NMS. Casos Clínicos

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Chapter 7 ♦ Pancreatic and Hepatic Disorders

Q: What is the next step? A: CT is an appropriate test to differentiate between the other possible diagnoses. Patients with focal nodular hyperplasia occasionally demonstrate a central stellate scar on CT scan but require a liver biopsy to establish a diagnosis. No treatment for focal nodular hyperplasia is indicated (Fig. 7-31). Hepatic adenoma may be difficult to distinguish from hepatocellular carcinoma, but its risk for malignancy is low. Hepatic adenomas are associated with oral contra- ceptives and may regress after their discontinuation. Persistent or large lesions should be resected to confirm the diagnosis and to prevent spontaneous rupture, which is a significant risk with pregnancy. Hepatic adenomas are thought to have an especially high risk of rupture during pregnancy and therefore should be treated prior to preg- nancy. The CT scan suggests hepatocellular carcinoma. You perform a biopsy, and the pathology returns hepatocellular carcinoma. Q: What management is appropriate? A: The first step is to determine whether metastatic disease exists , usually with a CT scan of the chest and abdomen to examine for lung metastasis and other abnormalities. Ab- dominal metastases are typically in the hepatic hilar lymph nodes and celiac nodes, and they extend locally into the diaphragm and other structures. If no metastases exist, then a surgical assessment of the hepatic lesions is appropriate. Hepatic resection is most commonly performed for primary hepatocellular carcinoma and colorectal cancer metastatic to the liver. For both tumors, the prognosis is favorable for patients with lesions that are resectable with a 1-cm margin, solitary, less than 5 cm in diameter, in noncirrhotic livers, without vascular invasion, and of low-grade malig- nancy . When resection is appropriate, surgeons should perform it aggressively because it offers the patient the highest rate of cure; similar factors are shown for colorectal metas- tasis to the liver (Table 7-2) . If these criteria are not met, resection is not warranted. In that case, it is treated medically except for special cases where hepatic transplantation protocols can be considered.

You decide to remove the mass.

Figure 7-31: CT scan of the liver showing focal nodular hyperplasia. SAMPLE