This document provides information on the histological classification and diagnostic evaluation of solitary space-occupying lesions of the liver. It discusses the classification of hepatocellular, bile duct, and miscellaneous lesions. It also outlines the diagnostic steps including history, examination, labs, imaging studies and algorithms for the workup of solitary and multiple liver lesions on ultrasound. Several clinical cases are then presented and discussed.

1. Dr Harshal Rajekar MS MRCS DNB
HPB, GI and Transplant Surgeon

2. Dr Harshal Rajekar MS MRCS
DNB

4. HISTOLOGICAL CLASSIFICATION OF TUMOR-LIKE PRIMARY HEPATIC SPACE-
OCCUPYING LESIONS
Hepatocellular lesions:
1. Focal nodular hyperplasia
2. Nodular regenerative hyperplasia
3. Partial nodular transformation
4. Adenomatoid hyperplasia
5. Compensatory lobar hyperplasia
6.Focal fatty change
7. Accessory lobe
Bile duct lesions:
1. Biliary microhamartoma
2. Cyst and polycystic liver
3. Ciliated foregut cyst
4. Epidermoid cyst
5. Intrahepatic peribiliary gland cyst
6. Mesothelial cyst
7. Cystic echinococcosis
8.Biloma
Miscellaneous lesions:
1. Mesenchymal hamartoma
2. Inflammatory pseudotumor
3. Pseudolymphoma
4. Solitary necrotic nodule
5. Peliosis hepatis
6. Hereditary hem. Telangiectasia
7. Sarcoidosis
8. Nodular extramed. Hematopoiesis
9. Abscess
10. Tuberculoma
11. Botryomycosis
12. Malacoplakia/ adrenal rest tumor
13. Granulomas

5.  History
 Clinical examination
 Lab – Hemogram, LFT, Albumin,INR
 Serology – ALA , Hydatid
 Tumor markers – AFP,CEA, CA 19-9
Dr Harshal Rajekar MS MRCS
DNB

6.  Asymptomatic
 Nodule on screening in cirrhotic patients
 Presenting with pain and fever
 SOL in a known patient of extrahepatic malignancy
Dr Harshal Rajekar MS MRCS
DNB

7. Algorithm for Solitary SOL of Liver on USG
Dr Harshal
Rajekar MS MRCS

8. Algorithm for Solid lesions on USG

9. Algorithm for Multiple Liver SOLs on USG
Dr Harshal Rajekar MS MRCS

10.  Symptomatic lesions – no response to
treatment
 Alterations in LFT
 Underlying liver disease
Dr Harshal Rajekar MS MRCS
DNB

13. When to do MRI -----
HCC vs regenerating nodule vs dysplastic
nodule
atypical lesions

14. Usually not required
Diagnostic uncertainty
Dr Harshal Rajekar MS MRCS
DNB

16. Screening strategy

17.  27 year old male
 vague abdominl discomfort.
 significant loss of apetite.
 no history of liver disease.
 ?Weight loss over the past 4 months.
Dr Harshal Rajekar MS MRCS

18.  Went to local doctor, had an abdominal
ultrasound.
 USG found a liver mass occupying most of
right lobe.
 What next?
Dr Harshal Rajekar MS MRCS
DNB

19.  Imaging?
 CT scan.
Dr Harshal Rajekar MS MRCS
DNB

22.  Bloods:
 Normal liver function tests, apart from a
raised Alkaline Phosphotase.
 Alpha Feto protein - >1,600,000 ng/dL
Dr Harshal Rajekar MS MRCS

24.  30 female.
 unmarried, no other medical or surgical
disease.
 No jaundice.
 Vague abdominal pain.
 Post-prandial discomfort.
Dr Harshal Rajekar MS MRCS
DNB

25.  went to GP, had an US scan.
 Large 15 cm cystic lesion in the central part
of the liver, reaching the hilum, with +/-
septations.
Dr Harshal Rajekar MS MRCS

26.  what next?
 Imaging?
 Blood tests?
 FNA?
Dr Harshal Rajekar MS MRCS

27.  patients GP did all three.
 Blood tests:
- Alk Phosp.- >800, rest normal.
- CECT - .....
Dr Harshal Rajekar MS MRCS

30.  Did a US guided FNA of cyst fluid.
 Cytology showed dysplastic cells, degenrate
hepatocytes.
Dr Harshal Rajekar MS MRCS

31. Dr Harshal Rajekar MS MRCS

32.  63 male.
 moderate alcohol intake.
 no co-morbidities.
 vague symptoms, weakness and
abdominal discomfort.
 episode of diarrhoeal illness.
Dr Harshal Rajekar MS MRCS
DNB

33.  Investigated:
- HBsAg +ve
- USG abdomen deteccted a 4.5cm
lesion in
liver , seg 5/8, altered liver
architechtexture.
 What next?
Dr Harshal Rajekar MS MRCS

34.  CECT - 4.5cm lesion in right lobe
occupying seg 5/8, with another satellite ?
8mm lesion in segment 8.
 The liver had a nodular outline, no ascites,
spleen size normal.
 AFP -181 ng/mL
Dr Harshal Rajekar MS MRCS

35.  Childs A status.
- No jaundice.
- No ascites.
- INR 1.1
- Noencephalopathy.
- Albumin 3.6 g/dL
 What next?
Dr Harshal Rajekar MS MRCS

38.  Patient was offered TACE (chemo-embolization).
 HBV treatment was commenced with tenofovir.
 Patient continued to do well, performance status
remained well.
 Repeat CT scan 8 months later showed an increase
in the size of the sae lesion to 10.5cm in diameter
and the satellite lesion was around the same size at
1.2cm.
 There were no new lesions.
 Liver function – Childs A. No PHT.
 What next?

39.  Offered repeat TACE.
 Tolerated procedure well.
 1 month post TACE – patient himself got a CT
scan, showed a slight increase in size to 13.1
cm.
 No new lesions.
 What does this mean?
Dr Harshal Rajekar MS MRCS

40.  3 months later.
 Repeat CT scan – multiple liver and lung mets.
Dr Harshal Rajekar MS MRCS

41.  54 yrs gentleman, no comorbidities
 Change in bowel habit
 incomplete evacuation
 No other GI symptoms
 USG abdomen – hypo echoic liver lesions
 Lab - normal
Dr Harshal Rajekar MS MRCS

44.  Ulcero proliferative lesion in sigmoid colon
 No synchronous lesions/polyps
 Biopsy - adenocarcinoma
Dr Harshal Rajekar MS MRCS

46.  FOLFOX + bevaxizumab – 7 cycles
 FOLFOX – 5 cycles
Dr Harshal Rajekar MS MRCS

48. PET CT

49.  Sigmoid colectomy + left lateral segmentectomy
+ metastectomy (seg 4b, seg 5, seg 7)
Dr Harshal Rajekar MS MRCS

50.  THANK YOU