Liver Tumors and Transplantation

• Audio chapter
  Single-voice audio, listen on the commute.
• ABIM-format MCQs
  5-option vignettes with full wrong-answer teaching.
• Study guide
  Tables, decision trees, primary sources.
• AI tutor
  Chapter-grounded, answers the question you're stuck on.

What this chapter covers

• Section 24.1: Benign liver lesions

  Cavernous hemangioma is the most common benign liver tumor (approximately 7 percent of autopsies, female predominance 1.5 to 5 to 1, multicentric in up to 30 percent).

• Section 24.2: HCC surveillance and AASLD 2023

  AASLD 2023 recommends HCC surveillance in all patients with Child-Pugh A or B cirrhosis regardless of etiology, including HCV cured by sustained virologic response, and in Child-Pugh C cirrhosis only if the patient is listed or being evaluated for transplant.

• Section 24.3: LI-RADS and HCC diagnosis

  LI-RADS grades cirrhotic liver lesions on a five-point scale plus two additional categories.

• Section 24.4: HCC treatment by BCLC stage

  BCLC 0 (single lesion under 2 cm, Child-Pugh A, ECOG 0) and BCLC A (single lesion or up to 3 lesions each at most 3 cm, Child-Pugh A or B, ECOG 0) are curative-intent stages.

• Section 24.5: Cholangiocarcinoma

  Cholangiocarcinoma is anatomically classified into three subtypes that drive different management.

• Section 24.6: Liver transplant evaluation and MELD 3.0

  MELD 3.0 replaced MELD-Na in 2023 for waitlist allocation.

• Section 24.7: Transplant exception points and donor types

  Standard exception points correct the calculated MELD when it undercounts severity.

• Section 24.8: Post-transplant complications and rejection

  Immunosuppression follows a trajectory mirroring rejection risk.

• Section 24.9: Recurrent disease post-transplant

  Recurrent disease patterns vary by underlying etiology, and disease-specific surveillance and treatment adjustments must continue indefinitely after transplant because the metabolic, viral, autoimmune, or biliary substrate that produced the original failure can re-establish itself in the allograft.

Podcast episodes

1. 01

   Liver Tumors and Transplantation: Benign Lesions

   Imaging, not biopsy, sorts a benign liver lesion found by chance in a liver without cirrhosis, and the episode follows three patients through that idea. A young woman's six-centimeter mass is separated on contrast MRI into hemangioma, with peripheral nodular enhancement and centripetal fill-in, focal nodular hyperplasia, which stays bright in the hepatobiliary phase on gadoxetate, and adenoma, which is dark. Adenoma then brings the surgery decisions: subtype, size, sex, bleeding, growth, and planned pregnancy, plus stopping estrogen and surveillance for smaller lesions. A man using anabolic steroids shows why sex changes the rule and what else steroids do to the liver. A woman on azathioprine shows nodular regenerative hyperplasia, which needs a reticulin stain.

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2. 02

   Liver Tumors and Transplantation: Liver Cancer

   Hepatocellular carcinoma care runs on a few fixed rules: surveillance follows the cirrhosis, imaging makes the diagnosis, and the BCLC stage picks the treatment. The episode starts with who is surveyed, using ultrasound and AFP every six months, and when MRI or CT replaces ultrasound. It covers hepatitis B without cirrhosis and the groups who are not surveyed. It then reads a new nodule with LI-RADS, including LR-5, LR-M, and tumor in vein. Staging follows, with resection, ablation, and transplant for early disease, chemoembolization or radioembolization for intermediate disease, and systemic drugs for advanced disease. The episode ends with the variceal check before bevacizumab.

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3. 03

   Liver Tumors and Transplantation: Biliary Cancer

   The organizing idea is that the location of a cholangiocarcinoma decides everything. The episode starts with a man with cirrhosis and an intrahepatic mass, then covers how progressive enhancement without washout separates this tumor from hepatocellular carcinoma. It reviews the risk factors and why CA 19-9 misleads, then explains why a transplant cannot cure him and how first-line drugs and FGFR2 and IDH1 testing guide treatment. A second patient with sclerosing cholangitis and a hilar stricture shows the Mayo transplant protocol and why tissue must be taken from inside the duct. A third patient, with a distal tumor, shows that resection is the cure and that IgG4-related disease can imitate cancer.

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4. 04

   Liver Tumors and Transplantation: Transplant Care

   Liver transplant care runs on a calendar and on rules for what MELD cannot measure. The episode begins with referral at a first decompensation or a MELD of 15, then covers MELD 3.0, the evaluation, vaccines before transplant, and sarcopenia. It moves to exception points for cancer within Milan and for lung syndromes, the review board, and what each donor type means. After transplant, complications are read by time since surgery, with rejection diagnosed by biopsy, CMV prevented, and drug toxicities matched to each agent. It closes with late kidney injury and cancers, recurrence of sclerosing cholangitis, hepatitis B and C, autoimmune hepatitis, and MASH, and the tacrolimus interactions to check whenever a drug is added.

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Key topics

• ·Imaging-first approach to benign liver lesions
• ·Hemangioma and Kasabach-Merritt syndrome
• ·Focal nodular hyperplasia and gadoxetate MRI
• ·Hepatic adenoma associations and subtypes
• ·Resection criteria for adenoma
• ·Adenoma surveillance and adenomatosis
• ·Adenoma in men and anabolic steroid liver injury
• ·Peliosis hepatis
• ·Nodular regenerative hyperplasia
• ·Board traps for benign liver lesions
• ·Surveillance in cirrhosis, including cured hepatitis C
• ·Ultrasound with AFP every six months
• ·Switching to MRI or CT when ultrasound fails
• ·Hepatitis B surveillance without cirrhosis
• ·Groups who are not surveyed
• ·LI-RADS categories and LR-5 diagnosis
• ·LR-M lesions and tumor in vein
• ·BCLC staging
• ·Resection, ablation, and transplant criteria
• ·TACE, TARE, and mRECIST
• ·Systemic therapy and the variceal check
• ·Three anatomic types of cholangiocarcinoma
• ·Bismuth-Corlette classification
• ·Imaging versus hepatocellular carcinoma
• ·Risk factors
• ·Limits of CA 19-9
• ·Transplant contraindication in intrahepatic tumors
• ·First-line therapy and molecular testing
• ·Mayo protocol for hilar tumors
• ·Safe tissue sampling