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Oudmaijer CAJ, Sprakel J, Sprengers D, Wiese KA, Tintel NV, Franken JI, Terkivatan T, Porte RJ, IJzermans JNM. Hepatocellular adenomas with severe intra-abdominal bleeding, related to an underlying coagulation disorder: a case report. J Med Case Rep 2024; 18:367. [PMID: 39135148 PMCID: PMC11321172 DOI: 10.1186/s13256-024-04709-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 07/18/2024] [Indexed: 08/15/2024] Open
Abstract
BACKGROUND Hepatocellular adenoma is a rare benign liver tumor. Typically, hepatocellular adenomas are solitary and are found in young women who use estrogen-containing contraceptives. The occurrence of multiple hepatocellular adenoma has been linked to higher body mass index, and as the prevalence of overweight increases, multiple hepatocellular adenomas are seen more often. An hepatocellular adenoma does not always necessitate treatment, as they can regress under conservative strategies. In incidental cases, an adenoma presents owing to bleeding, which is mostly self-limiting. If it is not, embolization of hepatic involved vessels is indicated. CASE PRESENTATION In this case report, we discuss a 42-year old Caucasian woman with multiple hepatocellular bleeds, treated by multiple endovascular procedures. After the first embolization of an adenoma in the right liver lobe, a second bleed occurred in the left lobe, necessitating additional endovascular intervention. During admittance, treatment was complicated by pulmonary embolism and a pneumonia. During follow-up, our patient was diagnosed with antiphospholipid syndrome. CONCLUSION Hepatocellular adenoma is a rare diagnosis that requires centralized expertise. This particular case illustrates the complexity of treatment strategies for associated intra-abdominal bleeding and possible complications. Although liver adenoma is often an incidental finding, it can also result in significant morbidity. Centralization of treatment leads to expertise in managing complex treatment strategies.
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Affiliation(s)
- C A J Oudmaijer
- Erasmus MC Transplant Institute, Department of Surgery, Division of Hepatobiliary and Transplantation Surgery, University Medical Center Rotterdam, Office RG-220, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands.
- Oncode Institute, Utrecht, the Netherlands.
| | - J Sprakel
- Erasmus MC Transplant Institute, Department of Surgery, Division of Hepatobiliary and Transplantation Surgery, University Medical Center Rotterdam, Office RG-220, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - D Sprengers
- Department of Gastro-Enterology, Division of Hepatology, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - K A Wiese
- Department of Radiology, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - N Vogelaar- Tintel
- Erasmus MC Transplant Institute, Department of Surgery, Division of Hepatobiliary and Transplantation Surgery, University Medical Center Rotterdam, Office RG-220, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - J I Franken
- Erasmus MC Transplant Institute, Department of Surgery, Division of Hepatobiliary and Transplantation Surgery, University Medical Center Rotterdam, Office RG-220, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - T Terkivatan
- Erasmus MC Transplant Institute, Department of Surgery, Division of Hepatobiliary and Transplantation Surgery, University Medical Center Rotterdam, Office RG-220, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - R J Porte
- Erasmus MC Transplant Institute, Department of Surgery, Division of Hepatobiliary and Transplantation Surgery, University Medical Center Rotterdam, Office RG-220, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - J N M IJzermans
- Erasmus MC Transplant Institute, Department of Surgery, Division of Hepatobiliary and Transplantation Surgery, University Medical Center Rotterdam, Office RG-220, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
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Pompili M, Ardito F, Brunetti E, Cabibbo G, Calliada F, Cillo U, de Sio I, Golfieri R, Grova M, Gruttadauria S, Guido M, Iavarone M, Manciulli T, Pagano D, Pettinari I, Santopaolo F, Soresi M, Colli A. Benign liver lesions 2022: Guideline for clinical practice of Associazione Italiana Studio del Fegato (AISF), Società Italiana di Radiologia Medica e Interventistica (SIRM), Società Italiana di Chirurgia (SIC), Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB), Associazione Italiana di Chirurgia Epatobilio-Pancreatica (AICEP), Società Italiana Trapianti d'Organo (SITO), Società Italiana di Anatomia Patologica e Citologia Diagnostica (SIAPEC-IAP) - Part II - Solid lesions. Dig Liver Dis 2022; 54:1614-1622. [PMID: 36089523 DOI: 10.1016/j.dld.2022.08.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/11/2022] [Accepted: 08/18/2022] [Indexed: 12/30/2022]
Abstract
Benign liver lesions are increasingly diagnosed in daily clinical practice due to the growing use of imaging techniques for the study of the abdomen in patients who have non-specific symptoms and do not have an increased risk of hepatic malignancy. They include simple or parasitic hepatic cysts and solid benign tumors which differ widely in terms of prevalence, clinical relevance, symptoms and natural history and often lead to significant clinical problems relating to diagnosis and clinical management. Following the need to have updated guidelines on the management of benign focal liver lesions, the Scientific Societies mainly involved in their management have promoted the drafting of a new dedicated document. This document was drawn up according to the present Italian rules and methodologies necessary to produce clinical, diagnostic, and therapeutic guidelines based on evidence. Here we present the second part of the guideline, concerning the diagnosis and clinical management of hemangioma, focal nodular hyperplasia, and hepatocellular adenoma.
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Affiliation(s)
- Maurizio Pompili
- Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Gemelli, Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Facoltà di Medicina e Chirurgia, "Agostino Gemelli", Largo A. Gemelli, 8, Roma 00168, Italy.
| | - Francesco Ardito
- Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Gemelli, Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Facoltà di Medicina e Chirurgia, "Agostino Gemelli", Largo A. Gemelli, 8, Roma 00168, Italy
| | - Enrico Brunetti
- Dipartimento di Scienze Cliniche, Chirurgiche, Diagnostiche e Pediatriche, Università di Pavia. Unità di Malattie Infettive e Immunologia, IRCCS Fondazione Ospedale San Matteo, Pavia, Italy
| | - Giuseppe Cabibbo
- Sezione di Gastroenterologia e Epatologia, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro" (PROMISE) Università di Palermo, Italy
| | - Fabrizio Calliada
- Dipartimento di Radiologia, Fondazione Policlinico San Matteo IRCCS, Università di Pavia, Italy
| | - Umberto Cillo
- Chirurgia Epatobiliare e Trapianto di Fegato, Ospedale Universitario di Padova, Italy
| | - Ilario de Sio
- Epatogastroenterologia, Università della Campania Luigi Vanvitelli, Facoltà di Medicina e Chirurgia, Napoli, Italy
| | - Rita Golfieri
- Dipartimento di Radiologia, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Mauro Grova
- Sezione di Gastroenterologia e Epatologia, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro" (PROMISE) Università di Palermo, Italy
| | - Salvatore Gruttadauria
- Dipartimento per la cura e lo studio delle Patologie Addominali e dei Trapianti Addominali, Dipartimento di Chirurgia e Specialità Medico-Chirurgiche, IRCCS-ISMETT-UPMCI, Palermo, Università di Catania, Italy
| | - Maria Guido
- Dipartimento di Anatomia Patologica, Azienda ULSS2 Marca Trevigiana, Treviso, Italy; Dipartimento di Medicina - DIMED, Università di Padova, Italy
| | - Massimo Iavarone
- Divisione di Gastroenterologia ed Epatologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Tommaso Manciulli
- Dipartimento di Medicina Sperimentale e Clinica - Università degli Studi, Firenze, Italy
| | - Duilio Pagano
- Dipartimento per la cura e lo studio delle Patologie Addominali e dei Trapianti Addominali, IRCCS-ISMETT-UPMC, Palermo, Italy
| | - Irene Pettinari
- Dipartimento di Radiologia, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Francesco Santopaolo
- Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Gemelli, Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Facoltà di Medicina e Chirurgia, "Agostino Gemelli", Largo A. Gemelli, 8, Roma 00168, Italy
| | - Maurizio Soresi
- Medicina Interna, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro" (PROMISE) Università di Palermo, Italy
| | - Agostino Colli
- Dipartimento di Medicina Trasfusionale ed Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
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Harrington J, Duncan G, DAngelo K, Gable BD. Multidisciplinary Simulation Improves Resident Confidence for Pregnant Patients Requiring Surgical Intervention. Cureus 2022; 14:e23454. [PMID: 35494927 PMCID: PMC9038506 DOI: 10.7759/cureus.23454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 03/24/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction: Hepatocellular adenomas are a rare but serious cause of bleeding, which is further complicated by pregnancy. Interprofessional cooperation is a key component of residency education, thus simulations designed to integrate multiple programs are mutually beneficial. This simulation details surgical and obstetric management of a pregnant patient in hemorrhagic shock from a bleeding hepatocellular adenoma. Objectives for the study were to evaluate learners’ confidence to 1) prioritize the care of a pregnant patient with hemoperitoneum and hemorrhagic shock, 2) demonstrate interdisciplinary collaboration with other specialties, 3) apply massive transfusion protocol (MTP) in the appropriate clinical setting, and 4) analyze critical decisions for evaluating pregnant females with severe abdominal pain. Methods: Obstetric, general surgery, and anesthesia residents, along with labor and delivery nurses participated in a simulated clinical scenario that focused on the management of a pregnant patient in hemorrhagic shock. The learners evaluated the educational session using a standard Return on Investment in Learning survey immediately following the session. Results: A total of 23 residents and medical students gave feedback on the experience. The main learning objectives were met with increased confidence in the four learning objectives by 77.3-95.4% of responders. Overall, greater than 90% of participants felt the simulation was relevant to their training and realistic, with 100% responding that the course provided new, or clarified existing information for them. Conclusion: A multidisciplinary simulation-based educational intervention was successful in improving learner confidence in managing a complicated surgical emergency in a pregnant patient with inter-residency cooperation.
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Oudmaijer CAJ, Berk KA, van der Louw EJTM, de Man R, van der Lelij AJ, Hoeijmakers JHJ, IJzermans J. KETOgenic diet therapy in patients with HEPatocellular adenoma: study protocol of a matched interventional cohort study. BMJ Open 2022; 12:e053559. [PMID: 35168973 PMCID: PMC8852750 DOI: 10.1136/bmjopen-2021-053559] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Hepatocellular adenoma (HCA) is an uncommon, solid and benign liver lesion, mainly occurring in women using oral contraceptives. Patients are advised to stop using oral contraceptives (OC) and, as overweight is frequently observed, dietary restrictions. Metabolic changes are assumed to play a role and it has been suggested that diet may help to reduce tumour size. A low-calorie ketogenic diet (LCKD) has been shown to induce weight loss and multiple metabolic changes, including the reduction of portal insulin concentrations, which downregulates hepatic growth hormone receptors. Weight reduction and an LCKD can potentially reduce the size of HCAs. METHODS AND ANALYSIS We designed a matched, interventional cohort study to determine the effect of an LCKD on the regression of HCA. The study population consists of female subjects with an HCA, 18-50 years of age, body mass index>25 kg/m2, who are entering a surveillance period including cessation of OC. A historical control group will be matched. The intervention consists of an LCKD (approximately 35 g carbohydrate/1500 kcal/day) for 3 months, followed by a less strict LCKD for 3 months (approximately 60 g carbohydrate/1500 kcal/day). Main study endpoint is the diameter of the HCA after 6 months, as compared with the historic control group. Secondary endpoints include adherence, quality of life, change in physical activity, liver fat content, body weight, body composition and resting energy expenditure. ETHICS AND DISSEMINATION The medical ethical committee has approved the study protocol, patient information files and consent procedure and other study-related documents and procedures. TRIAL REGISTRATION NUMBER NL75014.078.20; Pre-results. https://www.trialregister.nl/trial/9092.
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Affiliation(s)
- Christiaan Albert Johan Oudmaijer
- Erasmus MC Transplant Institute, Department of Surgery, Division of Hepatobiliary and Transplantation Surgery, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
- Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Kirsten Anna Berk
- Department of Internal Medicine, Division of Dietetics, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | | | - Rob de Man
- Department of Hepato-Gastroenterology, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - Aart-Jan van der Lelij
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - Jan Hendrik Jozef Hoeijmakers
- Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Erasmus MC Cancer Institute, Department of Molecular Genetics, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - Jan IJzermans
- Erasmus MC Transplant Institute, Department of Surgery, Division of Hepatobiliary and Transplantation Surgery, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
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Successful resection of a huge hepatocellular adenoma. Clin J Gastroenterol 2021; 14:1544-1549. [PMID: 34287778 DOI: 10.1007/s12328-021-01486-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 07/17/2021] [Indexed: 10/20/2022]
Abstract
Hepatocellular adenoma (HCA) is a rare benign liver tumor that has been reported to occur particularly more often in women who use contraceptives. A 72-year-old woman with no history of using contraceptives presented to our hospital for further examination of a liver tumor. Contrast-enhanced computed tomography and gadoxetic acid-enhanced magnetic resonance imaging revealed a huge solitary hepatic tumor measuring 83 × 76 mm in segments 4, 5, and 8. The differential diagnoses were cholangiocarcinoma and mixed-type hepatocellular carcinoma. Percutaneous needle biopsies were performed twice, and no malignant components were found. Central bi-segmentectomy of the liver was successfully performed. Immunohistochemical staining showed that β-catenin was positive in the membrane of the tumor cells, while fatty acid-binding protein, glutamine synthetase, and amyloid A were negative. These results led to a diagnosis of HCA, hepatocyte nuclear factor-1α-inactivated subtype. The patient's postoperative course was uneventful, and she developed no recurrence for 10 months after surgery. We experienced a rare case of benign HCA. Obtaining a correct preoperative diagnosis is sometimes difficult at the first evaluation. HCA should be considered as a differential diagnosis of liver tumors.
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Greenbaum LE, Ukomadu C, Tchorz JS. Clinical translation of liver regeneration therapies: A conceptual road map. Biochem Pharmacol 2020; 175:113847. [PMID: 32035080 DOI: 10.1016/j.bcp.2020.113847] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 02/04/2020] [Indexed: 02/07/2023]
Abstract
The increasing incidence of severe liver diseases worldwide has resulted in a high demand for curative liver transplantation. Unfortunately, the need for transplants by far eclipses the availability of suitable grafts leaving many waitlisted patients to face liver failure and often death. Routine use of smaller grafts (for example left lobes, split livers) from living or deceased donors could increase the number of life-saving transplants but is often limited by the graft versus recipient weight ratio defining the safety margins that minimize the risk of small for size syndrome (SFSS). SFSS is a severe complication characterized by failure of a small liver graft to regenerate and occurs when a donor graft is insufficient to meet the metabolic demand of the recipient, leading to liver failure as a result of insufficient liver mass. SFSS is not limited to transplantation but can also occur in the setting of hepatic surgical resections, where life-saving large resections of tumors may be limited by concerns of post-surgical liver failure. There are, as yet no available pro-regenerative therapies to enable liver regrowth and thus prevent SFSS. However, there is optimism around targeting factors and pathways that have been identified as regulators of liver regeneration to induce regrowth in vivo and ex vivo for clinical use. In this commentary, we propose a roadmap for developing such pro-regenerative therapy and for bringing it into the clinic. We summarize the clinical indications, preclinical models, pro-regenerative pathways and safety considerations necessary for developing such a drug.
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Affiliation(s)
- Linda E Greenbaum
- Novartis Institutes for Biomedical Research, Novartis Pharma AG, East Hanover, NJ, United States.
| | - Chinweike Ukomadu
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, Cambridge, MA, United States.
| | - Jan S Tchorz
- Novartis Institutes for BioMedical Research, Novartis Pharma AG, Basel, Switzerland.
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Growth of hepatocellular adenoma during pregnancy: A prospective study. J Hepatol 2020; 72:119-124. [PMID: 31550458 DOI: 10.1016/j.jhep.2019.09.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 08/28/2019] [Accepted: 09/10/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND & AIMS The presence of hepatocellular adenoma (HCA) in pregnant women requires special consideration, as it has been reported to carry the risk of growth and clinically significant haemorrhage. In this prospective study we assessed aspects of growth of HCA <5 cm during pregnancy. METHODS This was a multicentre prospective cohort study in pregnant women with suspected HCA <5 cm on imaging. Definitive HCA diagnosis was established by MRI with hepatobiliary contrast agents (LCE-MRI), preferably before pregnancy. If at study inclusion a definitive diagnosis was lacking, LCE-MRI was performed after giving birth. Growth of the adenoma (defined as an increase of >20%) was closely monitored with ultrasound examinations throughout pregnancy. RESULTS Of the 66 women included, 18 were excluded from analysis because postpartum LCE-MRI did not confirm the diagnosis of HCA and showed the lesion to be focal nodular hyperplasia. The remaining 48 women, with an HCA confirmed by LCE-MRI, were followed during 51 pregnancies. Median age was 30 years (IQR 27-33) and median body mass index 31.9 kg/m2 (IQR 26.3-36.6). Growth of HCA was seen in 13 of the pregnancies (25.5%); the median increase was 14 mm (IQR 8-19). One woman whose HCA grew to >70 mm successfully underwent transarterial embolization at week 26 of pregnancy to prevent further growth. The other 50 pregnancies proceeded without complications. CONCLUSION This study suggests that an HCA <5 cm confers minimal risk to a pregnant woman and none to her child. HCA increased in size during a quarter of pregnancies, so we recommend close monitoring with ultrasound examinations, enabling intervention if needed. In light of the large proportion of misdiagnosed HCA, LCE-MRI should be performed to prevent unnecessary anxiety in women with a benign liver lesion. LAY SUMMARY The presence of hepatocellular adenoma in pregnant women requires special consideration, as it carries the risk of growth and haemorrhage. In this study we followed 48 patients with hepatocellular adenoma <5 cm during 51 pregnancies and found that a hepatocellular adenoma during pregnancy confers minimal risk to the pregnant woman and none to her child.
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van Rosmalen BV, Klompenhouwer AJ, de Graeff JJ, Haring MPD, de Meijer VE, Rifai L, Dokmak S, Rawashdeh A, Abu Hilal M, de Jong MC, Dejong CHC, Doukas M, de Man RA, IJzermans JNM, van Delden OM, Verheij J, van Gulik TM. Safety and efficacy of transarterial embolization of hepatocellular adenomas. Br J Surg 2019; 106:1362-1371. [PMID: 31313827 PMCID: PMC6771810 DOI: 10.1002/bjs.11213] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 02/26/2019] [Accepted: 03/25/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hepatocellular adenoma (HCA) larger than 5 cm in diameter has an increased risk of haemorrhage and malignant transformation, and is considered an indication for resection. As an alternative to resection, transarterial embolization (TAE) may play a role in prevention of complications of HCA, but its safety and efficacy are largely unknown. The aim of this study was to assess outcomes and postembolization effects of selective TAE in the management of HCA. METHODS This retrospective, multicentre cohort study included patients aged at least 18 years, diagnosed with HCA and treated with TAE. Patient characteristics, 30-day complications, tumour size before and after TAE, symptoms before and after TAE, and need for secondary interventions were analysed. RESULTS Overall, 59 patients with a median age of 33.5 years were included from six centres; 57 of the 59 patients were women. Median tumour size at time of TAE was 76 mm. Six of 59 patients (10 per cent) had a major complication (cyst formation or sepsis), which could be resolved with minimal therapy, but prolonged hospital stay. Thirty-four patients (58 per cent) were symptomatic at presentation. There were no significant differences in symptoms before TAE and symptoms evaluated in the short term (within 3 months) after TAE (P = 0·134). First follow-up imaging was performed a median of 5·5 months after TAE and showed a reduction in size to a median of 48 mm (P < 0·001). CONCLUSION TAE is safe, can lead to adequate size reduction of HCA and, offers an alternative to resection in selected patients.
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Affiliation(s)
- B V van Rosmalen
- Department of Surgery, Amsterdam University Medical Centres, location AMC, Amsterdam, the Netherlands
| | - A J Klompenhouwer
- Department of Surgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - J Jaap de Graeff
- Department of Surgery, Amsterdam University Medical Centres, location AMC, Amsterdam, the Netherlands
| | - M P D Haring
- Division of Hepatopancreatobiliary Surgery and Liver Transplantation, University Medical Centre Groningen, University of Groningen, Maastricht, the Netherlands
| | - V E de Meijer
- Division of Hepatopancreatobiliary Surgery and Liver Transplantation, University Medical Centre Groningen, University of Groningen, Maastricht, the Netherlands
| | - L Rifai
- Division of Hepatopancreatobiliary Surgery, Beaujon Hospital, University of Paris, Clichy, France
| | - S Dokmak
- Division of Hepatopancreatobiliary Surgery, Beaujon Hospital, University of Paris, Clichy, France
| | - A Rawashdeh
- Division of Hepatopancreatobiliary Surgery, Southampton General Hospital, Southampton, UK
| | - M Abu Hilal
- Division of Hepatopancreatobiliary Surgery, Southampton General Hospital, Southampton, UK
| | - M C de Jong
- Division of Hepatopancreatobiliary Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - C H C Dejong
- Department of Surgery and School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre, Maastricht, the Netherlands.,Department of Surgery, Universitätsklinikum Aachen, Aachen, Germany
| | - M Doukas
- Department of Pathology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - R A de Man
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - J N M IJzermans
- Department of Surgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - O M van Delden
- Department of Interventional Radiology, Amsterdam University Medical Centres, location AMC, Amsterdam, the Netherlands
| | - J Verheij
- Department of Pathology, Amsterdam University Medical Centres, location AMC, Amsterdam, the Netherlands
| | - T M van Gulik
- Department of Surgery, Amsterdam University Medical Centres, location AMC, Amsterdam, the Netherlands
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Renzulli M, Clemente A, Tovoli F, Cappabianca S, Bolondi L, Golfieri R. Hepatocellular adenoma: An unsolved diagnostic enigma. World J Gastroenterol 2019; 25:2442-2449. [PMID: 31171888 PMCID: PMC6543239 DOI: 10.3748/wjg.v25.i20.2442] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 03/30/2019] [Accepted: 04/19/2019] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular adenoma (HCA) is a rare benign liver tumour associated with the use of oral contraceptives or other steroid medications which occurs predominantly in young and middle-aged women. Unlike other benign liver tumours, an HCA may be complicated by bleeding and malignant transformation. HCAs have been divided into four subtypes based on molecular and pathological features: hepatocyte nuclear factor 1α-mutated HCA, inflammatory HCA, β-catenin-mutated HCA, and unclassified HCA. β-catenin-mutated HCA has the highest risk of haemorrhage or malignant transformation. In the latest upgrade of the guidelines regarding the management of benign liver tumours published in 2016 by the European Association for the Study of the Liver, magnetic resonance imaging (MRI) was recognized to be superior to all other imaging modalities in detecting HCAs and in being able to subtype HCAs up to 80%, with positive identification of 1α-mutated HCA or inflammatory HCA achievable with > 90% specificity. This review analyzed the imaging features of HCA using MRI with hepato-specific contrast agents, focusing on the limitations in the HCA characterization.
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Affiliation(s)
- Matteo Renzulli
- Radiology Unit, Department of Experimental, Diagnostic and Speciality Medicine, Sant’Orsola Hospital, University of Bologna, Bologna 40138, Italy
| | - Alfredo Clemente
- Radiology and Radiotherapy Unit, Department of Precision Medicine, University of Campania "L. Vanvitelli", Naples 80138, Italy
| | - Francesco Tovoli
- Unit of Internal Medicine, Department of Medical and Surgical Sciences, University of Bologna, Bologna 40138, Italy
| | - Salvatore Cappabianca
- Radiology and Radiotherapy Unit, Department of Precision Medicine, University of Campania "L. Vanvitelli", Naples 80138, Italy
| | - Luigi Bolondi
- Unit of Internal Medicine, Department of Medical and Surgical Sciences, University of Bologna, Bologna 40138, Italy
| | - Rita Golfieri
- Radiology Unit, Department of Experimental, Diagnostic and Speciality Medicine, Sant’Orsola Hospital, University of Bologna, Bologna 40138, Italy
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Lange A, Muniraj T, Aslanian HR. Endoscopic Ultrasound for the Diagnosis and Staging of Liver Tumors. Gastrointest Endosc Clin N Am 2019; 29:339-350. [PMID: 30846157 DOI: 10.1016/j.giec.2018.12.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Endoscopic ultrasound examination may provide complementary information to cross-sectional imaging in lesions of the liver, portal vein, and surrounding lymph nodes. With fine needle aspiration, endoscopic ultrasound examination is a powerful tool for the diagnosis of focal liver lesions and has usefulness in the evaluation of indeterminate liver lesions. Endoscopic ultrasound examination may influence hepatocellular cancer staging and Endoscopic ultrasound examination with fine needle aspiration of locoregional nodes and portal vein thromboses changes management. Contrast-enhanced endoscopic ultrasound examination and endoscopic ultrasound examination elastography are likely to expand the usefulness of endoscopic ultrasound examination in evaluating liver malignancy with technologic improvements.
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Affiliation(s)
- Andrew Lange
- Department of Internal Medicine, Yale University School of Medicine, Yale Primary Care Center, 789 Howard Avenue, New Haven, CT 06511, USA
| | - Thiruvengadam Muniraj
- Section of Digestive Diseases, Laboratory for Medicine and Pediatrics, Yale University School of Medicine, 15 York Street, New Haven, CT 06510, USA
| | - Harry R Aslanian
- Section of Digestive Diseases, Yale University School of Medicine, PO Box 208056, 333 Cedar Street, New Haven, CT 06520, USA.
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11
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Dietrich CF, Tannapfel A, Jang HJ, Kim TK, Burns PN, Dong Y. Ultrasound Imaging of Hepatocellular Adenoma Using the New Histology Classification. ULTRASOUND IN MEDICINE & BIOLOGY 2019; 45:1-10. [PMID: 30396597 DOI: 10.1016/j.ultrasmedbio.2018.06.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 06/20/2018] [Accepted: 06/25/2018] [Indexed: 06/08/2023]
Abstract
Hepatocellular adenoma is a rare benign liver tumor. Predisposing factors include hepatic storage diseases and some genetic conditions. A new histology-based classification has been proposed but to date, the corresponding ultrasound imaging features have not been reported. Here we review the new classification scheme and discuss the corresponding features on contrast-enhanced ultrasound imaging.
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Affiliation(s)
- Christoph F Dietrich
- Medizinische Klinik 2, Caritas-Krankenhaus Bad Mergentheim, Bad Mergentheim, Germany; Ultrasound Department, First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
| | | | - Hyun-Jung Jang
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Tae Kyoung Kim
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Peter N Burns
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Yi Dong
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
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12
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Buzzetti E, Parikh PM, Gerussi A, Tsochatzis E. Gender differences in liver disease and the drug-dose gender gap. Pharmacol Res 2017; 120:97-108. [PMID: 28336373 DOI: 10.1016/j.phrs.2017.03.014] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 03/17/2017] [Accepted: 03/17/2017] [Indexed: 12/14/2022]
Abstract
Although gender-based medicine is a relatively recent concept, it is now emerging as an important field of research, supported by the finding that many diseases manifest differently in men and women and therefore, might require a different treatment. Sex-related differences regarding the epidemiology, progression and treatment strategies of certain liver diseases have long been known, but most of the epidemiological and clinical trials still report results only about one sex, with consequent different rate of response and adverse reactions to treatment between men and women in clinical practice. This review reports the data found in the literature concerning the gender-related differences for the most representative hepatic diseases.
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Affiliation(s)
- Elena Buzzetti
- UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK.
| | - Pathik M Parikh
- UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Alessio Gerussi
- UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK; Internal Medicine Unit, Department of Experimental and Clinical Medical Sciences, University of Udine, Udine, Italy
| | - Emmanuel Tsochatzis
- UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
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13
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EASL Clinical Practice Guidelines on the management of benign liver tumours. J Hepatol 2016; 65:386-98. [PMID: 27085809 DOI: 10.1016/j.jhep.2016.04.001] [Citation(s) in RCA: 317] [Impact Index Per Article: 35.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 04/05/2016] [Indexed: 02/06/2023]
Affiliation(s)
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- European Association for the Study of the Liver (EASL), The EASL Building – Home of European Hepatology, 7 rue Daubin, CH 1203 Geneva, Switzerland.
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14
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Algarni AA, Alshuhri AH, Alonazi MM, Mourad MM, Bramhall SR. Focal liver lesions found incidentally. World J Hepatol 2016; 8:446-451. [PMID: 27028805 PMCID: PMC4807306 DOI: 10.4254/wjh.v8.i9.446] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 01/23/2016] [Accepted: 03/14/2016] [Indexed: 02/06/2023] Open
Abstract
Incidentally found focal liver lesions are a common finding and a reason for referral to hepatobiliary service. They are often discovered in patients with history of liver cirrhosis, colorectal cancer, incidentally during work up for abdominal pain or in a trauma setting. Specific points should considered during history taking such as risk factors of liver cirrhosis; hepatitis, alcohol consumption, substance exposure or use of oral contraceptive pills and metabolic syndromes. Full blood count, liver function test and tumor markers can act as a guide to minimize the differential diagnosis and to categorize the degree of liver disease. Imaging should start with B-mode ultrasound. If available, contrast enhanced ultrasound is a feasible, safe, cost effective option and increases the ability to reach a diagnosis. Contrast enhanced computed tomography should be considered next. It is more accurate in diagnosis and better to study anatomy for possible operation. Contrast enhanced magnetic resonance is the gold standard with the highest sensitivity. If doubt still remains, the options are biopsy or surgical excision.
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15
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Lee SY, Kingham TP, LaGratta MD, Jessurun J, Cherqui D, Jarnagin WR, Kluger MD. PET-avid hepatocellular adenomas: incidental findings associated with HNF1-α mutated lesions. HPB (Oxford) 2016; 18:41-8. [PMID: 26776850 PMCID: PMC4750225 DOI: 10.1016/j.hpb.2015.07.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 07/06/2015] [Accepted: 07/07/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hepatocellular adenoma (HCA) is the second most common benign liver neoplasm and occurs predominantly in women in their reproductive years. Positron emission tomography (PET) using [18F] fluorodeoxyglucose (FDG) is commonly used in cancer staging, surveillance and evaluation of treatment response. PET-avid HCA are rare and can be falsely interpreted as malignancies. METHODS A retrospective review of four institutions' database was performed to identify the PET-avid HCAs with clinico-pathological correlation. RESULTS Nine patients with histological proven PET-avid HCA was identified. Eight out of 9 patients were female with a median age at diagnosis of 44 years. All patients' tumors with available histological subtyping (8/8) were HNF1-α mutated and had no inflammatory changes; 6 out the 9 lesions had prominent (>50%) steatotic changes. CONCLUSION Hepatocellular adenomas, specifically the HNF1-α subtype, can cause false-positive PET findings when seeking to identify malignancy. Concomitantly, PET-CT may have the potential to identify the HCA histopathologic variant with the lowest malignant and hemorrhagic potential.
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Affiliation(s)
- Ser Yee Lee
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, United States,Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - T. Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, United States
| | - Maria D. LaGratta
- New York-Presbyterian Hospital – Weill Cornell Medical Center, Diagnostic Radiology, 1305 York Avenue, New York, NY 10021, United States
| | - Jose Jessurun
- New York Presbyterian Hospital – Weill Cornell Medical College, Surgical Pathology, 525 East 68th Street, New York, NY 10065, United States
| | - Daniel Cherqui
- Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
| | - William R. Jarnagin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, United States
| | - Michael D. Kluger
- New York Presbyterian Hospital Columbia Presbyterian Medical Center, Department of Surgery, 161 Fort Washington Avenue 823, New York, NY 10024, United States,Correspondence Michael D. Kluger, New York Presbyterian Hospital Columbia Presbyterian Medical Center, Department of Surgery, 161 Fort Washington Avenue 823, New York, NY 10024, United States.
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16
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Lee SY, Kingham TP, LaGratta MD, Jessurun J, Cherqui D, Jarnagin WR, Kluger MD. PET-avid hepatocellular adenomas: incidental findings associated with HNF1-α mutated lesions. HPB (Oxford) 2015:n/a-n/a. [PMID: 26472264 DOI: 10.1111/hpb.12489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 07/07/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepatocellular adenoma (HCA) is the second most common benign liver neoplasm and occurs predominantly in women in their reproductive years. Positron-emission tomography (PET) using [18F] fluorodeoxyglucose (FDG) is commonly used in cancer staging, surveillance and evaluation of the treatment response. PET-avid HCA is rare and can be falsely interpreted as malignancies. METHODS A retrospective review of four institutions' database was performed to identify the PET-avid HCAs with clinico-pathological correlation. RESULTS Nine patients with histological proven PET-avid HCA was identified. Eight out of nine patients were female with a median age at diagnosis of 44 years. All patients' tumours with available histological subtyping (8/8) were HNF1-α mutated and had no inflammatory changes; six out the nine lesions had prominent (>50%) steatotic changes. CONCLUSION Hepatocellular adenomas, specifically the HNF1-α subtype, can cause false-positive PET findings when seeking to identify malignancy. Concomitantly, PET-CT may have the potential to identify the HCA histopathological variant with the lowest malignant and haemorrhagic potential.
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Affiliation(s)
- Ser Yee Lee
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, New York Presbyterian Hospital Weill-Cornell Medical Center, New York, NY, USA
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - T Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Maria D LaGratta
- Diagnostic Radiology, New York-Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA
| | - Jose Jessurun
- Surgical Pathology, New York Presbyterian Hospital - Weill Cornell Medical College, New York, NY, USA
| | - Daniel Cherqui
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, New York Presbyterian Hospital Weill-Cornell Medical Center, New York, NY, USA
- Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
| | - William R Jarnagin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael D Kluger
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, New York Presbyterian Hospital Weill-Cornell Medical Center, New York, NY, USA
- Department of Surgery, New York Presbyterian Hospital Columbia Presbyterian Medical Center, New York, NY, USA
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17
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Thomeer MG, E Bröker ME, de Lussanet Q, Biermann K, Dwarkasing RS, de Man R, Ijzermans JN, de Vries M. Genotype-phenotype correlations in hepatocellular adenoma: an update of MRI findings. Diagn Interv Radiol 2015; 20:193-9. [PMID: 24509184 DOI: 10.5152/dir.2013.13315] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hepatocellular adenoma (HCA) is a generally benign liver tumor with the potential for malignancy and bleeding. HCAs are categorized into four subtypes on the basis of genetic and pathological features: hepatocyte nuclear factor 1α-mutated HCA, β-catenin-mutated HCA, inflammatory HCA, and unclassified HCA. Magnetic resonance imaging (MRI) plays an important role in the diagnosis, subtype characterization, and detection of HCA complications; it is also used to differentiate HCA from focal nodular hyperplasia. In this review, we present an overview of the genetic abnormalities, oncogenesis, and typical and atypical MRI findings of specific subtypes of HCA using contrast-enhanced MRI with or without hepatobiliary contrast agents (gadobenate dimeglumine and gadoxetate disodium). We also discuss their different management implications after diagnosis.
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Affiliation(s)
- Maarten G Thomeer
- From the Departments of Radiology Medical Center Zuiderzee, Lelystad, the Netherlands.
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18
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Inaba K, Sakaguchi T, Kurachi K, Mori H, Tao H, Nakamura T, Takehara Y, Baba S, Maekawa M, Sugimura H, Konno H. Hepatocellular adenoma associated with familial adenomatous polyposis coli. World J Hepatol 2012; 4:322-326. [PMID: 23293720 PMCID: PMC3536841 DOI: 10.4254/wjh.v4.i11.322] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Revised: 08/27/2012] [Accepted: 10/22/2012] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular adenoma (HCA) is a benign liver tumor that most frequently occurs in young women using oral contraceptives. We report a rare case of HCA in a 29 years old female with familial adenomatous polyposis (FAP). The first proband was her sister, who underwent a total colectomy and was genetically diagnosed as FAP. A tumor, 3.0 cm in diameter, was detected in the right lobe of the liver during a screening study for FAP. A colonoscopy and gastroendoscopy revealed numerous adenomatous polyps without carcinoma. The patient underwent a total colectomy and ileo-anal anastomosis and hepatic posterior sectoriectomy. The pathological findings of the liver tumor were compatible with HCA. The resected specimen of the colon revealed multiple colonic adenomatous polyps. Examination of genetic alteration revealed a germ-line mutation of the adenomatous polyposis coli (APC) gene. Inactivation of the second APC allele was not found. Other genetic alterations in the hepatocyte nuclear factor 1 alpha and β-catenin gene, which are reported to be associated with HCA, were not detected. Although FAP is reported to be complicated with various neoplasias in extracolic organs, only six cases of HCA associated with FAP, including the present case, have been reported. Additional reports will establish the precise mechanisms of HCA development in FAP patients.
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Affiliation(s)
- Keisuke Inaba
- Keisuke Inaba, Department of Surgery, Iwata City Hospital, Iwata 438-8500, Japan
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Rodríguez de Lope C, Reig ME, Darnell A, Forner A. Approach of the patient with a liver mass. Frontline Gastroenterol 2012; 3:252-262. [PMID: 28839677 PMCID: PMC5369839 DOI: 10.1136/flgastro-2012-100146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 07/09/2012] [Accepted: 07/11/2012] [Indexed: 02/04/2023] Open
Abstract
The widespread use of imaging techniques has led to an increased diagnosis of incidental liver tumours. The differential diagnosis is extremely broad since it may range from benign asymptomatic lesions to malignant neoplasms. The correct characterisation of a liver mass has become a diagnostic challenge for most clinicians. They can be divided in two major categories; cystic lesions, usually benign with excellent long-term outcome, and solid lesions, in which malignancy should be excluded. A particular population is those patients with cirrhosis, who have high risk for hepatocellular carcinoma development. Dynamic imaging techniques have a pivotal role in the diagnostic work-up of liver tumours, allowing a confident diagnosis in most cases. If imaging is not conclusive, a biopsy should be requested to obtain a definitive diagnosis.
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Affiliation(s)
- Carlos Rodríguez de Lope
- Barcelona Clinic Liver Cancer (BCLC) Group, Liver Unit, Hospital Clinic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - María E Reig
- Barcelona Clinic Liver Cancer (BCLC) Group, Liver Unit, Hospital Clinic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Anna Darnell
- Barcelona Clinic Liver Cancer (BCLC) Group, Radiology Department, Hospital Clinic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Alejandro Forner
- Barcelona Clinic Liver Cancer (BCLC) Group, Liver Unit, Hospital Clinic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
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20
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van Aalten SM, Bröker MEE, Busschbach JJV, de Koning HJ, de Man RA, Steegers EAP, Steyerberg EW, Terkivatan T, Ijzermans JNM. Pregnancy and liver adenoma management: PALM-study. BMC Gastroenterol 2012; 12:82. [PMID: 22748109 PMCID: PMC3503786 DOI: 10.1186/1471-230x-12-82] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Accepted: 06/16/2012] [Indexed: 01/01/2023] Open
Abstract
Background Hepatocellular adenoma (HCA) in pregnant women requires special considerations because of the risk of hormone induced growth and spontaneous rupture, which may threaten the life of both mother and child. Due to scarcity of cases there is no evidence-based algorithm for the evaluation and management of HCA during pregnancy. Most experts advocate that women with HCA should not get pregnant or advise surgical resection before pregnancy. Whether it is justified to deny a young woman a pregnancy, as the biological behavior may be less threatening than presumed depends on the incidence of HCA growth and the subsequent clinical events during pregnancy. We aim to investigate the management and outcome of HCA during pregnancy and labor based on a prospectively acquired online database in the Netherlands. Methods/design The Pregnancy And Liver adenoma Management (PALM) - study is a multicentre prospective study in three cohorts of pregnant patients. In total 50 pregnant patients, ≥ 18 years of age with a radiologically and/or histologically proven diagnosis of HCA will be included in the study. Radiological diagnosis of HCA will be based on contrast enhanced MRI. Lesions at inclusion must not exceed 5 cm. The study group will be compared to a healthy control group of 63 pregnant patients and a group of 63 pregnant patients with diabetes mellitus without HCA. During their pregnancy HCA patients will be closely monitored by means of repetitive ultrasound (US) at 14, 20, 26, 32 and 38 weeks of gestation and 6 and 12 weeks postpartum. Both control groups will undergo US of the liver at 14 weeks of gestation to exclude HCA lesions in the liver. All groups will be asked to fill out quality of life related questionnaires. Discussion The study will obtain information about the behaviour of HCA during pregnancy, the clinical consequences for mother and child and the impact of having a HCA during pregnancy on the health related quality of life of these young women. As a result of this study we will propose a decision-making model for the management of HCA during pregnancy. Trial registration Dutch trial register: NTR3034
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21
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van Aalten SM, Witjes CDM, de Man RA, Ijzermans JNM, Terkivatan T. Can a decision-making model be justified in the management of hepatocellular adenoma? Liver Int 2012; 32:28-37. [PMID: 22098685 DOI: 10.1111/j.1478-3231.2011.02667.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Accepted: 09/14/2011] [Indexed: 12/15/2022]
Abstract
During recent years, there was a great development in the area of hepatocellular adenomas (HCA), especially regarding the pathological subtype classification, radiological imaging and management during pregnancy. This review discusses the current knowledge about diagnosis and treatment modalities of HCA and proposes a decision-making model for HCA. A Medline search of studies relevant to epidemiology, histopathology, complications, imaging and management of HCA lesions was undertaken. References from identified articles were hand-searched for further relevant articles.
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Bland embolization in the treatment of hepatic adenomas: preliminary experience. J Vasc Interv Radiol 2011; 22:795-9; quiz 800. [PMID: 21616432 DOI: 10.1016/j.jvir.2011.02.027] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2009] [Revised: 02/20/2011] [Accepted: 02/22/2011] [Indexed: 12/16/2022] Open
Abstract
The study presents preliminary, retrospective experience with bland embolization for hepatic adenomas (HAs) with the use of tris-acryl gelatin microspheres. Eight patients underwent bland embolization for biopsy-proven HAs. A biopsy specimen was taken from only one lesion when multiple lesions were present. Seventeen embolizations were performed for abdominal pain, active bleeding, or prophylaxis against bleeding. Five patients underwent multiple procedures. Technical success rate was 100%. Median follow-up was 24 months (range, 10-40 mo). No growth was observed at follow-up in any treated lesion, and many lesions (13 of 16) regressed. Bland embolization may be safely used for treatment of abdominal pain and bleeding from HAs.
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van Vledder MG, van Aalten SM, Terkivatan T, de Man RA, Leertouwer T, Ijzermans JNM. Safety and efficacy of radiofrequency ablation for hepatocellular adenoma. J Vasc Interv Radiol 2011; 22:787-93. [PMID: 21616431 DOI: 10.1016/j.jvir.2011.02.024] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2010] [Revised: 02/13/2011] [Accepted: 02/17/2011] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To investigate the safety and efficacy of radiofrequency (RF) ablation for the treatment of hepatocellular adenoma (HCA). MATERIALS AND METHODS From 2000 to 2009, 170 patients with HCA were referred to a single tertiary hepatobiliary center. Medical records of 18 patients treated with RF ablation were retrospectively analyzed. RESULTS All patients were female, and the majority had a history of hormonal contraceptive use. Ten patients (56%) had multiple HCAs, with a median number of two lesions (range, one to 12) per patient. Median size of HCA at the time of RF ablation was 3.0 cm (range, 0.8-7.3 cm). A total of 45 HCAs were ablated in 32 sessions (open, n = 4; percutaneous, n = 28). RF ablation was complete after the first session in 26 HCAs (57.8%), and the majority of patients underwent multiple RF ablation sessions to fully ablate all HCAs. Major complications developed in two patients. CONCLUSIONS RF ablation can be used effectively in the treatment of HCA. However, multiple sessions are often required, and signs of residual adenoma might persist in some patients despite repetitive treatment. RF ablation might be especially beneficial in cases not amenable to surgery or in patients who would require major hepatic resection otherwise.
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Affiliation(s)
- Mark G van Vledder
- Department of Surgery, Erasmus Medical Center, 'S Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
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van Aalten SM, Verheij J, Terkivatan T, Dwarkasing RS, de Man RA, Ijzermans JNM. Validation of a liver adenoma classification system in a tertiary referral centre: implications for clinical practice. J Hepatol 2011; 55:120-5. [PMID: 21145863 DOI: 10.1016/j.jhep.2010.10.030] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Revised: 09/27/2010] [Accepted: 10/13/2010] [Indexed: 01/01/2023]
Abstract
BACKGROUND & AIMS A molecular and pathological classification system for hepatocellular adenomas (HCA) was recently introduced and four major subgroups were identified. We aimed to validate this adenoma classification system and to determine the clinical relevance of the subtypes for surgical management. METHODS Paraffin fixed liver tissue slides and resection specimens of patients radiologically diagnosed as HCA were retrieved from the department of pathology. Immunostainings included liver-fatty acid binding protein (L-FABP), serum amyloid A (SAA), C-reactive protein (CRP), glutamine synthetase (GS) and β-catenin. RESULTS From 2000 to 2010, 58 cases (71 lesions) were surgically resected. Fourteen lesions were diagnosed as focal nodular hyperplasia with a characteristic map-like staining pattern of GS. Inflammatory HCA expressing CRP and SAA was documented in 36 of 57 adenomas (63%). Three of these inflammatory adenomas were also β-catenin positive as well as GS positive and only one was CRP and SAA and GS positive. We identified eleven L-FABP-negative HCA (19%) and four β-catenin positive HCA (7%), without expression of CRP and SAA and with normal L-FABP staining, one of which was also GS positive. Six HCA were unclassifiable (11%). In three patients multiple adenomas of different subtypes were found. CONCLUSIONS Morphology and additional immunohistochemical markers can discriminate between different types of HCA in>90% of cases and this classification, including the identification of β-catenin positive adenomas may have important implications in the decision for surveillance or treatment. Interpretation of nuclear staining for β-catenin can be difficult due to uneven staining distribution or focal nuclear staining and additional molecular biology may be required.
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Affiliation(s)
- Susanna M van Aalten
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
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25
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Management of hepatocellular adenoma during pregnancy. J Hepatol 2011; 54:553-8. [PMID: 21094555 DOI: 10.1016/j.jhep.2010.07.022] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2010] [Revised: 06/24/2010] [Accepted: 07/07/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Hepatocellular adenoma in pregnant women requires special considerations because of the risk of hormone induced growth and rupture. To prevent these potential lethal complications, pregnancy is either often discouraged or the surgical resection of large adenomas is recommended. It may be questioned whether it is justified to deny a young woman a pregnancy, as the biological behaviour of hepatocellular adenoma may be less threatening than presumed. In this study we establish the management of hepatocellular adenoma during pregnancy based on our own experience and literature. METHODS Twelve women with documented hepatocellular adenoma were closely monitored during a total of 17 pregnancies between 2000 and 2009. Their files were reviewed. RESULTS In four cases, hepatocellular adenomas grew during pregnancy, requiring a Caesarean section in one patient (two pregnancies) at 36 and 34 weeks because of an assumed high risk of rupture. In one case radiofrequency ablation therapy was applied in the first trimester to treat a hormone sensitive hepatocellular adenoma, thereby excluding potential growth later in pregnancy. No intervention was performed in the other 14 cases and all pregnancies had an uneventful course with a successful maternal and fetal outcome. CONCLUSIONS A "wait and see" management may be advocated in pregnant women presenting with a hepatocellular adenoma. In women with large tumours or in whom hepatocellular adenoma had complicated previous pregnancies, surgical resection may be recommended. In women with smaller adenomas it may no longer be necessary to discourage pregnancy.
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Fernández Luque A, Urra I, López-Martos R. [A 41 year old woman with renal insufficiency and a mass in the liver]. Med Clin (Barc) 2010; 135:519-26. [PMID: 20537360 DOI: 10.1016/j.medcli.2010.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2010] [Accepted: 02/16/2010] [Indexed: 11/19/2022]
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Stoot JHMB, Coelen RJS, de Jong MC, Dejong CHC. Malignant transformation of hepatocellular adenomas into hepatocellular carcinomas: a systematic review including more than 1600 adenoma cases. HPB (Oxford) 2010; 12:509-22. [PMID: 20887318 PMCID: PMC2997656 DOI: 10.1111/j.1477-2574.2010.00222.x] [Citation(s) in RCA: 242] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Malignant transformation of hepatocellular adenomas (HCAs) into hepatocellular carcinomas (HCCs) has been reported repeatedly and is considered to be one of the main reasons for surgical treatment. However, its actual risk is currently unknown. OBJECTIVE To provide an estimation of the frequency of malignant transformation of HCAs and to discuss its clinical implications. METHODS A systematic literature search was conducted using the following databases: The Cochrane Hepatobiliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, MEDLINE and EMBASE. RESULTS One hundred and fifty-seven relevant series and 17 case reports (a total of 1635 HCAs) were retrieved, reporting an overall frequency of malignant transformation of 4.2%. Only three cases (4.4%) of malignant alteration were reported in a tumour smaller than 5 cm in diameter. DISCUSSION Malignant transformation of HCAs into HCCs remains a rare phenomenon with a reported frequency of 4.2%. A better selection of exactly those patients presenting with an HCA with an amplified risk of malignant degeneration is advocated in order to reduce the number of liver resections and thus reducing the operative risk for these predominantly young patients. The Bordeaux adenoma tumour markers are a promising method of identifying these high-risk adenomas.
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Affiliation(s)
- Jan HMB Stoot
- Department of Surgery, Maastricht University Medical CentreSittard,Department of Surgery, Orbis Medical CentreSittard
| | - Robert JS Coelen
- Department of Surgery, Maastricht University Medical CentreSittard,Department of Surgery, Orbis Medical CentreSittard
| | | | - Cornelis HC Dejong
- Department of Surgery, Maastricht University Medical CentreSittard,Maastricht University, Nutrim School for Nutrition, Toxicology and MetabolismMaastricht, the Netherlands
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28
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Abstract
BACKGROUND Spontaneous hepatic rupture is a rare clinical event associated with various pathologies of the liver. Most series to date reported the incidence and characteristics of a single etiology. METHODS Data were collected for all patients admitted with spontaneous hepatic rupture from 1995 to 2007. RESULTS Ten patients met the study criteria. Hepatocellular adenoma was the cause of the rupture in six female patients, in their second to fourth decade. In the remaining patients, the ruptures were because of hepatocellular carcinoma in two, metastatic gastrointestinal stromal tumor in one, and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) in one. Nine out of 10 patients were treated surgically. CONCLUSION Spontaneous hepatic rupture requires a high index of suspicion for a correct and timely diagnosis. Outcome is potentially grave and greatly depends on the underlying condition.
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29
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Kamaya A, Maturen KE, Tye GA, Liu YI, Parti NN, Desser TS. Hypervascular Liver Lesions. Semin Ultrasound CT MR 2009; 30:387-407. [DOI: 10.1053/j.sult.2009.06.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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30
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Assy N, Assy N, Samuel N, Lerman A, Nseir W. Approach to Solid Liver Masses in the Cirrhotic Patient. Gastroenterology Res 2009; 2:259-267. [PMID: 27956969 PMCID: PMC5139772 DOI: 10.4021/gr2009.10.1314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/17/2009] [Indexed: 12/27/2022] Open
Abstract
Liver masses in cirrhosis are increasingly being recognized with the use of new imaging modalities. The majority of these lesions are detected by ultrasound, enhanced CT and MRI. The most likely diagnosis of a solid liver lesion in a cirrhotic liver is hepatocellular carcinoma, followed by high grade or low grade dysplastic nodule, and cholangiocarcinoma. Lymphoma and liver metastasis are extremely rare. Diagnosis is made by contrast enhanced ultrasound, multi detector (MDCT) and MRI. Fine needle core biopsy (FNCB) or aspiration (FNAB) or both may be required in doubtful cases. If uncertainty persists on the nature of the lesion, surgical liver resection is recommended. This review discusses the main characteristics of the most common solid liver masses in cirrhotic patient.
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Affiliation(s)
- Nimer Assy
- Liver Unit, Ziv Medical Center, Safed, Israel; Technion Institute, Haifa, Israel
| | - Najib Assy
- Liver Unit, Ziv Medical Center, Safed, Israel
| | - Nir Samuel
- Liver Unit, Ziv Medical Center, Safed, Israel
| | - Aracdi Lerman
- Department of Radiology, Ziv Medical Centre, Safed, Israel
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31
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Assy N, Nasser G, Djibre A, Beniashvili Z, Elias S, Zidan J. Characteristics of common solid liver lesions and recommendations for diagnostic workup. World J Gastroenterol 2009; 15:3217-27. [PMID: 19598296 PMCID: PMC2710776 DOI: 10.3748/wjg.15.3217] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Due to the widespread clinical use of imaging modalities such as ultrasonography, computed tomography and magnetic resonance imaging (MRI), previously unsuspected liver masses are increasingly being found in asymptomatic patients. This review discusses the various characteristics of the most common solid liver lesions and recommends a practical approach for diagnostic workup. Likely diagnoses include hepatocellular carcinoma (the most likely; a solid liver lesion in a cirrhotic liver) and hemangioma (generally presenting as a mass in a non-cirrhotic liver). Focal nodular hyperplasia and hepatic adenoma should be ruled out in young women. In 70% of cases, MRI with gadolinium differentiates between these lesions. Fine needle core biopsy or aspiration, or both, might be required in doubtful cases. If uncertainty persists as to the nature of the lesion, surgical resection is recommended. If the patient is known to have a primary malignancy and the lesion was found at tumor staging or follow up, histology is required only when the nature of the liver lesion is doubtful.
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32
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Hepatocellular adenoma in a male with familial adenomatous polyposis coli. ACTA ACUST UNITED AC 2009; 16:571-4. [PMID: 19288049 DOI: 10.1007/s00534-009-0050-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2008] [Accepted: 03/17/2008] [Indexed: 02/07/2023]
Abstract
Hepatocellular adenoma (HA) is a benign liver tumor most frequently occurring in young women using oral contraceptives. We report a rare case of HA in a 27-year-old male patient with familial adenomatous polyposis (FAP). The patient underwent a total colectomy and ileo-rectal anastomosis for FAP in 2003. A preoperative computed tomography scan of the abdomen disclosed a tumor in the left-lobe of the liver, 5.8 cm in diameter. Pathologic examination of a needle biopsy disclosed HA, but he had never used anabolic steroids or other known inducers of HA. The size of the liver mass gradually increased to 8.5 cm during a follow-up period of 38 months, and a left hepatectomy was performed in 2006. Pathology of the resected specimen confirmed the diagnosis of HA. Although FAP is known to be complicated with neoplasia in various extracolonic organs, only five reported cases of HA have developed in patients with FAP, including this case. This is the first report of HA to develop in a male FAP patient.
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33
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Use of accumulation images obtained by arterial-phase contrast-enhanced harmonic grayscale ultrasonography to evaluate tumor vessels in focal nodular hyperplasia and other hepatic tumors. J Med Ultrason (2001) 2007; 34:3-10. [PMID: 27278173 DOI: 10.1007/s10396-006-0132-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2006] [Accepted: 07/19/2006] [Indexed: 01/21/2023]
Abstract
PURPOSE To evaluate the usefulness of accumulation images obtained by arterial-phase contrast-enhanced harmonic grayscale ultrasonography for examining tumor vessels in focal nodular hyperplasia and other hepatic lesions. METHODS After injecting a galactose-palmitic acid contrast agent, we used conventional contrast-enhanced harmonic grayscale ultrasonography to scan 8 focal nodular hyperplasia lesions, 21 hepatocellular carcinomas, 2 cholangiocellular carcinomas, 12 hepatic metastases, 17 hemangiomas, and 2 angiomyolipomas. We then accumulated and superimposed consecutive conventional images (accumulation images) and compared them with corresponding conventional images to evaluate serial images of hepatic tumor vessels. RESULTS Serial tumor vessel findings obtained from accumulation images were superior to those obtained from conventional images in 51 (77%) of the 66 various hepatic lesions examined. Evidence of the spoke-wheel artery pattern in 2 of the 8 focal nodular hyperplasia lesions was equivocal in the conventional images, but accumulation images clearly depicted serial images of spoke-wheel arteries, clearly indicating a diagnosis of focal nodular hyperplasia. Accumulation images allowed the diagnosis of two additional focal nodular hyperplasia lesions that had not been correctly diagnosed as focal nodular hyperplasia from conventional images. CONCLUSION Accumulation images obtained by arterial-phase contrast-enhanced harmonic grayscale ultrasonography are useful in evaluating hepatic tumor vessels, especially spoke-wheel arteries, which specifically indicate focal nodular hyperplasia.
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34
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van der Windt DJ, Kok NFM, Hussain SM, Zondervan PE, Alwayn IPJ, de Man RA, IJzermans JNM. Case-orientated approach to the management of hepatocellular adenoma. Br J Surg 2006; 93:1495-502. [PMID: 17051603 DOI: 10.1002/bjs.5511] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Abstract
Background
Treatment of suspected hepatocellular adenoma (HA) remains controversial. The aim of this study was to evaluate the management of HA at a time when magnetic resonance imaging (MRI) and computed tomography (CT) are highly sensitive methods for diagnosing HA.
Methods
Between January 2000 and January 2005, data from 48 consecutive women with HA (median age 36 years) were prospectively collected. The protocol for diagnostic work-up consisted of multiphasic MRI or CT. Management was observation if the tumour was smaller than 5 cm and surgical intervention if it was 5 cm or larger.
Results
The median follow-up was 24 (range 3–73) months. Sixteen (33 per cent) patients had invasive procedures because of tumour size 5 cm or larger, malignant characteristics or haemorrhage. The remaining 32 patients (67 per cent) were observed; haemorrhage and malignant degeneration did not occur and none of the lesions showed enlargement after withdrawal of oral contraceptives. Multiple HAs were found in 32 (67 per cent) patients; liver steatosis was significantly more common in these patients than in those with a solitary lesion (59 versus 19 per cent; P = 0·008).
Conclusion
Observation of adenomas smaller than 5 cm is justified because of improved radiological reliability. Resection should be reserved for patients with malignant tumour characteristics or with single lesions 5 cm or larger.
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Affiliation(s)
- D J van der Windt
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
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35
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Psatha EA, Semelka RC, Armao D, Woosley JT, Firat Z, Schneider G. Hepatocellular adenomas in men: MRI findings in four patients. J Magn Reson Imaging 2005; 22:258-64. [PMID: 16028257 DOI: 10.1002/jmri.20375] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To demonstrate both MRI and histopathological findings of hepatocellular adenomas (HCAs) in men. MATERIALS AND METHODS HCAs in four men are reported. All patients underwent MR studies at 1.5T including serial gadolinium-enhanced gradient echo imaging. RESULTS Three men had solitary non-hemorrhagic adenomas that exhibited a uniform capillary blush with no central scar, and uniform fading of the tumor to near isointensity with the liver parenchyma by one minute. One of the subjects had uniform fat content as shown by uniform low signal on out-of-phase images. One patient had a solitary hemorrhagic adenoma that measured 17 cm in diameter and was heterogeneous on all sequences. Two of the four patients had a history of anabolic steroid use, and in the other two patients no underlying explanation for the tumor was found. CONCLUSIONS Although three of the four patients had tumors that exhibited uniform homogeneous tumor blush and rapid fading of enhancement, because HCAs are rare in men and resemble hepatocellular carcinoma (HCC) in appearance, our findings suggest that histological confirmation of HCAs may not be avoidable in men.
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Affiliation(s)
- Evlampia A Psatha
- Department of Radiology, University of North Carolina, 101 Manning Drive, Chapel Hill, NC 27599, USA
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36
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Abstract
Liver biopsy is traditionally the 'gold standard' for the evaluation of liver diseases. There are several situations in which its role is being challenged. In hepatitis C, liver biopsy helps assess prognosis and treatment candidacy. An important exception is genotype 2 or 3 because treatment is more likely to succeed and therapy is relatively short in duration. For hepatitis B, liver biopsy gives some prognostic information, but serologic tests and hepatic biochemical tests are the primary determinants of treatment candidacy. Non-alcoholic fatty liver disease can be accurately diagnosed without a liver biopsy and, furthermore, there are no specific therapies available. The role of liver biopsy to assess methotrexate-associated hepatotoxicity remains controversial. Finally, patients with focal liver lesions usually do not require biopsy and, in the case of hepatocellular carcinoma, biopsy carries a risk of needle-track seeding. In short, the need for liver biopsy depends on the specific situation and should be performed when there is sufficient uncertainty about diagnosis, severity of disease, prognosis, and treatment decisions.
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Affiliation(s)
- M S Campbell
- Hospital of the University of Pennsylvania, Division of Gastroenterology, Philadelphia, PA, USA
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37
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Affiliation(s)
- Silvana C Faria
- Department of Radiology, Division of Diagnostic Imaging, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Box 57, Houston, TX 77030, USA
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38
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Abstract
Numerous diagnostic modalities may be employed in the assessment of liver disease. In this article we outline radiologic approaches to several clinical problems including the evaluation of abnormal liver function tests and jaundice, evaluation of liver masses, and management of the patient with cirrhosis and portal hypertension.
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Affiliation(s)
- Sarathchandra I Reddy
- Division of Gastroenterology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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39
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Porayko MK, Choudhary C. Benign Neoplasms of the Liver. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2001; 4:479-491. [PMID: 11696274 DOI: 10.1007/s11938-001-0013-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Tumors of the liver often are discovered incidentally in asymptomatic individuals during diagnostic imaging or exploratory laparotomy performed for alternative reasons. Hemangiomas are the most common benign liver tumors, followed in prevalence by focal nodular hyperplasia (FNH); other benign tumors are rare. The growth and development of hemangiomas, FNH, and hepatic adenomas especially, have been linked to hormonal (eg, estrogen) stimulation. Differentiating between benign and malignant neoplasms of the liver can be challenging. Radiologic imaging is essential for preliminary identification and classification of hepatic tumors, but tissue biopsy or surgical excision sometimes is required for a definitive diagnosis. Individuals with hemangioma or FNH usually are asymptomatic, have a benign course, and can be managed conservatively. In contrast, hepatic adenomas need to be followed more carefully and often are excised to provide symptomatic relief, remove the risk of rupture, and avoid potential malignant transformation. Liver transplantation in patients with benign hepatic neoplasms is exceedingly uncommon, and is recommended only when alternative methods of treatment are not feasible or have failed to control significant symptoms.
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Affiliation(s)
- Michael K. Porayko
- Liver Division, Department of Medicine, Thomas Jefferson University, 132 South 10th Street, Suite 4, Thompson Building, Philadelphia, PA 19107, USA.
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40
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Grazioli L, Federle MP, Brancatelli G, Ichikawa T, Olivetti L, Blachar A. Hepatic adenomas: imaging and pathologic findings. Radiographics 2001; 21:877-92; discussion 892-4. [PMID: 11452062 DOI: 10.1148/radiographics.21.4.g01jl04877] [Citation(s) in RCA: 278] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Hepatocellular adenoma is a rare benign lesion that is most often seen in young women with a history of oral contraceptive use. It is typically solitary, although multiple lesions have been reported, particularly in patients with glycogen storage disease and liver adenomatosis. Because of the risk of hemorrhage and malignant transformation, hepatocellular adenomas must be identified and treated promptly. At pathologic analysis, hepatocellular adenoma is usually a well-circumscribed, nonlobulated lesion, and at gross examination, resected adenomas frequently demonstrate areas of hemorrhage and infarction. Most adenomas are not specifically diagnosed at ultrasonography (US) and are usually further evaluated with computed tomography (CT) or other imaging modalities. Color Doppler US may help differentiate hepatocellular adenoma from focal nodular hyperplasia. Multiphasic helical CT allows more accurate detection and characterization of focal hepatic lesions. Hepatocellular adenomas are typically bright on T1-weighted magnetic resonance images and predominantly hyperintense relative to liver on T2-weighted images. The prognosis of hepatic adenoma is not well established. Criteria that guide treatment include the number and size of the lesions, the presence of symptoms, and the surgical risk incurred by the patient. Understanding the imaging appearance of hepatocellular adenoma can help avoid misdiagnosis and facilitate prompt, effective treatment.
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Affiliation(s)
- L Grazioli
- Department of Radiology, University of Brescia, Brescia, Italy
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41
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Abstract
This article focuses on the origin, diagnosis, and management of focal benign lesions of the liver. The most common lesions include cavernous hemangioma, focal nodular hyperplasia, hepatic adenoma, and nodular regenerative hyperplasia. A number of less frequent occurring lesions are also discussed. In general, the common lesions can be diagnosed by radiologic imaging, but occasionally biopsies are required, and surgical removal is often needed.
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Affiliation(s)
- J F Trotter
- University of Colorado Health Sciences Center, Division of Gastroenterology/Hepatology, Denver, Colorado, USA
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42
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Reddy KR, Kligerman S, Levi J, Livingstone A, Molina E, Franceschi D, Badalamenti S, Jeffers L, Tzakis A, Schiff ER. Benign and Solid Tumors of the Liver: Relationship to Sex, Age, Size of Tumors, and Outcome. Am Surg 2001. [DOI: 10.1177/000313480106700217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
From 1983 through 1997, our center diagnosed 130 cases of benign neoplasms: 27 with focal nodular hyperplasia (FNH), 25 with hepatic adenoma, 71 with cavernous hemangioma, and seven with mixed tumors of different diagnoses. Most often these lesions were seen in females [female-to-male ratio (f/m): 5.5/1]. Hepatic adenomas and mixed tumors were seen exclusively in females and FNH predominantly in females (f/m: 26/1). Hemangiomas, however, were not uncommon in men (f/m: 52/19) relative to the other tumors ( P < 0.001). Furthermore patients with hemangioma were older (mean age: 49 years) whereas patients with hepatic adenoma, FNH, and mixed tumors were often younger (mean age: 33, 35, and 44 years respectively; P < 0.004). Oral contraceptive steroid use was related by 21 of 25 patients (84%) with hepatic adenoma, 22 of 26 (85%) females with FNH, five of seven (71%) females with mixed tumors, and 10 of 52 (19%) patients with hemangioma. Ninety-five of the 130 patients (73%) had one or more symptoms. There was no statistically significant correlation between symptoms and the size of the lesion, the final diagnosis, and whether there were solitary or multiple masses. Three of 25 (12%) with hepatic adenoma presented with rupture, and one of 27 (4%) with FNH had such a consequence. None of the hemangiomas presented with rupture or progressed to such a state. One patient with hepatic adenoma (4%) had a focus of malignancy. Surgical removal of benign tumors was performed in 82 of 130 patients (63%), and there was one operative mortality (1.2%) in a patient who had a caudate lobe FNH. The types of surgical procedures included segmentectomy (62%), lobectomy (34%), and trisegmentectomy (4%). In two of 84 patients who had undergone laparotomy resection was not technically possible. Resection is recommended in all cases of hepatic adenoma because of fear of rupture or associated focus of malignancy. FNH was not observed to undergo a malignant transformation and will rarely rupture. Surgery is only recommended for symptomatic hemangioma, and size of the lesion is not a criterion for excision.
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Affiliation(s)
- K. Rajender Reddy
- Departments of Medicine, Center for Liver Diseases, Division of Hepatology, University of Miami School of Medicine and Veterans Administration Medical Center, Miami, Florida
| | - Seth Kligerman
- Departments of Medicine, Center for Liver Diseases, Division of Hepatology, University of Miami School of Medicine and Veterans Administration Medical Center, Miami, Florida
| | - Joe Levi
- Departments of Surgery, Center for Liver Diseases, Division of Hepatology, University of Miami School of Medicine and Veterans Administration Medical Center, Miami, Florida
| | - Alan Livingstone
- Departments of Surgery, Center for Liver Diseases, Division of Hepatology, University of Miami School of Medicine and Veterans Administration Medical Center, Miami, Florida
| | - Enrique Molina
- Departments of Medicine, Center for Liver Diseases, Division of Hepatology, University of Miami School of Medicine and Veterans Administration Medical Center, Miami, Florida
| | - Dido Franceschi
- Departments of Surgery, Center for Liver Diseases, Division of Hepatology, University of Miami School of Medicine and Veterans Administration Medical Center, Miami, Florida
| | - Salvatore Badalamenti
- Departments of Medicine, Center for Liver Diseases, Division of Hepatology, University of Miami School of Medicine and Veterans Administration Medical Center, Miami, Florida
| | - Lennox Jeffers
- Departments of Medicine, Center for Liver Diseases, Division of Hepatology, University of Miami School of Medicine and Veterans Administration Medical Center, Miami, Florida
| | - Andreas Tzakis
- Departments of Surgery, Center for Liver Diseases, Division of Hepatology, University of Miami School of Medicine and Veterans Administration Medical Center, Miami, Florida
| | - Eugene R. Schiff
- Departments of Medicine, Center for Liver Diseases, Division of Hepatology, University of Miami School of Medicine and Veterans Administration Medical Center, Miami, Florida
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Groell R, Kugler C, Aschauer M, Rienmueller R, Stauber R, Trauner M, Mischinger HJ. Quantitative perfusion parameters of focal nodular hyperplasia and normal liver parenchyma as determined by electron beam tomography. Br J Radiol 1995; 68:1185-9. [PMID: 8542223 DOI: 10.1259/0007-1285-68-815-1185] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Eight patients with known focal nodular hyperplasia (FNH) were studied by electron beam tomography (EBT) in a multisection flow mode at defined time intervals after intravenous contrast agent injection. Various regions of interest (ROIs) were defined in the areas of FNH, normal liver parenchyma, aorta and portal vein. In each ROI density changes were measured and plotted against time. In those time-density curves (TDCs) the slope, the time of maximal enhancement and the absolute density value of peak enhancement were determined. Arterial tissue perfusion was calculated for normal liver parenchyma and FNH. In all eight patients significant differences in peak density (123.88 +/- 18.92 HU vs 102.5 +/- 15.49 HU, p = 0.012), in the rate of arterial contrast enhancement (252.63 +/- 28.05 HU min-1 vs 38.88 +/- 4.19 HU min-1, p = 0.012) and in the arterial tissue perfusion (1.36 +/- 0.19 ml min-1 cm-3 vs 0.21 +/- 0.03 ml min-1 cm-3, p = 0.012) between FNH and normal liver parenchyma were found. Perfusion values of normal liver parenchyma correspond to those determined by inert gas clearance. Further studies will determine the practicability of this quantitative method in the evaluation of global and other focal liver diseases.
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Affiliation(s)
- R Groell
- Department of Radiology, University of Graz, Austria
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