STEPTRACKERGASTROINTESTINAL + ONCOLOGY | PATHOLOGY | HIGH-YIELD REVIEW

Liver Tumors & Vascular Disorders

Benign masses you shouldn't biopsy, the cancers that arise in damaged livers, and what happens when blood can't leave the liver.

FOCUS ON
Metastases are the most common liver malignancy. HCC: HBV, HCV, alcohol, NAFLD, hemochromatosis, aflatoxin; ↑ AFP; vascular invasion. Hemangioma: most common benign (don't biopsy). Adenoma: OCPs/steroids, can rupture. Budd-Chiari: hepatic vein thrombosis → painful hepatomegaly, ascites, no JVD.
LESION
MECHANISM · RISK
FEATURES
CLUE
Cavernous hemangioma
most common benign
Dilated vascular channels
Usually incidental; adults
No biopsy — hemorrhage risk
Focal nodular hyperplasia
Hyperplastic response to an abnormal artery
Young women; well-circumscribed with a central stellate scar
No malignant potential
Hepatic adenoma
Oral contraceptives, anabolic steroids, GSD I; β-catenin-mutant subtype can turn malignant
Young women; subcapsular; may rupture and bleed (esp. pregnancy)
Often regresses after stopping estrogen
Hepatocellular carcinoma
Chronic injury and regeneration: HBV (even without cirrhosis), HCV, alcohol, NAFLD, hemochromatosis, α1AT, Wilson, aflatoxin (TP53)
Weight loss, RUQ pain, decompensated cirrhosis; invades portal/hepatic veins (Budd-Chiari)
↑ AFP · arterial enhancement with washout · sorafenib
HCC paraneoplastic
Tumor products
Erythrocytosis (EPO), hypoglycemia, hypercalcemia (PTHrP)
Rising Hb in a cirrhotic
Fibrolamellar carcinoma
HCC variant; DNAJB1-PRKACA fusion
Adolescents/young adults, no cirrhosis; layered fibrous bands; normal AFP
Better prognosis
Hepatoblastoma
Embryonal tumor
Children < 3; abdominal mass, ↑ AFP
Beckwith-Wiedemann, FAP, prematurity
Angiosarcoma
Malignant endothelial tumor; vinyl chloride, arsenic, Thorotrast
Aggressive, hemorrhagic
CD31 ⁺
Metastases
most common malignancy
Portal and systemic spread
Multiple nodules; colon, breast, lung, pancreas, stomach
Multiple masses = metastases first
Budd-Chiari syndrome
Hepatic vein / IVC thrombosis: polycythemia vera, hypercoagulable states, pregnancy, OCPs, HCC
Painful hepatomegaly, ascites, varices; centrilobular congestion; no JVD
Caudate lobe hypertrophy (separate drainage)
Congestive hepatopathy
Right heart failure, constrictive pericarditis → backflow
Nutmeg liver (dark congested centrilobular zones); ↑ JVD; cardiac cirrhosis late
JVD distinguishes from Budd-Chiari
Sinusoidal obstruction syndrome
Endothelial injury to sinusoids/venules: stem cell transplant conditioning, pyrrolizidine alkaloids
Weight gain, painful hepatomegaly, jaundice within weeks
Veno-occlusive disease

Mechanism — chronic injury to HCC

Chronic injuryVirus, alcohol, fat, iron
→
Cycles of death + regeneration
→
Cirrhotic nodules
→
Dysplastic nodule
→
HCC
HBV DNA integrationHBx protein
→
HCC without cirrhosis
Aflatoxin (Aspergillus)
→
TP53 G:C → T:A

Telling liver masses apart

MASS
WHO
KEY FEATURE
RISK
Hemangioma
Any adult
Vascular, peripheral fill-in
None
FNH
Young women
Central stellate scar
None
Adenoma
Women on OCPs
Subcapsular, bleeds
Rupture, rare cancer
HCC
Cirrhosis, HBV
↑ AFP, vein invasion
Malignant
Fibrolamellar
Young, normal liver
Fibrous bands
Malignant, better
Metastases
Known cancer
Multiple
Malignant

How it's tested

COMMON CONFUSIONBudd-Chiari and right heart failure both congest the liver. Right heart failure has raised JVD; Budd-Chiari does not, because the block is below the heart.
THE TRAPA known hemangioma on imaging should not be biopsied. A young woman on OCPs with sudden RUQ pain and shock may have a ruptured adenoma.
YOUR APPROACHSingle or multiple → patient profile (cirrhosis, HBV, OCPs, child, toxic exposure) → AFP and imaging feature → benign, premalignant or malignant.

If you see… think…

Cirrhotic with weight loss, new liver mass, ↑ AFP → hepatocellular carcinoma
HCC in an HBV carrier without cirrhosis → viral DNA integration
Liver cancer with moldy grain/peanut exposure in Africa or Asia → aflatoxin (TP53)
Young woman on OCPs, sudden RUQ pain, hemoperitoneum → ruptured hepatic adenoma
Mass with a central stellate scar in a young woman → focal nodular hyperplasia
Adolescent with a liver tumor, normal liver, normal AFP → fibrolamellar carcinoma
PVC factory worker with a hemorrhagic liver tumor → angiosarcoma
Polycythemia vera, painful hepatomegaly, ascites, no JVD → Budd-Chiari
Nutmeg pattern on the cut liver + raised JVD → right heart failure
Painful hepatomegaly and jaundice weeks after bone marrow transplant → sinusoidal obstruction syndrome