Tumours of liver by bvishaal

VIEWS: 25 PAGES: 34

									                   TUMORS OF LIVER


• Benign                          Malignant
• Liver cell adenomas   •   Primary
                        •   Hepatoblastoma (Infancy)
• Cavernous
  hemangiomas           •   Angiosarcoma
                                            HCC
                        •   Carcinoma
                                          Cholangiocarcinoma


                        • Secondary
                        • More common
                        • From breast, lung, colon
                          commonly
               Adenomas

• Benign neoplasms
• Occur in young women on OCs
• Reduce in size after stopping OCs
• Clinical importance
  May present as intrahepatic mass mistaken for the
  more ominous hepatocellular carcinoma.
• Subcapsular adenomas have a tendency to rupture,
  particularly during pregnancy (under estrogen
  stimulation)
• severe intraperitoneal hemorrhage.
• Rarely, they may harbor hepatocellular carcinoma.
• Pale, yellow tan,bile-stained
  nodules,
• Common below capsule,

• Small to 30 cm in diameter.
• Usually well demarcated,
• Sheets and chords of
  hepatocytes
• Variation in cell and nuclear size
  may be seen
• No Portal tracts
• Prominent arterial vessels &
  draining veins throughout
                  Hemangioma
o Most common Benign neoplasm

o usually solitary and < 5 cm;

o a common incidental finding at autopsy

o Avoid biopsy/excision (risk of hemorrhage)

o LEAVE IT ALONE (it doesn’t hurt anyone)
         Hemangioma: pathology
                           Spongy, red-purple
                           nodule with
                           variable
                           hemorrhage &
                           fibrosis




Dilated vessels lined by
single layer endothelial
cells
               PRIMARY CARCINOMA OF LIVER

• Types:
• Hepatocellular carcinoma (Hepatoma) HCC
• Accounts for 90%

•   Cholangiocarcinoma
•   Arises from bile duct epithelium
•   Accounts for 10%
•   Mixed

• Hepatocholangiocarcinoma
• rare
                             Incidence
  •Globally – 5.4% of cancers
  •Highest in Africa -76%

• High incidence:       Moderate              Low incidence :
  40/100,000            incidence :           2-5/100,000
• Korea, Taiwan,                              America, North &
  Mozambique            15/100,000
  and SE China          Countries bordering   Central Europe,
                        Mediterranean         Australia
 Males : Females 3:1                              M:F 1.5:1

 Between 20 and 40yrs                            > 60years


Race: Blacks : Caucasians 4:1
Etiology of HCC      Etiology of
                     Cholangiocarcinoma

                  Chronic sclerosing inflammation,
HBV and HCV       congenital diseases of biliary system
Cirrhosis         Thorotrast
                  Liver fluke invasion
Aflatoxins
Hereditary
tyrosinemia
Hormones
           Pathogenesis

•   Repeated cycles of cell death and regeneration , as in
    chronic hepatitis is the most important pathogenesis of
    HCC

•   Point mutations in cellular genes & loss of
    heterozygosity in tumour supressor genes,

•   Induction of genomic instability – deletions,
    translocations and duplications – result

•   Viral proteins may stimulate further replication of
    hepatocytes
•   Mechanism of HBV carcinogenesis:
•   HBX – transcriptional activator of many genes

•    HBX activates host’s growth factors like Insulin –
    like growth factor (IGF)II, receptor for insulin –
    like growth factor

•   Binds to and inactivates tumor suppressor
    p53gene.

•   HBx is a potent co-transactivator of viral and
    cellular promoters like c-myc
• Chronic infection with HCV infection and
  alcohol :
• Major cause in Western countries where HBV
  is not prevalent.

• Aflatoxins:
• Aflatoxins, mycotoxins formed by Aspergillus
  flavus
• Frequent contaminant of improperly stored
  grains and nuts
• Acts only in mitotically active liver
• Cirrhosis :
• Important cause of HCC but not requisite
• In patients not infected with HBV, other causes of
  cirrhosis
• HCV infection, alcohol, hemochromatosis
• Less common with- alpha 1-antitrypsin deficiency,
  glycogen storage disease, tyrosinemia, and Wilson’s
  disease , rarely biliary cirrhosis
• Hereditary tyrosinemia – 40% of these patients
  develop hepatocellular carcinoma
• Other causes suggested:
• Age, sex
• Hormones – both androgens and
  progesterone
• Nutrition
•   Gross :
•   Patterns :
•   1. Unifocal
•   2. Multifocal
•   3. Diffusely infiltrative

• paler than the surrounding liver
  tissue
• May be greenish due to bile
  production by tumour cells
• Strong propensity to invade
  vascular channels
• Tumour invades the portal vein
  or hepatic vein and inferior vena
  cava, extending even into the
  right atrium.
• Microscopy:
• Hepatocellular carcinoma
• Usually associated with
  cirrhosis
• Well differentiated tumors-
  are composed of cells
  recognizable as hepatocytes
  in trabecular, acinar or
  pseudoglandular patterns.
• The cells contain bile.
• Poorly differentiated tumor –
  composed of pleomorphic
  cells with giant cells.
Well
differentiated
HCC
Poorly differentiated HCC
• Cholangiocarcinoma
• Is a malignancy of the biliary tree, arising from
  bile ducts within and outside of the liver.
• The incidence is approximately 0.6 case per
  100,000 in north America,
• Caucasians : non-Caucasians – 1:1
• Men : women 1:1
                   Causes
• Primary sclerosing cholangitis,
• Congenital fibropolycystic diseases of biliary
  system - caroli disease and choledochal cysts,
• Thorotrast
• Liver fluke invasion of biliary tract:-
  clonorchis sinensis and opisthotonus felineus
 An adult Opistorchis viverrini is seen in a dilated bile
  duct (HE, low power). A cross section of the fluke
         around the ventral sucker is shown
• .
Liver fluke
           Cholangiocarcinomas




Are white since the tumour cells do not
produce bile.
Firm and gritty
• Microscopy:
• Adenocarcinomas –
• The tumour may be markedly desmoplastic,
  dense collagenous stroma separates the glandular
  elements.
 Fibrolamellar carcinoma:
• A variant of hepatocellular carcinoma,
• Occurs in younger patients (20-40yrs),
• no association with HBV or cirrhosis has a better prognosis.




Gross: a single, large, hard (schirrous)
tumor with fibrous septa coursing through
it.
 Polygonal cells



Parallel lamellae of
dense collagen.
• Spread:
• Hematogenous –
• 50% of cholangiocarcinomas - to lungs, bones
   (vertebrae), adrenals, brain.
  In HCC- Late occurrence, lungs are involved.
• Lymphatic:-
• Perihilar, peripancreatic and para-aortic nodes
• In 50% of cholangiocarcinoma
• less frequently with hepatocellular carcinoma.
• Clinical features:
• Upper abdominal pain, malaise, weight loss.
• Rarely jaundice, fever and gastrointestinal or
  esophageal variceal bleeding.
• The liver is enlarged – irregular and nodular
• Laboratory investigations:-
• Alpha Fetoprotein (AFP) -50% to 75% of
  HCC
• Carcinoembryonic antigen (CEA)
• Ultrasonography,
• Hepatic angiography,
• CT and MRI
              Angiosarcomas
• Associated with exposure to :

• vinyl chloride,
• arsenic,
• Thorotrast .
             Hepatoblastomas
•   Most common liver tumor of young childhood.
•   1 to 2 in 1 million births
•   fatal within a few years if not treated.
•    The epithelial type,
•    The mixed epithelial and mesenchymal type,
    which contains foci of mesenchymal
    differentiation that may consist of primitive
    mesenchyme, osteoid, cartilage, or striated
    muscle
Hepatoblastoma
• Metastatic Tumors
• More common than primary
  neoplasms.
• Most common primaries are
  carcinomas of the breast, lung,
  and colon
•
• Multiple nodular metastases
• Outgrow their blood supply,
  producing central necrosis and
  umbilication
• Absence of clinical or laboratory
  evidence of

								
To top