hepatocellular carcinoma if it has not yet metastasized.