Liver Tumors and Transplantation

Episode one of the Liver Tumors and Transplant chapter runs the benign masses on a single decision: imaging appearance plus hormonal or drug context usually settles the diagnosis, and biopsy enters only when the imaging is atypical or the lesion has real malignant potential. Peripheral nodular enhancement filling inward is a hemangioma, hepatobiliary-phase retention is focal nodular hyperplasia, and hepatobiliary-phase darkening is an adenoma. From the adenoma you stratify by sex, size, growth, and beta-catenin status, because that subtype is what turns a benign mass into a resection case. The two edge entities, nodular regenerative hyperplasia and peliosis hepatis, round out the pattern-recognition set.

Episode two works hepatocellular carcinoma as one continuous algorithm built on a single override: a new lesion in a cirrhotic or chronic hepatitis B liver is HCC until proven otherwise. Surveillance goes to every Child-Pugh A or B cirrhotic and to high-risk hepatitis B, by ultrasound and AFP every six months timed to the tumor doubling time and the curative-size cutoffs. LI-RADS turns that finding into a diagnosis, with the definite category diagnostic by imaging alone and the two special categories forcing biopsy or excluding transplant. The BCLC system then turns the diagnosis into the treatment the physiology will actually permit, from resection and ablation, through transplant within Milan, to locoregional therapy and first-line atezolizumab plus bevacizumab for advanced disease.

Episode three organizes cholangiocarcinoma anatomy first, biology second, because where the tumor sits dictates the operation and the transplant path. Intrahepatic disease is resected when possible and is a transplant contraindication over two centimeters, distal disease gets a Whipple, and perihilar disease is resected when resectable with a narrow unresectable subset going through a neoadjuvant-then-transplant protocol. The imaging is delayed enhancement without washout, the mirror image of HCC, because the fibrous stroma traps contrast rather than letting it run through. CA 19-9 is a trend rather than a yes-or-no and is unusable in Lewis-negative patients, so sclerosing cholangitis patients with a new dominant stricture get FISH on the brushings when cytology fails them.

Episode four follows a patient across the whole transplant arc, organized by two clocks: the allocation score that triages who is sickest, and time itself, which orders both the drop in immunosuppression intensity and the shift from acute risk to cumulative toxicity. The calculated score does the primary triage with its sex and albumin corrections fixing real undervaluation, the workup confirms the operation can succeed medically, infectiously, and psychosocially, and the exception points cover the diseases the labs cannot see. Donor type then sets the complication profile, immunosuppression intensity organizes the early timeline of rejection and opportunistic infection with CMV dominant, and cumulative toxicity organizes the late timeline. The original disease returns in a pattern specific to its cause, which is why surveillance continues indefinitely.