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Old 06-24-2011
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Liver Intense SPECT circular focus in the left liver lobe!

A 35-year-old multiparous woman visits her primary care physician complaining of early satiety for the last month. She also reports episodes of postprandial nausea and vomiting, and an unintentional weight-loss of 5 kg (11 pounds). She denies any other symptoms. She does not smoke or drink alcohol, and is currently only taking oral contraceptive pills. Vital signs are within normal limits. Her physical examination is unremarkable, and complete blood count (CBC), liver function tests (LFTs), prothrombin time (PT) and partial thromboplastin time (PTT) are within normal limits. An initial abdominal ultrasound reveals a homogenous echogenic mass in her left liver lobe. A dynamic abdominal computed tomography (CT) with contrast shows a circular rim-enhancing lesion in the same location with centripetal progression of contrast. A similar pattern is seen with a gadolinium-enhanced abdominal magnetic resonance imaging (MRI). Based on these findings, a serum alpha fetoprotein (AFP) is ordered, which is reported as normal. A single-photon emission CT (SPECT) study with radiolabeled red blood cells is then conducted, which demonstrates an intense circular focus in the left lobe. What is the most appropriate treatment at this time?

Answer Choices
A. Discontinue medication
B. Liver transplantation
C. Observation and follow-up ultrasound
D. Percutaneous drainage
E. Surgical resection
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Old 06-24-2011
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Warning!

this is typical radiolog finding of hepatic hemangioma (centripetal flow) ...in contrast to carcinoma ......
with a history of ocp........ mostly the underlying mech.... stopping the drug -i think- will be most appropriate response
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Old 06-24-2011
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A discontinue medication

OCPs also cause hepatic adenoma !!!
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Old 06-25-2011
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Option E (Surgical resection) is correct. Most patients with hepatic hemangiomas are asymptomatic and are diagnosed when the liver is imaged for other reasons. However, a hemangioma may present with symptoms indicating compression of an adjacent structure, as in this case. Early satiety and postprandial nausea and vomiting are symptoms of gastric outlet obstruction, which is consistent with a left lobe hemangioma. Other symptom complexes associated with hepatic hemangiomas include biliary tract obstruction, acute intraperitoneal hemorrhage, and high-output cardiac failure. Surgical resection is the treatment of choice for symptomatic patients.

Option A (Discontinue medication) is incorrect. High estrogen states such as pregnancy or use of oral contraception may be a risk factor for the development of hepatic hemangiomas, and are known to promote growth of existing lesions. However, no medical therapy has been shown to eliminate or reduce the size of existing hepatic hemangiomas. There is therefore no benefit to discontinuing the patient’s oral contraception at this point.

Option B (Liver transplantation) is incorrect. Most hepatic hemangiomas are amenable to surgical resection if so indicated. A liver transplant carries a high morbidity and would only be offered when the liver cannot be salvaged due to diffuse or very large hemangiomas. This is clearly not applicable to a patient with an isolated left lobe lesion.

Option C (Observation and follow-up ultrasound) is incorrect. This is the treatment of choice for an asymptomatic patient, regardless of the size of the hepatic hemangioma. Generally, if a follow-up ultrasound at 6 and 12 months shows no change in size, no further monitoring is necessary. Patients who become pregnant, receive any form of estrogen treatment, or have lesions larger than 10 cm should receive additional follow-up studies. Furthermore, patients with known hemangiomas who present with new onset abdominal pain should be re-imaged to exclude an acute hemorrhage. Since this patient is symptomatic, she requires surgical intervention.

Option D (Percutaneous drainage) is incorrect. This is a surgical modality usually reserved for the treatment of a hepatic abscess. This patient’s symptom complex, vital signs, and CBC do not support the presence of an infectious process, and the appearance of the lesion on dynamic CT, MRI, and SPECT are instead strongly suggestive of a hepatic hemangioma. However, percutaneous drainage is not a viable treatment option for a hemangioma due to the risk of iatrogenic hemorrhaging.

High-yield Hit 1
Table 10-3. Tumors of the Liver

Type Description Evaluation Treatment

Hemangioma

(1) Most common benign tumor.
(2) Patients have right upper quadrant abdominal pain, bruits, congestive heart failure, or shock with bleeding (in cases of rupture).
Diagnose with CT, ultrasonography, or MRI. Treat by observation, and resect if the patient is symptomatic.

Hepatic adenoma

(1) The main risk factor is oral contraceptive use. Anabolic steroid use and glycogen storage disease are also risk factors.
(2) Patients may have abdominal fullness, or rupture of the tumor may cause hemoperitoneum and shock (more common in pregnancy).
(1) Ultrasound and CT scans show a solid tumor with cystic areas of hemorrhage or necrosis.
(2) Histologically, the tumor will look like normal hepatocytes without bile ducts.
Discontinue oral contraceptives. Employ surgical resection for subcapsular lesions or if pregnancy might occur, because of the risk of rupture.
Focal nodular hyperplasia Patients may have abdominal pain and right upper quadrant abdominal mass. CT scan shows a liver mass with a central scar. Surgery is needed only for rapidly growing or symptomatic lesions.

Hepatocellular carcinoma
(1) Associated with hepatitis B, cirrhosis, aflatoxin (from Aspergillus), schistosomiasis, and glycogen storage disease.
(2) 10% of patients with cirrhosis progress to hepatocellular carcinoma.
(3) Patients have right upper quadrant abdominal pain, hepatomegaly, constitutional signs, and splenomegaly.
(4) The most common site of metastasis is the lung.
(1) Alpha-fetoprotein is elevated.
(2) CT or MRI imaging can visualize the tumor.
Possible therapies include resection, transplantation, and interventional radiologic techniques.


Cholangiocarcinoma (intrahepatic)
(1) Risk factors include liver fluke infection (from Southeast Asia), sclerosing cholangitis, biliary atresia, cholelithiasis, and exposure to Thorotrast.
(2) Patients may have abdominal pain, pruritus, and constitutional symptoms.
(1) Alkaline phosphatase and gamma-glutaryltransferase (GGT) will be increased.
(2) Use CT or MRI for localization.
(1) Resection or palliative stent placement can be performed. Half of cases are nonresectable.
(2) Chemotherapy using 5-fluorouracil, doxorubicin, or mitomycin C can also be used.
Angiosarcoma Rare tumor associated with vinyl chloride, arsenic, or Thorotrast contrast exposure. CT, MRI, and angiography detect lesions. Perform surgical resection, but most patients die within 6 months.


Metastatic
(1) The patient may have symptoms indicating the primary tumor.
(2) Metastatic tumors are 20 times more common than primary tumors of the liver.
Imaging (CT or MRI) and biopsy may help determine the primary tumor location. Depends on primary tumor type.

Last edited by USMLE-Syndrome; 06-25-2011 at 02:20 PM.
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cerebrum85 (06-28-2011)
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Old 06-28-2011
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perfect ....u help me correcting a misinterpreted concept...!!...thx a lot
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