notes by
dr Claudio Italiano
They are divided into benign and malignant and, above all, secondary or metastatic, that is for which we recognize an original tumor, called technically, primitive, which is usually from the colon, where the liver sinks its roots through the portal system in which the blood of the intestine flows, or from the lung, from the breast and in fact we speak of "secondarisms", ie metastasis.
It is very easy, therefore, in clinical practice to identify suspicious liver lesions; in general, if the lesions are well defined, s thinks of a hemangioma, but it is possible to identify other nodular lesions that necessarily have to be followed over time and investigated with biopsy, if this maneuver is considered indicated by the specialist. We describe the benign lesions here and follow the malignant lesions of the liver.
Prevail in the female sex, probably due to hormonal factors, since the introduction of estrro-progestin contraceptives. In the case of multiple tumors, an association with a tesaurismosis, type I glycogenosis, is possible. They are observed in the right lobe and are voluminous up to 10 cm in diameter.
Histologically it is normal or only slightly atypical hepatocytes, with increased glycogen content, abdominal pain and palpable mass.
The diagnosis is not simple, because the doctor, in front of an injury, always thinks of the
worst and then makes use of different diagnostic techniques:
- it starts from abdominal ultrasound, which already provides the idea of the
lesion, if hypoechoic, if hyperechogenic;
- then go to the abdomen CT with contrast medium and to the magnetic resonance;
- in the specific case, hepatic arteriography is also used to demonstrate that
the lesion is hypervascularized whereas technetium 99m scintigraphy demonstrates
an area that is not colored, as Kupffer cells are absent in this type of lesions.
The therapy includes the immediate suspension of contraceptives and the
resection with histological examination of the piece at the time of surgery.
Focal nodular hyperplasia is a benign tumor identified by chance during diagnostic investigations; it is observed in the female sex, more than anything else, and it is a solid tumor, localized to the right lobe, consisting of stellate cells with atypical hepatocytes, biliary epithelium, Kuppfer cells and inflammatory cells. Hepatic scintigraphy with technetium 99m demonstrates areas of hypercaptivity and angiography in which case the lesion is hypervascularized. Surgery is always indicated here as well.
It is a benign tumor of very frequent confirmation and, probably, who is reading us suffers from this type of injury and thinks of the worst! It is observed in the female sex randomly, as incidentaloma. Its prevalence is 0.5 - 7% and by chance during a CT scan of the abdomen or an MRI or using marked hems or hepatic angiography, hemangiomas are diagnosed. The only risk of death may be due to rare internal bleeding, but it is a remote occurrence and so is a possible neoplastic transformation.
It is characterized by multiple nodules deriving from the regeneration of
periportal hepatocytes with surrounding atrophic zones. Other benign tumors are
the adenomas of the bile ducts, cystadenomas and hemimagendotheliomas.
HCC. It is a primitive tumor or HCC, as defined in acronym, particularly widespread in the countries of Asia and Africa where the incidence is of 500 cases per 100,000 inhabitants, while elsewhere, in Europe and the USA, represents the 1 o 2% of neoplasms. More frequent in men, with a ratio of 4: 1.
The tumor almost always recognizes as a cause a virus infection of hepatitis B (HBV) and hepatitis C (HCV). In fact these infections tend to chronicize and evolve towards the forms of chronic hepatitis and cirrhosis. Thus in 60% of the cases, in the cirrhotic subjects, affected by the "macronodular" forms it can happen at some point to observe a malignant lesion developing, while the values of the alpha-fetus.protein which is the key marker of the neoplasia develop. The correlation between HBV and cancer is now established, so that in China it is estimated that 40% of patients with cirrhosis of the liver will develop a carcinoma.
The cause of this is related to the integration of the HBV genome into the hepatocyte, an integration that underlies gene mutations in particular in the X and pre-S2 regions. After the discovery of HCV, numerous studies have also shown the correlation between this virus and hepatocellular carcinoma, especially in those with HCV and HBV coinfection. Furthermore, it seems that any chemical agent that stimulates the DNA of the hepatocellis is responsible for the neoplastic transformation of the same. These conditions include alcoholic liver disease, alpha-antitrypsin deficiency and aflatoxin B, which in the Chinese cause p53-induced mutation and a mutation of codon 249.
Hepatic carcinomas can escape the diagnosis because they often occur in cirrhotic and the presence of symptoms and signs may indicate a progression of the basic hepatopathy. The most frequent form of presentation is pain, with the presence of abdominal mass, pain of the right hypochondrium associated with a noise like crackling or rubbing. Jaundice is rare but may also be present initially for an important and further loss of an already precarious hepatic function or because, more simply, occlusion of a bile duct due to extrinsic compression of the mass itself is determined, with an increase in the indices of cholestasis, neither more nor less for pancreatic cancer. A small percentage of patients may present a form called paraneoplastic syndrome with erythrocytosis due to tumor similetitropoietic activity and hypercalcaemia.
It uses techniques that start from the trivial but pre-abdominal ultrasound, to go to the CT abdomen and to the MRI, to the arteriography of the hepatic artery, with the intent to sometimes implement the chemoembolization of the mass. Furthermore, the survey we mentioned earlier, the alpha-feto-protein, is a fairly sensitive index of the tumor, as it rears on the values of 500-1000 micrograms / l. The percutaneous tac or ecoguidate liver biopsy completes the diagnostic procedure, while it is almost useless to practice exploratory paracentesis, which gives little information about the presence of cells in the ascitic sediment.
When the disease is evident, its evolution is rapid and most patients, as far as
treated, live for three to six months. On the other hand, if the diagnosis is
made in time, surgery resection can be performed successfully, especially if
there are no distant metastases, resection that often spreads to an entire liver
lobe. Survival, however, even in these selected cases is always low at five
years. The screening, then, which is carried out to search patients in time, as
well as the alphafetoprotein, search for markers of hepatitis and that the HbsAg
positive subjects were treated surgically in time, as the oriental authors
always kept them under observation and in them the resection of small capsulated
hepatocellular carcinomas gave a survival of up to 70% even at five years.
Finally, liver transplantation, in limited cases, can be used as a therapeutic
option. Other approaches are chemoembolization and alcoholization of lesions via
percutaneous or cryoablation and gene therapy or radio-ablation therapy.
Other types of liver tumors are:
- childhood hepatoblastoma
- angiosarcoma from the vascularized spaces
- epithelioid angioendothelioma
They generally derive from primitive lesions that have given metastases to the liver, which we know sinks its venous "roots" into the digestive tract. We are talking about colon tumors, since the liver functions as a sort of filter, being equipped with Kuppfer cells and, therefore, easily retains the metastatic cells. Virtually, except for tumors of the nervous system, any primary neoplasm can give metastases to the liver, beyond the gastro-intestinal tract, the lung, the breast and the melanomas. The signs, in these cases, are cachexia, neoplastic fever, hepatic pain, the signs of cholestasis, the neoplastic ascites that suddenly occur. Therapy in these cases becomes more difficult, as it is necessary to understand how to attack the secondary lesion of the liver and also this primitive one. These are decisions that must be entrusted to the expert hands of professionals in cancer centers.