Benign conditions of liver
- Liver Abscess
- Liver Cyst
- Hydatid Cyst
- Haemangioma
- Focal Nodular Hyperplasia
- Adenoma
Malignant conditions of liver
- Primary liver tumours
- Hepatocellular carcinoma
- Primary cholangiocarcinoma
- Secondary/metastatic liver tumours from
- Colon/rectal cancers
- Neuroendocrine tumour
- Renal cell carcinoma
- Melanoma
- Others – gastric, oesophageal, pancreatic, small bowel, ovarian, breast, prostate cancers
Clinical presentation
They are a numerous surgical conditions that affect the liver as shown above. Most conditions have few symptoms or signs and are detected incidentally on imaging of abdomen.
A patient may develop right upper quadrant pain if a lesion has reached a significant size or suddenly ruptures (in the case of hepatocellular carcinoma or adenoma).
Jaundice, (yellow skin or sclera [whites of eyes]), may develop if a tumour blocks the bile duct. A patient may notice passing dark urine, pale stools or pruritus (itching of the skin).
Liver lesions may be found on follow up imaging after cancer treatments. Other symptoms such as weight loss, lethargy, anaemia and ascites (build-up of fluids inside the abdominal cavity) often present in patients with a very advanced stage of cancer.
Investigations
A patient with such symptoms or incidental detected liver lesions, needs a thorough assessment and a review by a specialist with experience in liver disease. Routine blood tests, including FBE, UE, LFT and INR are often performed as a base line. Other special tests, including viral hepatitis or hydatid serology, tumour markers (AFP, CA 19.9, CEA, Chromogranin A) and screening for various chronic liver diseases, are performed as required.
Radiological imaging forms the cornerstone for accurate assessment. Abdominal Ultrasound performed and reviewed by experienced radiologists is an important first step. This will enable us to distinguish cystic lesions (simple cyst, abscess, hydatid cyst) from solid lesions (benign and malignant liver lesions). A dynamic CT of abdomen and pelvis using a contrast agent (pre-contrast, arterial, portovenous and delayed phase) is usually the next step. This enables us to identify if a lesion is either hypervascular (haemangioma, focal nodular hyperplasia, adenoma, hepatocellular carcinoma) or hypovascular (metastases).
These investigations should be reviewed, and if necessary, MRI/MRCP with Primovist contrast is performed to further characterise the liver lesions. Most liver lesions can be confidently characterised by these modalities, but occasionally other tests such as contrast enhanced ultrasounds or PET scan are required. A biopsy is rarely required, unless all tests are carefully reviewed, and a diagnosis could not be achieved. An inappropriate biopsy may lead to seeding of a tumour, bleeding or inconclusive results.
