Neoplastic Conditions

Adenoma: rare, causing acute abdominal presentation due to lesional haemorrhage in a middle-aged female with a history of oral contraception. Devoid of portal tracts or central veins within the nodule but preservation of the pericellular reticulin pattern and liver cell plates - these features help distinguish it from well-differentiated hepatocellular carcinoma.

Adenomatous hyperplastic or macroregenerative nodules: irregular nodules in background cirrhosis, 2-3 cm diameter with cytoarchitectural atypia and potentially premalignant.

Hepatocellular carcinoma: often in background cirrhosis and serum AFP is elevated in 25-40% of cases. Single, diffuse or multifocal, bile stained and prone to venous invasion with metastases to lung, adrenal gland and bone. The commonest patterns are trabecular, plate-like or sinusoidal comprising variably differentiated hepatoid cells.

A minority are encapsulated, pedunculated or in a younger patient fibrolamellar in type; these variants having a better prognosis than usual hepatoma.

Cholangiocarcinoma (intrahepatic): scirrhous, solitary or multifocal adenocarcinoma with a ductuloacinar pattern and predisposed to by primary sclerosing cholangitis, ulcerative colitis, liver fluke and biliary tree anomalies.

Metastatic carcinoma: commonly from gastrointestinal tract, lung and breast, there are some characteristic clues as to origin:

• colorectum - multiple, large nodules with central necrosis/umbilication, ± mucin ± calcification.

• gall bladder - bulk of disease centred on the gall bladder bed.

• stomach, breast - medium-sized nodules or diffuse cirrhotic-like pattern.

Note that carcinoma rarely metastases to a cirrhotic liver, i.e., the tumour is more likely to be primary.

Other cancers: malignant lymphoma (portal infiltrates or tumour nodules), leukaemia (sinusoidal infiltrate), angiosarcoma, epithelioid haemangioendothelioma.

Prognosis: in hepatocellular carcinoma this relates to size (> 5 cm), differentiation, encapsulation, multifocality, high serum AFP levels, vascular invasion and the presence of background cirrhosis (adverse). The majority die within several months of presentation and five-year survival is at most 5-10%. Chemotherapy is used palliatively. Small tumours, encapsulated, pedunculated and fibrolamellar variants are potentially curable by resection. Few patients with cholangiocarcinoma survive longer than 2-3 years due to late presentation and limited resectability. Solitary metastases, e.g., colorectal carcinoma or carcinoid tumour, can be resected to good effect.

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