Rare Malignant Liver Tumors

Although hepatocellular carcinoma Hepatocellular carcinoma Hepatocellular carcinoma (HCC) typically arises in a chronically diseased or cirrhotic liver and is the most common primary liver cancer. Diagnosis may include ultrasound, CT, MRI, biopsy (if inconclusive imaging), and/or biomarkers. Hepatocellular Carcinoma (HCC) and Liver Metastases ( HCC HCC Hepatocellular carcinoma (HCC) typically arises in a chronically diseased or cirrhotic liver and is the most common primary liver cancer. Diagnosis may include ultrasound, CT, MRI, biopsy (if inconclusive imaging), and/or biomarkers. Hepatocellular Carcinoma (HCC) and Liver Metastases) is by far the most common malignant liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy tumor Tumor Inflammation, there are several rare malignant tumors that are important to keep in mind when making a differential diagnosis. These tumors include cholangiocarcinoma; hepatoblastoma and mesenchymal tumors, such as epithelioid hemangioendothelioma (EHE); and angiosarcoma. While these conditions differ in their etiology and pathology, they often present similarly, with nonspecific symptoms such as fatigue Fatigue The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. Fibromyalgia, weight loss Weight loss Decrease in existing body weight. Bariatric Surgery, and abdominal discomfort. Diagnosis is by imaging, which can be supported by a biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma. Surgical excision is the only curative approach for these tumors.

Last updated: Sep 1, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Cholangiocarcinoma

Epidemiology and etiology

  • 2nd most common primary malignant liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy tumor Tumor Inflammation
  • Accounts for 7.6% of cancer deaths worldwide and 3% of cancer deaths in the United States
  • Very common in Southeast Asian countries due to a higher prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency of liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy fluke infestation:
    • Thailand
    • Laos
    • Cambodia

Pathogenesis and risk factors

Genetic disorders: 

  • Lynch syndrome Lynch syndrome Lynch syndrome, also called hereditary non-polyposis colorectal cancer (HNPCC), is the most common inherited colon cancer syndrome, and carries a significantly increased risk for endometrial cancer and other malignancies. Lynch syndrome has an autosomal dominant inheritance pattern involving pathogenic variants in one of the mismatch repair (MMR) genes or epithelial cell adhesion molecule (EpCAM). Lynch syndrome (hereditary nonpolyposis colorectal cancer Colorectal cancer Colorectal cancer (CRC) is the 2nd leading cause of cancer-related deaths in the United States. Colorectal cancer is a heterogeneous disease that arises from genetic and epigenetic abnormalities, with influence from environmental factors. Colorectal Cancer)
  • Cystic Cystic Fibrocystic Change fibrosis Fibrosis Any pathological condition where fibrous connective tissue invades any organ, usually as a consequence of inflammation or other injury. Bronchiolitis Obliterans
  • Multiple biliary papillomatosis

Toxins:

Cholangiocarcinoma is associated with work in the following industries:

  • Automotive 
  • Rubber 
  • Chemical
  • Wood finishing 

Precursor/pre-malignant lesions:

  • Biliary intraepithelial neoplasia: can become cholangiocarcinoma
  • Mucin-producing bile Bile An emulsifying agent produced in the liver and secreted into the duodenum. Its composition includes bile acids and salts; cholesterol; and electrolytes. It aids digestion of fats in the duodenum. Gallbladder and Biliary Tract: Anatomy duct tumors of the hepatobiliary system, noninvasive and invasive types

Other causes:

  • Chronic inflammatory conditions involving the bile Bile An emulsifying agent produced in the liver and secreted into the duodenum. Its composition includes bile acids and salts; cholesterol; and electrolytes. It aids digestion of fats in the duodenum. Gallbladder and Biliary Tract: Anatomy ducts → injury and reaction promote acquisition of cancer driver mutations
  • Primary sclerosing cholangitis Primary Sclerosing Cholangitis Primary sclerosing cholangitis (PSC) is an inflammatory disease that causes fibrosis and strictures of the bile ducts. The exact etiology is unknown, but there is a strong association with IBD. Patients typically present with an insidious onset of fatigue, pruritus, and jaundice, which can progress to cirrhosis and complications related to biliary obstruction. Primary Sclerosing Cholangitis
  • Infestation by liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy flukes (Opisthorchis and Clonorchis spp.)
  • Hepatolithiasis (recurrent pyogenic cholangitis)
  • Chronic liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy diseases that predispose to hepatocellular carcinoma Hepatocellular carcinoma Hepatocellular carcinoma (HCC) typically arises in a chronically diseased or cirrhotic liver and is the most common primary liver cancer. Diagnosis may include ultrasound, CT, MRI, biopsy (if inconclusive imaging), and/or biomarkers. Hepatocellular Carcinoma (HCC) and Liver Metastases ( HCC HCC Hepatocellular carcinoma (HCC) typically arises in a chronically diseased or cirrhotic liver and is the most common primary liver cancer. Diagnosis may include ultrasound, CT, MRI, biopsy (if inconclusive imaging), and/or biomarkers. Hepatocellular Carcinoma (HCC) and Liver Metastases):
    • Hepatitis B Hepatitis B Hepatitis B virus (HBV) is a partially double-stranded DNA virus, which belongs to the Orthohepadnavirus genus and the Hepadnaviridae family. Most individuals with acute HBV infection are asymptomatic or have mild, self-limiting symptoms. Chronic infection can be asymptomatic or create hepatic inflammation, leading to liver cirrhosis and hepatocellular carcinoma (HCC). Hepatitis B Virus and C
    • Nonalcoholic fatty liver disease Nonalcoholic Fatty Liver Disease Nonalcoholic fatty liver disease is a spectrum of liver pathology that arises due to accumulation of triglycerides in hepatocytes. Risk factors include diabetes mellitus, insulin resistance, obesity, and hypertension, among others. Nonalcoholic fatty liver disease ranges from fatty liver or hepatic steatosis but can lead to nonalcoholic steatohepatitis (NASH), which features fatty deposits and inflammation. Nonalcoholic Fatty Liver Disease

Pathology

  • Arises from epithelial cells of intrahepatic and extrahepatic bile ducts Extrahepatic bile ducts Passages external to the liver for the conveyance of bile. These include the common bile duct and the common hepatic duct. Gallbladder and Biliary Tract: Anatomy
  • Firm, gray-white mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast or masses
  • Klatskin tumor Tumor Inflammation: extrahepatic tumor Tumor Inflammation at junction of the right and left hepatic ducts; represents 60%–70% of extrahepatic tumors
  • Common bile duct common bile duct The largest bile duct. It is formed by the junction of the cystic duct and the common hepatic duct. Gallbladder and Biliary Tract: Anatomy: 30%–40% of extrahepatic tumors
    • Discovered earlier because they cause obstructive jaundice Jaundice Jaundice is the abnormal yellowing of the skin and/or sclera caused by the accumulation of bilirubin. Hyperbilirubinemia is caused by either an increase in bilirubin production or a decrease in the hepatic uptake, conjugation, or excretion of bilirubin. Jaundice early
    • Morphology varies: solid, infiltrative, or papillary
  • Microscopic appearance:
    • Adenocarcinoma, well to moderately differentiated
    • Abundant fibrous Fibrous Fibrocystic Change stroma
    • Lymphovascular and perineural invasion are common.
    • Combined hepatocellular-cholangiocarcinoma also occurs.

Clinical presentation

  • Symptoms related to biliary obstruction ( jaundice Jaundice Jaundice is the abnormal yellowing of the skin and/or sclera caused by the accumulation of bilirubin. Hyperbilirubinemia is caused by either an increase in bilirubin production or a decrease in the hepatic uptake, conjugation, or excretion of bilirubin. Jaundice, pruritus Pruritus An intense itching sensation that produces the urge to rub or scratch the skin to obtain relief. Atopic Dermatitis (Eczema))
  • Weight loss Weight loss Decrease in existing body weight. Bariatric Surgery 
  • Symptomatic liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast: RUQ discomfort

Diagnosis

Cholangiocarcinoma may be detected incidentally on imaging or may present with symptoms.

Laboratory tests: 

  • Assess for cholestasis:
    • Alkaline phosphatase Alkaline Phosphatase An enzyme that catalyzes the conversion of an orthophosphoric monoester and water to an alcohol and orthophosphate. Osteosarcoma
    • Gamma-glutamyltransferase Gamma-glutamyltransferase An enzyme, sometimes called ggt, with a key role in the synthesis and degradation of glutathione; (GSH, a tripeptide that protects cells from many toxins). It catalyzes the transfer of the gamma-glutamyl moiety to an acceptor amino acid. Liver Function Tests ( GGT GGT An enzyme, sometimes called ggt, with a key role in the synthesis and degradation of glutathione; (gsh, a tripeptide that protects cells from many toxins). It catalyzes the transfer of the gamma-glutamyl moiety to an acceptor amino acid. Alcoholic Liver Disease)
    • Bilirubin Bilirubin A bile pigment that is a degradation product of heme. Heme Metabolism (total, direct, and indirect) 
  • AST AST Enzymes of the transferase class that catalyze the conversion of l-aspartate and 2-ketoglutarate to oxaloacetate and l-glutamate. Liver Function Tests and ALT ALT An enzyme that catalyzes the conversion of l-alanine and 2-oxoglutarate to pyruvate and l-glutamate. Liver Function Tests may be normal or minimally elevated. 
  • Biomarkers: 
    • Carbohydrate antigen Antigen Substances that are recognized by the immune system and induce an immune reaction. Vaccination ( CA CA Condylomata acuminata are a clinical manifestation of genital HPV infection. Condylomata acuminata are described as raised, pearly, flesh-colored, papular, cauliflower-like lesions seen in the anogenital region that may cause itching, pain, or bleeding. Condylomata Acuminata (Genital Warts) 19-9) 
    • Carcinoembryonic antigen Antigen Substances that are recognized by the immune system and induce an immune reaction. Vaccination ( CEA CEA A glycoprotein that is secreted into the luminal surface of the epithelia in the gastrointestinal tract. It is found in the feces and pancreaticobiliary secretions and is used to monitor the response to colon cancer treatment. Serum Tumor Markers
    • Both are usually elevated.

Imaging:

  • Ultrasound to exclude a benign Benign Fibroadenoma cause of obstruction
  • MRCP MRCP Non-invasive diagnostic technique for visualizing the pancreatic ducts and bile ducts without the use of injected contrast media or x-ray. Mri scans provide excellent sensitivity for duct dilatation, biliary stricture, and intraductal abnormalities. Primary Sclerosing Cholangitis:
    • Distal extrahepatic cholangiocarcinoma: intrahepatic and extrahepatic ductal dilation
    • Perihilar cholangiocarcinoma: intrahepatic ductal dilatation with normal-caliber extrahepatic ducts
    • Intrahepatic cholangiocarcinoma: mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast lesion
  • Biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma: if imaging not conclusive
Arterial and portal venous phase ct of cholangiocarcinoma

Arterial and portal venous phase CT of cholangiocarcinoma

Image: “Arterial and portal venous phase CT of cholangiocarcinoma” by Kristie Guite, Louis Hinshaw and Fred Lee. License: CC BY 3.0
Photomicrographs of intrahepatic cholangiocarcinoma

Photomicrographs of intrahepatic cholangiocarcinoma:
a: markedly atypical epithelial cells (H&E, 200x)
b and c: immunohistochemical stains for the cytokeratins CK7 (b) and CK19 (c), supporting the diagnosis of cholangiocarcinoma ( immunohistochemistry Immunohistochemistry Histochemical localization of immunoreactive substances using labeled antibodies as reagents. Myeloperoxidase Deficiency, 200x)

Image: “Photomicrographs of intrahepatic cholangiocarcinoma” by Liu ZY, Sun JJ, He KW, Zhuo PY, Yu ZY. License: CC BY 4.0

Management

  • Surgical resection
  • Neoadjuvant or adjuvant Adjuvant Substances that augment, stimulate, activate, potentiate, or modulate the immune response at either the cellular or humoral level. The classical agents (freund’s adjuvant, bcg, corynebacterium parvum, et al.) contain bacterial antigens. Some are endogenous (e.g., histamine, interferon, transfer factor, tuftsin, interleukin-1). Their mode of action is either non-specific, resulting in increased immune responsiveness to a wide variety of antigens, or antigen-specific, i.e., affecting a restricted type of immune response to a narrow group of antigens. The therapeutic efficacy of many biological response modifiers is related to their antigen-specific immunoadjuvanticity. Vaccination chemotherapy Chemotherapy Osteosarcoma

Prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas

  • Overall prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas is poor: 20%–40% survival after surgical resection
  • Metastatic disease is present in 50%–60% of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship at presentation.
  • Recurrences are common after surgery.
  • Favorable if surgical resection margins are negative and there is no lymph Lymph The interstitial fluid that is in the lymphatic system. Secondary Lymphatic Organs node involvement.

Hepatoblastoma

Epidemiology and etiology

  • The most common primary hepatic malignancy Malignancy Hemothorax in early childhood
  • 1% of all childhood malignancies
  • Boys:girls ratio: 2:1 
  • Most occur in the first 2 years of life. 
  • Arises from primitive cells

Pathogenesis and risk factors

  • Prematurity Prematurity Neonatal Respiratory Distress Syndrome with a very low birth weight
  • Early exposure to hepatitis B Hepatitis B Hepatitis B virus (HBV) is a partially double-stranded DNA virus, which belongs to the Orthohepadnavirus genus and the Hepadnaviridae family. Most individuals with acute HBV infection are asymptomatic or have mild, self-limiting symptoms. Chronic infection can be asymptomatic or create hepatic inflammation, leading to liver cirrhosis and hepatocellular carcinoma (HCC). Hepatitis B Virus infection
  • Biliary atresia Atresia Hypoplastic Left Heart Syndrome (HLHS)
  • Genetic conditions: 
    • Beckwith-Wiedemann syndrome
    • Familial adenomatous polyposis Familial Adenomatous Polyposis Familial adenomatous polyposis (FAP) is an autosomal dominant inherited genetic disorder that presents with numerous adenomatous polyps in the colon. Familial adenomatous polyposis is the most common of the polyposis syndromes, which is a group of inherited or acquired conditions characterized by the growth of polyps in the GI tract, associated with other extracolonic features. Familial Adenomatous Polyposis ( FAP FAP Familial adenomatous polyposis (FAP) is an autosomal dominant inherited genetic disorder that presents with numerous adenomatous polyps in the colon. Familial adenomatous polyposis is the most common of the polyposis syndromes, which is a group of inherited or acquired conditions characterized by the growth of polyps in the GI tract, associated with other extracolonic features. Familial Adenomatous Polyposis)
    • Trisomy Trisomy The possession of a third chromosome of any one type in an otherwise diploid cell. Types of Mutations 21

Pathology

  • Well-circumscribed single or multiple lesions, up to 20 cm (8 in)
  • Hemorrhage and necrosis Necrosis The death of cells in an organ or tissue due to disease, injury or failure of the blood supply. Ischemic Cell Damage due to rapid growth 
  • Microscopically: 
    • Malignant liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy cells, at various stages of maturation
    • Scattered mesenchymal components, including bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types and cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage: Histology

Clinical presentation

  • Often asymptomatic at presentation
  • Abdominal distension, rapidly growing abdominal mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast
  • Anorexia Anorexia The lack or loss of appetite accompanied by an aversion to food and the inability to eat. It is the defining characteristic of the disorder anorexia nervosa. Anorexia Nervosa, weight loss Weight loss Decrease in existing body weight. Bariatric Surgery
  • Fatigue Fatigue The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. Fibromyalgia
  • Disease is advanced at diagnosis in 40% of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship, with pulmonary metastases in 20% of cases.
  • Death may occur from tumor Tumor Inflammation rupture, and may be the 1st manifestation of the disease.

Diagnosis

  • Serum alpha-fetoprotein Alpha-fetoprotein The first alpha-globulins to appear in mammalian sera during fetal development and the dominant serum proteins in early embryonic life. Hepatocellular Carcinoma (HCC) and Liver Metastases levels are markedly elevated. 
  • Imaging: All modes may be used. 
    • Ultrasound
    • CT
    • MRI
    • Radionuclide bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types scanning
    • PET PET An imaging technique that combines a positron-emission tomography (PET) scanner and a ct X ray scanner. This establishes a precise anatomic localization in the same session. Nuclear Imaging scanning
  • Biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma: open surgical biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma preferred (if tumor Tumor Inflammation not resected) because of the high vascularity of the tumor Tumor Inflammation

Management

  • Surgical resection
  • Neoadjuvant or adjuvant Adjuvant Substances that augment, stimulate, activate, potentiate, or modulate the immune response at either the cellular or humoral level. The classical agents (freund’s adjuvant, bcg, corynebacterium parvum, et al.) contain bacterial antigens. Some are endogenous (e.g., histamine, interferon, transfer factor, tuftsin, interleukin-1). Their mode of action is either non-specific, resulting in increased immune responsiveness to a wide variety of antigens, or antigen-specific, i.e., affecting a restricted type of immune response to a narrow group of antigens. The therapeutic efficacy of many biological response modifiers is related to their antigen-specific immunoadjuvanticity. Vaccination chemotherapy Chemotherapy Osteosarcoma
  • Adjuvant Adjuvant Substances that augment, stimulate, activate, potentiate, or modulate the immune response at either the cellular or humoral level. The classical agents (freund’s adjuvant, bcg, corynebacterium parvum, et al.) contain bacterial antigens. Some are endogenous (e.g., histamine, interferon, transfer factor, tuftsin, interleukin-1). Their mode of action is either non-specific, resulting in increased immune responsiveness to a wide variety of antigens, or antigen-specific, i.e., affecting a restricted type of immune response to a narrow group of antigens. The therapeutic efficacy of many biological response modifiers is related to their antigen-specific immunoadjuvanticity. Vaccination radiotherapy may be used.

Prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas

The overall survival rate has greatly improved over the past 4 decades and now stands at 81%.

Hepatoblastoma

Hepatoblastoma:
characteristic of the embryonal cell type, fine-needle biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma aspirate consists of small, oval-to-spindle shaped cells with a small amount of cytoplasm and prominent nucleoli

Image: “Hepatoblastoma” by David C Chhieng. License: CC BY 2.0

Mesenchymal Tumors

Epithelioid hemangioendothelioma (EHE)

Epithelioid hemangioendothelioma is a low-grade malignant vascular neoplasm Vascular neoplasm Neoplasms located in the vasculature system, such as arteries and veins. They are differentiated from neoplasms of vascular tissue (neoplasms, vascular tissue), such as angiofibroma or hemangioma. Hemangioblastoma

  • Epidemiology: more common in women than men
  • Pathology
    • Tumor Tumor Inflammation arises around medium- and large-sized veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins: Histology
    • Vascular channels Channels The Cell: Cell Membrane are inconspicuous; +/- calcification, fibrosis Fibrosis Any pathological condition where fibrous connective tissue invades any organ, usually as a consequence of inflammation or other injury. Bronchiolitis Obliterans
    • Neoplastic cells are plump and often cuboidal.
  • Clinical presentation: 
  • Management:
    • Surgical excision curative in most cases
    • 40% recurrence rate
    • 20%–30% of EHE metastasize.
    • 15% of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship will die from their tumor Tumor Inflammation.

Angiosarcoma

Angiosarcoma is a high-grade malignant vascular neoplasm Vascular neoplasm Neoplasms located in the vasculature system, such as arteries and veins. They are differentiated from neoplasms of vascular tissue (neoplasms, vascular tissue), such as angiofibroma or hemangioma. Hemangioblastoma.

  • Epidemiology: 
    • The most common sarcoma arising in the liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy 
    • Mostly older patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship (> 60 years old)
    • Men > women
  • Etiology: various risk factors account for 25% of cases, and include:
    • Vinyl chloride Chloride Inorganic compounds derived from hydrochloric acid that contain the Cl- ion. Electrolytes
    • Arsenic Arsenic A shiny gray element with atomic symbol as, atomic number 33, and atomic weight 75. It occurs throughout the universe, mostly in the form of metallic arsenides. Most forms are toxic. According to the fourth annual report on carcinogens, arsenic and certain arsenic compounds have been listed as known carcinogens. Metal Poisoning (Lead, Arsenic, Iron) (e.g., in pesticides)
    • Anabolic steroids Steroids A group of polycyclic compounds closely related biochemically to terpenes. They include cholesterol, numerous hormones, precursors of certain vitamins, bile acids, alcohols (sterols), and certain natural drugs and poisons. Steroids have a common nucleus, a fused, reduced 17-carbon atom ring system, cyclopentanoperhydrophenanthrene. Most steroids also have two methyl groups and an aliphatic side-chain attached to the nucleus. Benign Liver Tumors
    • Oral contraceptives
    • Radiation Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma
    • Thorium dioxide
  • Pathology:
    • Morphology varies from well-differentiated tumors that resemble hemangiomas to anaplastic lesions.
    • Forms many variably sized hemorrhagic nodules
    • The entire liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy is often involved.
    • Invades and grows into sinusoids Sinusoids Liver: Anatomy and branches of portal, hepatic veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins: Histology
    • Immunostaining shows positivity for vascular markers.
  • Clinical presentation:
    • Abdominal pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways
    • Fatigue Fatigue The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. Fibromyalgia
    • Jaundice Jaundice Jaundice is the abnormal yellowing of the skin and/or sclera caused by the accumulation of bilirubin. Hyperbilirubinemia is caused by either an increase in bilirubin production or a decrease in the hepatic uptake, conjugation, or excretion of bilirubin. Jaundice
    • Ascites Ascites Ascites is the pathologic accumulation of fluid within the peritoneal cavity that occurs due to an osmotic and/or hydrostatic pressure imbalance secondary to portal hypertension (cirrhosis, heart failure) or non-portal hypertension (hypoalbuminemia, malignancy, infection). Ascites
    • Weight loss Weight loss Decrease in existing body weight. Bariatric Surgery
    • Hepatomegaly, +/- splenomegaly Splenomegaly Splenomegaly is pathologic enlargement of the spleen that is attributable to numerous causes, including infections, hemoglobinopathies, infiltrative processes, and outflow obstruction of the portal vein. Splenomegaly
    • Thrombocytopenia Thrombocytopenia Thrombocytopenia occurs when the platelet count is < 150,000 per microliter. The normal range for platelets is usually 150,000-450,000/µL of whole blood. Thrombocytopenia can be a result of decreased production, increased destruction, or splenic sequestration of platelets. Patients are often asymptomatic until platelet counts are < 50,000/µL. Thrombocytopenia
  • Management: surgical excision
  • Prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas: 
    • Metastases occur frequently and rapidly to the spleen Spleen The spleen is the largest lymphoid organ in the body, located in the LUQ of the abdomen, superior to the left kidney and posterior to the stomach at the level of the 9th-11th ribs just below the diaphragm. The spleen is highly vascular and acts as an important blood filter, cleansing the blood of pathogens and damaged erythrocytes. Spleen: Anatomy, lymph Lymph The interstitial fluid that is in the lymphatic system. Secondary Lymphatic Organs nodes, lung, bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types, and adrenals.
    • Liver failure Liver failure Severe inability of the liver to perform its normal metabolic functions, as evidenced by severe jaundice and abnormal serum levels of ammonia; bilirubin; alkaline phosphatase; aspartate aminotransferase; lactate dehydrogenases; and albumin/globulin ratio. Autoimmune Hepatitis and intraabdominal bleeding due to liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy rupture are common causes of death.
    • 5-year survival is approximately 30%.

Mnemonic

Risk factors of hepatic angiosarcoma can be remembered as “VAT”:

  • Vinyl chloride Chloride Inorganic compounds derived from hydrochloric acid that contain the Cl- ion. Electrolytes
  • Arsenic
  • Thorium dioxide

Differential Diagnosis

The following conditions encompass the most important benign Benign Fibroadenoma lesions included in the differential diagnosis of a solid mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast in the liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy:

  • Hepatic hemangioma Hemangioma A vascular anomaly due to proliferation of blood vessels that forms a tumor-like mass. The common types involve capillaries and veins. It can occur anywhere in the body but is most frequently noticed in the skin and subcutaneous tissue. Imaging of the Liver and Biliary Tract ( cavernous hemangioma Cavernous hemangioma A vascular anomaly that is a collection of tortuous blood vessels and connective tissue. This tumor-like mass with the large vascular space is filled with blood and usually appears as a strawberry-like lesion in the subcutaneous areas of the face, extremities, or other regions of the body including the central nervous system. Benign Liver Tumors): the most common benign Benign Fibroadenoma liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy lesion. More common in women than men. Usually asymptomatic, with an excellent prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas.
  • Focal nodular hyperplasia Hyperplasia An increase in the number of cells in a tissue or organ without tumor formation. It differs from hypertrophy, which is an increase in bulk without an increase in the number of cells. Cellular Adaptation (FNH): a proliferation of hyperplastic Hyperplastic Colon Polyps hepatocytes Hepatocytes The main structural component of the liver. They are specialized epithelial cells that are organized into interconnected plates called lobules. Liver: Anatomy surrounding a central stellate scar Scar Dermatologic Examination. More common in women than men. Management includes transarterial embolization Embolization A method of hemostasis utilizing various agents such as gelfoam, silastic, metal, glass, or plastic pellets, autologous clot, fat, and muscle as emboli. It has been used in the treatment of spinal cord and intracranial arteriovenous malformations, renal arteriovenous fistulas, gastrointestinal bleeding, epistaxis, hypersplenism, certain highly vascular tumors, traumatic rupture of blood vessels, and control of operative hemorrhage. Gastrointestinal Bleeding, radiofrequency ablation Radiofrequency ablation Removal of tissue using heat generated from electrodes delivering an alternating electrical current in the frequency of radio waves. Hepatocellular Carcinoma (HCC) and Liver Metastases, and surgical resection.
  • Hepatocellular adenoma Hepatocellular adenoma A benign epithelial tumor of the liver. Benign Liver Tumors ( hepatic adenoma Hepatic adenoma A benign epithelial tumor of the liver. Benign Liver Tumors): develops in normal liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy. Solitary lesion mostly in young women who use estrogen-containing medications and in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with glycogen storage disease Glycogen storage disease A group of inherited metabolic disorders involving the enzymes responsible for the synthesis and degradation of glycogen. In some patients, prominent liver involvement is presented. In others, more generalized storage of glycogen occurs, sometimes with prominent cardiac involvement. Benign Liver Tumors or metabolic syndrome Metabolic syndrome Metabolic syndrome is a cluster of conditions that significantly increases the risk for several secondary diseases, notably cardiovascular disease, type 2 diabetes, and nonalcoholic fatty liver. In general, it is agreed that hypertension, insulin resistance/hyperglycemia, and hyperlipidemia, along with central obesity, are components of the metabolic syndrome. Metabolic Syndrome. Management includes observation and surveillance Surveillance Developmental Milestones and Normal Growth, transarterial embolization Embolization A method of hemostasis utilizing various agents such as gelfoam, silastic, metal, glass, or plastic pellets, autologous clot, fat, and muscle as emboli. It has been used in the treatment of spinal cord and intracranial arteriovenous malformations, renal arteriovenous fistulas, gastrointestinal bleeding, epistaxis, hypersplenism, certain highly vascular tumors, traumatic rupture of blood vessels, and control of operative hemorrhage. Gastrointestinal Bleeding, and surgical resection.
  • Regenerative nodules: usually seen in cirrhosis Cirrhosis Cirrhosis is a late stage of hepatic parenchymal necrosis and scarring (fibrosis) most commonly due to hepatitis C infection and alcoholic liver disease. Patients may present with jaundice, ascites, and hepatosplenomegaly. Cirrhosis can also cause complications such as hepatic encephalopathy, portal hypertension, portal vein thrombosis, and hepatorenal syndrome. Cirrhosis as a response to liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy injury; consist of proliferations of hepatocytes Hepatocytes The main structural component of the liver. They are specialized epithelial cells that are organized into interconnected plates called lobules. Liver: Anatomy and stroma. 

References

  1. Gill, R.M., Kakar S. (2020). Liver and Gallbladder. In Kumar, V., Abbas, A. K., Aster, J.C., (Eds.), Robbins & Cotran Pathologic Basis of Disease. 10th ed. pp. 868–872. Elsevier, Inc.
  2. Ranganathan, S., Lopez-Terrada, D., & Alaggio, R. (2020). Hepatoblastoma and Pediatric Hepatocellular Carcinoma: An Update. Pediatric and Developmental Pathology. 23(2), 79–95. https://doi.org/10.1177/1093526619875228
  3. Yasir, S., Torbenson, M. S. (2019). Angiosarcoma of the Liver: Clinicopathologic Features and Morphologic Patterns. The American Journal of Surgical Pathology. 43(5), 581–590. https://doi.org/10.1097/PAS.0000000000001228
  4. Rosenberg, A., Agulnik, M. (2018). Epithelioid Hemangioendothelioma: Update on Diagnosis and Treatment. Current Treatment Options in Oncology. 19(4), 19. https://doi.org/10.1007/s11864-018-0536-y
  5. El-Diwany, R., Pawlik, T. M., & Ejaz, A. (2019). Intrahepatic Cholangiocarcinoma. Surgical Oncology Clinics of North America. 28(4), 587–599. https://pubmed.ncbi.nlm.nih.gov/31472907/

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