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Kountouri I, Kokkali E, Giotas A, Katsarelas I, Dimasis P. A Rare Case of a Spontaneously Ruptured Hepatocellular Adenoma in the Third Trimester of Pregnancy. Cureus 2024; 16:e72447. [PMID: 39600766 PMCID: PMC11588674 DOI: 10.7759/cureus.72447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2024] [Indexed: 11/29/2024] Open
Abstract
This case report details the management of a 29-year-old primigravida who presented at 35 weeks of gestation with abdominal pain and vomiting. The patient exhibited tachycardia and fetal bradycardia, with laboratory findings indicating severe anemia and elevated liver enzymes. An emergency cesarean section was performed due to hemodynamic instability, during which a ruptured hepatocellular adenoma (HCA) was discovered, necessitating an atypical left hepatectomy. Despite successful maternal recovery, the neonate succumbed to multiple organ failure. Hepatocellular adenomas (HCA), also known as hepatic adenomas, are rare benign epithelial liver tumors that predominantly occur in women during their reproductive years and have been strongly associated with the intake of oral contraceptives. This case highlights the rare occurrence of HCA rupture during pregnancy, emphasizing the importance of prompt diagnosis and intervention to prevent life-threatening complications. Additionally, it underscores the need for careful monitoring and potential preemptive intervention in pregnant women with large HCAs due to the elevated risk of rupture.
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Affiliation(s)
- Ismini Kountouri
- Department of General Surgery, General Hospital of Katerini, Katerini, GRC
| | - Eftychia Kokkali
- Department of Radiology, General Hospital of Katerini, Katerini, GRC
| | - Amyntas Giotas
- Department of Obstetrics and Gynecology, General Hospital of Katerini, Katerini, GRC
| | | | - Periklis Dimasis
- Department of General Surgery, General Hospital of Katerini, Katerini, GRC
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Aziz H, Nordan T, Feng LR, Kwon YK, Khreiss M, Karagozian R, Schnelldorfer T. Association Between Preoperative Angioembolization and Bleeding Complications in Patients With Benign Liver Tumors: Analysis of a National Database. J Surg Res 2023; 291:536-545. [PMID: 37540971 DOI: 10.1016/j.jss.2023.07.004] [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: 01/14/2023] [Revised: 06/28/2023] [Accepted: 07/05/2023] [Indexed: 08/06/2023]
Abstract
INTRODUCTION The role of angioembolization (AE) in patients with benign liver diseases is an area of active research. This study aims to assess any difference in liver resection outcomes in patients with benign tumors dependent on utilization of preoperative AE. METHODS A retrospective cohort study of patients undergoing elective liver resections for benign liver tumors was performed using the National Surgical Quality Improvement Program database (2014-2019). Only tumors of 5 cm in size or more were included in the analysis. We categorized the patients based on preoperative AE (AE + versus AE -). The primary outcome measured included bleeding complications within 72 h. The secondary outcomes were to determine predictors of bleeding. RESULTS After propensity score matching, there were 103 patients in both groups. There was no difference in intraoperative or postoperative blood transfusions within 72 h of surgery (14.6% versus 12.6%; P = 0.68), reoperation (1.9% versus 1.9%; P = 1), or mortality (1.0% versus 0.0%; P = 1) between the two groups. Multivariate regression analysis revealed an open surgical approach (odds ratio [OR]: 4.59 confidence interval [CI]: 2.94-7.16), use of Pringle maneuver (OR: 1.7, CI: 1.26-2.310), preoperative anemia (OR: 2.79, CI: 2.05-3.80), and preoperative hypoalbuminemia (OR: 1.53 [1.14-2.05]) were associated with the need for intraoperative or postoperative blood transfusions within 72 h of surgery. CONCLUSIONS Preoperative AE was not associated with reducing intraoperative or postoperative bleeding complications or blood transfusions within 72 h after surgery.
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Affiliation(s)
- Hassan Aziz
- Division of Transplant and Hepatobiliary Surgery, University of Iowa Hospital and Clinics, Iowa City, Iowa.
| | - Taylor Nordan
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lawrence R Feng
- Division of Transplant and Hepatobiliary Surgery, University of Iowa Hospital and Clinics, Iowa City, Iowa
| | - Yong K Kwon
- Division of Transplant and Hepatobiliary Surgery, University of Washington, Seattle, Washington
| | - Mohammad Khreiss
- Division of Surgical Oncology, Banner University Medical Center, Tucson, Arizona
| | - Raffi Karagozian
- Department of Surgery, Tufts Medical Center, Boston, Massachusetts
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Aziz H, Brown ZJ, Eskander MF, Aquina CT, Baghdadi A, Kamel IR, Pawlik TM. A Scoping Review of the Classification, Diagnosis, and Management of Hepatic Adenomas. J Gastrointest Surg 2022; 26:965-978. [PMID: 35083725 DOI: 10.1007/s11605-022-05246-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 01/05/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hepatic adenomas (HA), or hepatocellular adenomas, are benign, solid liver lesions that develop in otherwise normal livers, often in the setting of increased estrogen levels. While considered a benign tumor, there is a risk for substantial complications such as hemorrhage and malignant transformation. We review the diagnosis, classification, and potential therapeutic management options for patients with HA. METHODS A scoping narrative review was conducted based on recent literature regarding classification, diagnosis, and management of HA. RESULTS While HAs are typically considered benign, complications such as hemorrhage and malignant transformation may occur in approximately 25% and 5% of patients, respectively. Recent advances in imaging and molecular profiling have allowed for the classification of HAs into subtypes allowing for patient risk stratification that helps guide management. Surgical resection should be considered in asymptomatic patients who are male, have an adenoma ≥5 cm in diameter, or have the β-catenin-activated subtype due to an increased risk of hemorrhage and/or malignant transformation. CONCLUSION Molecular profiling has aided in the stratification of patients relative to the risk of complications to predict better the potential behavior of HAs.
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Affiliation(s)
- Hassan Aziz
- Department of Surgery, Tufts University School of Medicine, Boston, MA, USA
| | - Zachary J Brown
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Mariam F Eskander
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | - Christopher T Aquina
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA
| | | | - Ihab R Kamel
- Department of Radiology, Johns Hopkins University, Baltimore, MD, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA.
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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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Klompenhouwer AJ, de Man RA, Dioguardi Burgio M, Vilgrain V, Zucman‐Rossi J, Ijzermans JNM. New insights in the management of Hepatocellular Adenoma. Liver Int 2020; 40:1529-1537. [PMID: 32464711 PMCID: PMC7383747 DOI: 10.1111/liv.14547] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/30/2020] [Accepted: 05/21/2020] [Indexed: 12/12/2022]
Abstract
Hepatocellular adenoma (HCA) are benign liver tumours that may be complicated by haemorrhage or malignant transformation to hepatocellular carcinoma. Epidemiological data are fairly outdated, but it is likely to assume that the incidence has increased over the past decades as HCA are more often incidentally found due to the more widespread use of imaging techniques and the increased incidence of obesity. Various molecular subgroups have been described. Each of these molecular subgroups are defined by specific gene mutations and pathway activations. Additionally, they are all related to specific risk factors and show a various biological behaviour. These molecular subgroups may be identified using immunohistochemistry and molecular characterization. Contrast-enhanced MRI is the recommended imaging modality to analyse patients with suspected hepatocellular adenoma allowing to determine the subtype in up to 80%. Surgical resection remains to be the golden standard in treating HCA, although resection is deemed unnecessary in a large number of cases, as studies have shown that the majority of HCA will regress over time without complications such as haemorrhage or malignant transformation occurring. It is preferable to treat patients with suspected HCA in high volume centres with combined expertise of liver surgeons, hepatologists, radiologists and (molecular) pathologists.
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Affiliation(s)
| | - Robert A. de Man
- Department of Gastroenterology and HepatologyErasmus MC University Medical CenterRotterdamthe Netherlands
| | - Marco Dioguardi Burgio
- Department of RadiologyHauts‐de‐SeineUniversity Hospitals Paris Nord Val de SeineBeaujon, APHPClichyFrance,Centre de Recherche sur l'inflammation (CRI)INSERM U1149et Université de ParisParisFrance
| | - Valerie Vilgrain
- Department of RadiologyHauts‐de‐SeineUniversity Hospitals Paris Nord Val de SeineBeaujon, APHPClichyFrance,Centre de Recherche sur l'inflammation (CRI)INSERM U1149et Université de ParisParisFrance
| | - Jessica Zucman‐Rossi
- Centre de Recherche des CordeliersSorbonne Université, INSERMUniversité de ParisParisFrance,Oncology DepartmentAPHPHôpital européen Georges PompidouParisFrance
| | - Jan N. M. Ijzermans
- Department of SurgeryErasmus MC University Medical CenterRotterdamthe Netherlands
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Hepatocellular adenomas: is there additional value in using Gd-EOB-enhanced MRI for subtype differentiation? Eur Radiol 2020; 30:3497-3506. [PMID: 32086574 PMCID: PMC8645538 DOI: 10.1007/s00330-020-06726-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 02/03/2020] [Accepted: 02/05/2020] [Indexed: 12/19/2022]
Abstract
Purpose To differentiate subtypes of hepatocellular adenoma (HCA) based on enhancement characteristics in gadoxetic acid (Gd-EOB) magnetic resonance imaging (MRI). Materials and methods Forty-eight patients with 79 histopathologically proven HCAs who underwent Gd-EOB-enhanced MRI were enrolled (standard of reference: surgical resection). Two blinded radiologists performed quantitative measurements (lesion-to-liver enhancement) and evaluated qualitative imaging features. Inter-reader variability was tested. Advanced texture analysis was used to evaluate lesion heterogeneity three-dimensionally. Results Overall, there were 19 (24%) hepatocyte nuclear factor (HNF)-1a-mutated (HHCAs), 37 (47%) inflammatory (IHCAs), 5 (6.5%) b-catenin-activated (bHCA), and 18 (22.5%) unclassified (UHCAs) adenomas. In the hepatobiliary phase (HBP), 49.5% (39/79) of all adenomas were rated as hypointense and 50.5% (40/79) as significantly enhancing (defined as > 25% intralesional GD-EOB uptake). 82.5% (33/40) of significantly enhancing adenomas were IHCAs, while only 4% (1/40) were in the HHCA subgroup (p < 0.001). When Gd-EOB uptake behavior was considered in conjunction with established MRI features (binary regression model), the area under the curve (AUC) increased from 0.785 to 0.953 for differentiation of IHCA (atoll sign + hyperintensity), from 0.859 to 0.903 for bHCA (scar + hyperintensity), and from 0.899 to 0.957 for HHCA (steatosis + hypointensity). Three-dimensional region of interest (3D ROI) analysis showed significantly increased voxel heterogeneity for IHCAs (p = 0.038). Conclusion Gd-EOB MRI is of added value for subtype differentiation of HCAs and reliably identifies the typical heterogeneous HBP uptake of IHCAs. Diagnostic accuracy can be improved significantly by the combined analysis of established morphologic MR appearances and intralesional Gd-EOB uptake. Key Points •Gd-EOB-enhanced MRI is of added value for subtype differentiation of HCA. •IHCA and HHCA can be identified reliably based on their typical Gd-EOB uptake patterns, and accuracy increases significantly when additionally taking established MR appearances into account. •The small numbers of bHCAs and UHCAs remain the source of diagnostic uncertainty.
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7
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Goel N. Malignant degeneration of hepatic adenomas to hepatocellular carcinoma. Surg Case Rep 2018. [DOI: 10.31487/j.scr.2018.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background
Hepatic adenomas (HA) are rare, benign proliferations of hepatocytes with high glycogen and fat content that lack normal hepatic architecture. In general, the long-term incidence of malignant degeneration to HCC has not been well characterized. This case report discusses a 37 male with a 10-year history of weekly anabolic steroid abuse who presented with bilobar hepatic adenomas with subsequent malignant degeneration to hepatocellular carcinoma (HCC).
Case Presentation
Our patient is a 37 old male with a 10-year history of weekly anabolic steroid abuse who presented to his primary care physician (PCP) in July 2013 with intermittent right upper quadrant (RUQ) pain. He was subsequently referred to our cancer center after abdomen/pelvis computed tomography (CT A/P) with oral and intravenous (IV) contrast at an outside hospital revealed two large hepatic masses. The larger mass in segment 2 measured 6.5 x 9.1 cm, while the segment 6/7 mass measured 7.5 x 7.6 cm. Abdomen magnetic resonance imaging (MRI) with and without IV contrast performed at our institution on July 23, 2013 confirmed the presence of the two above noted masses, which were felt to be consistent with probable HA, although HCC could not be definitely ruled out. Of note, his carcinoembryonic antigen (CEA) and alpha-fetoprotein (AFP) were within normal limits. Percutaneous, ultrasound-guided (US) biopsy of the left lobe mass was consistent with probable HA, although HCC could not be definitely ruled out.
Conclusion
We present the case of a 37-year-old male 10-year history of weekly anabolic steroid abuse who presented to us in 2013 with HA which had malignant degeneration to HCC while on surveillance over a 2-year period. This case report stresses the importance of having a high clinical suspicion for HA in patients with a history of anabolic steroid abuse and liver masses. Additionally, it reiterates that it can be difficult to differentiate HA from well-differentiated HCC on imaging and/or with a limited biopsy. Furthermore, it is important to keep in mind that the growth of a mass, especially off steroids is highly concerning for malignancy (and masses that fail to regress completely can harbor occult HCC).
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Dokmak S, Aussilhou B, Rasoaherinomenjanahary F, Ronot M, Dahdouh R, Ftériche FS, Cauchy F, Paradis V, Belghiti J, Soubrane O. Hemorrhage of hepatocellular adenoma: a complication that can be treated by conservative management without surgery. HPB (Oxford) 2018; 20:1198-1205. [PMID: 31217088 DOI: 10.1016/j.hpb.2018.06.1796] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 06/03/2018] [Accepted: 06/08/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hemorrhage is the main complication of hepatocellular adenoma (HCA). The aim of this study was to describe a single center's evolving management of patients with hemorrhagic HCA. METHOD Between 1990 and 2013, all patients with hemorrhagic HCA were included. During the study period, the management evolved from urgent surgery (period <2004) to arterial embolization with (period, 2004-2010) or without (period > 2010) delayed resection. RESULTS A total of 56 patients were identified. The median (range) size of HCA and the hematoma was 80 mm (35-160) and 50 mm (10-160). Patients were treated by urgent resection (group 1, n = 6), delayed resection with or without embolization (group 2, n = 43) and systematic embolization without surgery (group 3, n = 7). Embolization was performed in 0/6, 15/43 and 7/7 in groups 1, 2 and 3. Urgent resection was associated with higher morbidity (p < 0.001). Complete necrosis was observed in 0/6, 13/43 and 3/7 patients, and on histology it was associated with embolization (p = 0.001), a hematoma-tumor ratio > 60% (p = 0.046) and a cystic non-viable lesion before surgery (p < 0.001). CONCLUSION Hemodynamic stability can be achieved in patients presenting with hemorrhagic HCA by none surgical means. Subsequent surgery can be completely avoided with such an approach in up to 40% of patients.
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Affiliation(s)
- Safi Dokmak
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France.
| | - Béatrice Aussilhou
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France
| | | | - Maxime Ronot
- Department of Radiology, Beaujon Hospital, Clichy, France
| | - Rafik Dahdouh
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France
| | - Fadhel S Ftériche
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France
| | - François Cauchy
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France
| | - Valérie Paradis
- Department of Pathology, Beaujon Hospital, Assistance Publique Hôpitaux de Paris, University Paris VII, Clichy, France
| | - Jacques Belghiti
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France
| | - Olivier Soubrane
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France
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9
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Klompenhouwer AJ, de Man RA, Thomeer MGJ, Ijzermans JNM. Management and outcome of hepatocellular adenoma with massive bleeding at presentation. World J Gastroenterol 2017; 23:4579-4586. [PMID: 28740346 PMCID: PMC5504373 DOI: 10.3748/wjg.v23.i25.4579] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 03/13/2017] [Accepted: 04/12/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate outcome of acute management and risk of rebleeding in patients with massive hemorrhage due to hepatocellular adenoma (HCA).
METHODS This retrospective cohort study included all consecutive patients who presented to our hospital with massive hemorrhage (grade II or III) due to ruptured HCA and were admitted for observation and/or intervention between 1999-2016. The diagnosis of HCA was based on radiological findings from contrast-enhanced magnetic resonance imaging (MRI) or pathological findings from biopsy or resection of the HCA. Hemorrhage was diagnosed based on findings from computed tomography or MRI. Medical records were reviewed for demographic features, clinical presentation, tumor features, initial and subsequent management, short- and long-term complications and patient and lesion follow-up.
RESULTS All patients were female (n = 23). Treatment in the acute phase consisted of embolization (n = 9, 39.1%), conservative therapy (n = 13, 56.5%), and other intervention (n = 1, 4.3%). Median hemoglobin level decreased significantly more on days 0-3 in the intervention group than in the patients initially treated conservatively (0.9 mmol/L vs 2.4 mmol/L respectively, P = 0.006). In total, 4 patients suffered severe short-term complications, which included hypovolemic shock, acute liver failure and abscess formation. After a median follow-up of 36 mo, tumor regression in non-surgically treated patients occurred with a median reduction of 76 mm down to 25 mm. Four patients underwent secondary (elective) treatment (i.e., tumor resection) to address HCA size of > 5 cm and/or desire for future pregnancy. One case of rebleeding was documented (4.3%). None of the patients experienced long-term complication (mean follow-up time: 36 mo).
CONCLUSION With a 4.3% risk of rebleeding, secondary (elective) treatment of HCA after massive hemorrhage may only be considered in patients with persistent HCA > 5 cm.
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MESH Headings
- Adenoma, Liver Cell/complications
- Adenoma, Liver Cell/diagnostic imaging
- Adenoma, Liver Cell/pathology
- Adenoma, Liver Cell/therapy
- Adult
- Biopsy
- Embolization, Therapeutic
- Female
- Hemoglobins/analysis
- Hemoperitoneum/blood
- Hemoperitoneum/diagnostic imaging
- Hemoperitoneum/etiology
- Hemoperitoneum/therapy
- Humans
- Hypovolemia/epidemiology
- Hypovolemia/etiology
- Liver/pathology
- Liver Abscess/epidemiology
- Liver Abscess/etiology
- Liver Failure, Acute/epidemiology
- Liver Failure, Acute/etiology
- Liver Neoplasms/complications
- Liver Neoplasms/diagnostic imaging
- Liver Neoplasms/pathology
- Liver Neoplasms/therapy
- Magnetic Resonance Imaging
- Middle Aged
- Remission, Spontaneous
- Retrospective Studies
- Risk
- Rupture, Spontaneous/diagnostic imaging
- Rupture, Spontaneous/etiology
- Rupture, Spontaneous/therapy
- Tomography, X-Ray Computed
- Treatment Outcome
- Young Adult
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Addeo P, Cesaretti M, Fuchshuber P, Langella S, Simone G, Oussoultzoglou E, Bachellier P. Outcomes of liver resection for haemorrhagic hepatocellular adenoma. Int J Surg 2016; 27:34-38. [PMID: 26805568 DOI: 10.1016/j.ijsu.2016.01.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 12/30/2015] [Accepted: 01/13/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Intratumoral bleeding and/or intraperitoneal rupture occurs in up to 20% of patients with hepatocellular adenoma (HCA). Hepatectomy in the presence of haemorrhagic HCA has been associated with increased morbidity and mortality rates. This study evaluates the outcomes of hepatectomy for haemorrhagic HCA at a single institution. METHODS Between January 1997 and December 2012, 52 consecutive patients underwent liver resection for HCA. Among them, 14 patients were resected for haemorrhagic (H)-HCAs (including 9 cases of intratumoural bleeding and 5 cases of intraperitoneal bleeding) and 38 for non-haemorrhagic (NH)-HCAs. RESULTS The preoperative characteristics were similar between the two groups except for younger age (p = .001) and shorter duration of hormonal use (p = .001) in (H)-HCAs. There were no mortalities. Intraoperative blood loss, transfusion rate, and postoperative morbidity were comparable between the two groups of patients (p = ns). The length of hospital stay was significantly longer in (H)-HCAs (p = .03). In all the resected H-HCAs, pathology showed central haemorrhagic changes with tumoral cells at the periphery of the lesions. CONCLUSIONS Liver resection for H- and NH-HCAs can be achieved with no mortality and comparable short-term outcomes.
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Affiliation(s)
- Pietro Addeo
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France.
| | - Manuela Cesaretti
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Pascal Fuchshuber
- Department of Surgery, The Permanente Medical Group, Kaiser Medical Center Walnut Creek, CA, USA
| | - Serena Langella
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Gael Simone
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Elie Oussoultzoglou
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Philippe Bachellier
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
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Pinto LEV, Silva JPR, Rêgo GC, Garcia JHP. LATE SURGICAL TREATMENT FOR SPONTANEOUS RUPTURE OF HEPATOCELLULAR ADENOMA: CASE REPORT. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2016; 28:297-9. [PMID: 26734808 PMCID: PMC4755190 DOI: 10.1590/s0102-6720201500030022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 03/26/2015] [Indexed: 11/23/2022]
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12
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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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Tse JR, Naini BV, Lu DSK, Raman SS. Qualitative and Quantitative Gadoxetic Acid-enhanced MR Imaging Helps Subtype Hepatocellular Adenomas. Radiology 2015; 279:118-27. [PMID: 26505921 DOI: 10.1148/radiol.2015142449] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
PURPOSE To determine which clinical variables and gadoxetic acid disodium (Gd-EOB-DTPA)-enhanced magnetic resonance (MR) imaging features are associated with histologically proved hepatocellular adenoma (HCA) genotypic subtypes. MATERIALS AND METHODS In this institutional review board-approved and Health Insurance Portability and Accountability Act-compliant study, clinical information and MR images of 49 histologically proved HCAs from January 2002 to December 2013 (21 patients; mean age, 39 years; age range, 15-59 years) were retrospectively reviewed by two radiologists. Qualitative and quantitative imaging features, including the signal intensity ratio relative to liver in each phase, were studied. HCA tissues were stained with subtype-specific markers and subclassified by a pathologist. Clinical and imaging data were correlated with pathologic findings and compared by using Fisher exact or t test, with a Bonferroni correction for multiple comparisons. RESULTS Forty-nine HCAs were subclassified into 14 inflammatory, 20 hepatocyte nuclear factor (HNF)-1α-mutated, one β-catenin-activated, and 14 unclassified lesions. Intralesional steatosis was exclusively seen in HNF-1α-mutated lesions. Marked hyperintensity on T2-weighted images was seen in 12 of 14 (86%) inflammatory lesions compared with four of 21 (19%) HNF-1α-mutated, seven of 14 (50%) unclassified, and zero of one (0%) β-catenin-activated lesion. Two large lesions (one β-catenin-activated and one unclassified) transformed into hepatocellular carcinomas and were the only lesions to enhance with marked heterogeneity. In the hepatobiliary phase, all HCA subtypes were hypoenhancing compared with surrounding liver parenchyma, and they reached their nadir signal intensity by 10 minutes after the administration of contrast material before plateauing. HNF-1α-mutated lesions had the lowest lesion signal intensity ratio of 0.47 ± 0.09, compared with 0.73 ± 0.18 for inflammatory lesions (P = .0004), 0.82 for the β-catenin-activated lesion, and 0.73 ± 0.06 for the unclassified lesion (P = .00002). CONCLUSION In this study, all HCA subtypes were hypoenhancing at Gd-EOB-DTPA-enhanced MR imaging in the hepatobiliary phase and reached their nadir signal intensity at 10 minutes. HNF-1α-mutated lesions could be distinguished from other subtypes by having the lowest lesion signal intensity ratio.
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Affiliation(s)
- Justin R Tse
- From the Department of Radiological Sciences (J.R.T., D.S.K.L., S.S.R.) and Department of Pathology and Laboratory Medicine (B.V.N.), David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, 10833 Le Conte Ave, 1P-172 CHS, Los Angeles, CA 90095-1732
| | - Bita V Naini
- From the Department of Radiological Sciences (J.R.T., D.S.K.L., S.S.R.) and Department of Pathology and Laboratory Medicine (B.V.N.), David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, 10833 Le Conte Ave, 1P-172 CHS, Los Angeles, CA 90095-1732
| | - David S K Lu
- From the Department of Radiological Sciences (J.R.T., D.S.K.L., S.S.R.) and Department of Pathology and Laboratory Medicine (B.V.N.), David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, 10833 Le Conte Ave, 1P-172 CHS, Los Angeles, CA 90095-1732
| | - Steven S Raman
- From the Department of Radiological Sciences (J.R.T., D.S.K.L., S.S.R.) and Department of Pathology and Laboratory Medicine (B.V.N.), David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, 10833 Le Conte Ave, 1P-172 CHS, Los Angeles, CA 90095-1732
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14
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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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15
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Agrawal S, Agarwal S, Arnason T, Saini S, Belghiti J. Management of Hepatocellular Adenoma: Recent Advances. Clin Gastroenterol Hepatol 2015; 13:1221-30. [PMID: 24909909 DOI: 10.1016/j.cgh.2014.05.023] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 05/20/2014] [Accepted: 05/20/2014] [Indexed: 02/07/2023]
Abstract
Hepatocellular adenoma (HCA) is a rare benign liver cell neoplasm that occurs more frequently in young women with a history of prolonged use of oral contraceptives. Surgical resection is considered because of the risk of hemorrhage in 25% and of malignant transformation in 5% of patients with HCA. HCA is a heterogeneous disease comprising 3 subtypes with distinct molecular and complication profiles. The inflammatory or telangiectatic subtype is at increased risk for hemorrhage, the β-catenin-activated subtype is at increased risk for malignant transformation, and the hepatocyte nuclear factor-1α-inactivated or steatotic subtype is at the least risk for complications. One-third of the patients with HCA have multiple tumors on imaging with no increased risk of complications. Magnetic resonance imaging is the modality of choice for the diagnosis and subtype characterization of HCA. Systematic resection of HCA is recommended in male patients owing to the higher incidence of malignant transformation, and surgical excision in women should be reserved for tumors 5 cm or larger associated with an increased risk of complications. Cessation of hormonal therapy and radiologic surveillance in women with HCA tumors smaller than 5 cm shows that the vast majority of HCA remain stable or undergo spontaneous regression. Percutaneous core needle biopsy is of limited value because the therapeutic strategy is based primarily on patient sex and tumor size. Transarterial embolization is the initial treatment for HCA complicated by hemorrhage. Pregnancy should not be discouraged in the presence of HCA, however, frequent sonographic surveillance is recommended.
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Affiliation(s)
- Shefali Agrawal
- Hepatobiliary and Pancreatic Surgery, Department of Surgical Oncology, Indraprastha Apollo Hospitals, New Delhi, India
| | - Sheela Agarwal
- Division of Abdominal Imaging and Intervention, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Thomas Arnason
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sanjay Saini
- Division of Abdominal Imaging and Intervention, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jacques Belghiti
- Department of Hepatobiliary and Transplant Surgery, Beaujon Hospital, University of Paris, Clichy, France.
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16
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Margonis GA, Ejaz A, Spolverato G, Rastegar N, Anders R, Kamel IR, Pawlik TM. Benign solid tumors of the liver: management in the modern era. J Gastrointest Surg 2015; 19:1157-68. [PMID: 25560181 DOI: 10.1007/s11605-014-2723-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 12/04/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Recently, there has been a growing interest in solid benign liver tumors as the understanding of the pathogenesis and molecular underpinning of these lesions continues to evolve. We herein provide an evidence-based review of benign solid liver tumors with particular emphasis on the diagnosis and management of such tumors. METHODS A search of all available literature on benign hepatic tumors through a search of the MEDLINE/PubMed electronic database was conducted. RESULTS New diagnostic and management protocols for benign liver tumors have emerged, as well as new insights into the molecular pathogenesis. In turn, these data have spawned a number of new studies seeking to correlate molecular, clinicopathological, and clinical outcomes for benign liver tumors. In addition, significant advances in surgical techniques and perioperative care have reduced the morbidity and mortality of liver surgery. Despite current data that supports conservative management for many patients with benign liver tumors, patients with severe preoperative symptomatic disease seem to benefit substantially from surgical treatment based on quality of life data. CONCLUSION Future studies should seek to further advance our understanding of the underlying pathogenesis and natural history of benign liver tumors in order to provide clinicians with evidence-based guidelines to optimize treatment of patients with these lesions.
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Affiliation(s)
- Georgios Antonios Margonis
- Department of Surgery, The Johns Hopkins Hospital, 600 N. Wolfe Street, Blalock 688, Baltimore, MD, 21287, USA
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17
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Blanc JF, Frulio N, Chiche L, Bioulac-Sage P, Balabaud C. Hepatocellular adenoma management: advances but still a long way to go. Hepat Oncol 2015; 2:171-180. [PMID: 30190996 DOI: 10.2217/hep.14.41] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Hepatocellular adenomas (HCAs) are composed of four molecular subgroups: mutations inactivating the HNF1A gene; the inflammatory phenotype with mutations of different genes leading to STAT3 activation; the activation of β-catenin by mutations in exon 3; among β-HCA, half display both inflammatory and β-catenin-activated phenotypes; and the unclassified tumors. The identification of these subtypes by MRI and immunohistochemistry on tissue is considered as a major criterion to manage patients. Of particular relevance is the identification of the β-catenin-mutated group due to its high risk of malignant transformation. In spite of this progress, the classification has not gained recognition among surgeons. It is hoped that by working as a multidisciplinary team, including surgeons, radiologists, pathologists and molecular biologists, patients will be managed more rationally. In this article, we will present known and new data, well accepted and that which is still controversial. The progress made in the field of HCA in the last 12 years, whether in epidemiology, diagnosis (clinical, pathology, imaging) or management, is related in one way or another to molecular advances.
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Affiliation(s)
- Jean Frédéric Blanc
- Hepato-gastroenterology & Digestive Oncology Unit, CHU Bordeaux, Saint-André Hospital, 1 rue Jean Burguet 33075 Bordeaux, France.,Hepato-gastroenterology & Digestive Oncology Unit, CHU Bordeaux, Saint-André Hospital, 1 rue Jean Burguet 33075 Bordeaux, France
| | - Nora Frulio
- Department of Diagnostic & Interventional Imaging, CHU Bordeaux, Saint André hospital, 1 rue Jean Burguet 33075 Bordeaux, France.,Department of Diagnostic & Interventional Imaging, CHU Bordeaux, Saint André hospital, 1 rue Jean Burguet 33075 Bordeaux, France
| | - Laurence Chiche
- Department of Digestive Surgery, Haut Lévêque Hospital, CHU Bordeaux, Avenue de Magellan 33604 PESSAC cedex, France.,Department of Digestive Surgery, Haut Lévêque Hospital, CHU Bordeaux, Avenue de Magellan 33604 PESSAC cedex, France
| | - Paulette Bioulac-Sage
- Department of Pathology, Pellegrin Hospital, CHU Bordeaux, 33076 Bordeaux, France.,Inserm, UMR-1053, Université de Bordeaux, 33076 Bordeaux, France.,Department of Pathology, Pellegrin Hospital, CHU Bordeaux, 33076 Bordeaux, France.,Inserm, UMR-1053, Université de Bordeaux, 33076 Bordeaux, France
| | - Charles Balabaud
- Inserm, UMR-1053, Université de Bordeaux, 33076 Bordeaux, France.,Inserm, UMR-1053, Université de Bordeaux, 33076 Bordeaux, France
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18
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Current updates on the molecular genetics and magnetic resonance imaging of focal nodular hyperplasia and hepatocellular adenoma. Insights Imaging 2015; 6:347-62. [PMID: 25790815 PMCID: PMC4444792 DOI: 10.1007/s13244-015-0399-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 01/29/2015] [Accepted: 02/04/2015] [Indexed: 12/19/2022] Open
Abstract
UNLABELLED Focal nodular hyperplasia (FNH) and hepatocellular adenomas (HCAs) constitute benign hepatic neoplasms in adults. HCAs are monoclonal neoplasms characterised by an increased predilection to haemorrhage and also malignant transformation. On the other hand, FNH is a polyclonal tumour-like lesion that occurs in response to increased perfusion and has an uneventful clinical course. Recent advances in molecular genetics and genotype-phenotype correlation in these hepatocellular neoplasms have enabled a new classification system. FNHs are classified into the typical and atypical types based on histomorphological and imaging features. HCAs have been categorised into four subtypes: (1) HCAs with HNF-1α mutations are diffusely steatotic, do not undergo malignant transformation, and are associated with familial diabetes or adenomatosis. (2) Inflammatory HCAs are hypervascular with marked peliosis and a tendency to bleed. They are associated with obesity, alcohol and hepatic steatosis. (3) HCAs with β-catenin mutations are associated with male hormone administration and glycogen storage disease, frequently undergo malignant transformation and may simulate hepatocellular carcinoma on imaging. (4) The final type is unclassified HCAs. Each of these except the unclassified subtype has a few distinct imaging features, often enabling reasonably accurate diagnosis. Biopsy with immunohistochemical analysis is helpful in difficult cases and has strong implications for patient management. TEACHING POINTS • FNHs are benign polyclonal neoplasms with no risk of haemorrhage or malignancy. • HCAs are benign monoclonal neoplasms classified into four subtypes based on immunohistochemistry. • Inflammatory HCAs show an atoll sign with a risk of bleeding and malignant transformation. • HNF-1α HCAs are steatotic HCAs with minimal complications and the best prognosis. • β-Catenin HCA shows variable MRI features and a high risk of malignancy.
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Belghiti J, Cauchy F, Paradis V, Vilgrain V. Diagnosis and management of solid benign liver lesions. Nat Rev Gastroenterol Hepatol 2014; 11:737-49. [PMID: 25178878 DOI: 10.1038/nrgastro.2014.151] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
More and more asymptomatic benign liver tumours are discovered incidentally and can be divided into regenerative lesions and true neoplastic lesions. The most common regenerative lesions include hemangioma, focal nodular hyperplasia and inflammatory pseudotumours of the liver. Neoplastic lesions include hepatocellular adenomas and angiomyolipomas. Regenerative lesions rarely increase in volume, do not yield a higher risk of complications and usually do not require treatment. By contrast, hepatocellular adenomas and angiomyolipomas can increase in volume and are associated with a risk of complications. Large hepatocellular adenomas (>5 cm in diameter) are undoubtedly associated with a risk of bleeding and malignant transformation, particularly the inflammatory (also known as telangiectatic) and β-catenin mutated subtypes. Accurate diagnosis needs to be obtained to select patients eligible for surgical resection. MRI has markedly improved diagnosis and can identify the major hepatocellular adenomas subtypes. The use of biopsy results to inform the indication for resection remains questionable. However, when diagnosis remains uncertain after imaging, percutaneous biopsy could help improve diagnostic accuracy.
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Affiliation(s)
- Jacques Belghiti
- Department of Hepatobiliary Surgery and Liver Transplantation, Beaujon Hospital, University Paris-Diderot, 100 Boulevard du General Leclerc, 92110 Clichy, France
| | - François Cauchy
- Department of Hepatobiliary Surgery and Liver Transplantation, Beaujon Hospital, University Paris-Diderot, 100 Boulevard du General Leclerc, 92110 Clichy, France
| | - Valérie Paradis
- Department of Pathology, Beaujon Hospital, University Paris-Diderot, 100 Boulevard du General Leclerc, 92110 Clichy, France
| | - Valérie Vilgrain
- Department of Radiology, Beaujon Hospital, University Paris-Diderot, 100 Boulevard du General Leclerc, 92110 Clichy, France
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20
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Dokmak S, Cauchy F, Belghiti J. Resection, transplantation and local regional therapies for liver adenomas. Expert Rev Gastroenterol Hepatol 2014; 8:803-10. [PMID: 24957321 DOI: 10.1586/17474124.2014.917957] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Hepatocellular adenoma (HCA) is a rare benign liver-cell neoplasm, occurring predominantly in young obese women using oral contraceptives. HCA is a heterogeneous disease, which includes four subtypes (including unclassified) associated with various risks of haemorrhagic complications and malignant transformation. Magnetic resonance imaging is the modality of choice for both diagnosis and subtype characterization of HCA whereas percutaneous biopsy has only limited impact on the therapeutic strategy. In men HCA should be always resected while in women surgery should only be considered for lesions ≥5 cm and after cessation of hormonal therapy. Women with single or multiple HCAs <5 cm may be followed with regular MRI imaging since the vast majority of HCA remains stable or decreases in size. Pregnancy should not be discouraged provided close sonographic surveillance is undertaken.
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Affiliation(s)
- Safi Dokmak
- Department of Hepatobiliary Surgery and Liver Transplantation Beaujon Hospital, AP-HP, University Paris-Diderot, Clichy, France
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21
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de'Angelis N, Memeo R, Calderaro J, Felli E, Salloum C, Compagnon P, Luciani A, Laurent A, Cherqui D, Azoulay D. Open and laparoscopic resection of hepatocellular adenoma: trends over 23 years at a specialist hepatobiliary unit. HPB (Oxford) 2014; 16:783-8. [PMID: 24852081 PMCID: PMC4159449 DOI: 10.1111/hpb.12257] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 01/27/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepatocellular adenoma (HCA) is a rare benign liver epithelial tumour that can require surgery. This retrospective study reports a 23-year experience of open and laparoscopic resections for HCA. METHODS Patients with a histological diagnosis of HCA were included in this analysis. Surgical resection was performed in all symptomatic patients and in those with lesions measuring >5 cm. RESULTS Between 1989 and 2012, 62 patients, 59 of whom were female, underwent surgery for HCA (26 by open surgery and 36 by laparoscopic surgery). Overall, 96.6% of female patients had a history of contraceptive use; 54.8% of patients presented with abdominal pain and 11.2% with haemorrhage; the remaining patients were asymptomatic. Patients who underwent laparoscopy had smaller lesions (mean ± standard deviation diameter: 68.3 ± 35.2 mm versus 91.9 ± 42.5 mm; P = 0.022). Operatively, laparoscopic and open liver resection did not differ except in the number of pedicle clamps, which was significantly lower in the laparoscopic group (27.8% versus 57.7% of patients; P = 0.008). Postoperative variables did not differ between the groups. Mortality was nil. Two surgical specimens were classified as HCA/borderline hepatocellular carcinoma. At the 3-year follow-up, all patients were alive with no recurrence of HCA. CONCLUSIONS Open and laparoscopic liver resections are both safe and feasible approaches for the surgical management of HCA. However, laparoscopic liver resections may be limited by lesion size and location and require advanced surgical skills.
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Affiliation(s)
- Nicola de'Angelis
- Digestive Surgery and Liver Transplant Unit, Henri-Mondor Hospital, Université Paris-EstCréteil, France
| | - Riccardo Memeo
- Digestive Surgery and Liver Transplant Unit, Henri-Mondor Hospital, Université Paris-EstCréteil, France
| | - Julien Calderaro
- Department of Pathology, Henri-Mondor Hospital, Université Paris-EstCréteil, France
| | - Emanuele Felli
- Digestive Surgery and Liver Transplant Unit, Henri-Mondor Hospital, Université Paris-EstCréteil, France
| | - Chady Salloum
- Digestive Surgery and Liver Transplant Unit, Henri-Mondor Hospital, Université Paris-EstCréteil, France
| | - Philippe Compagnon
- Digestive Surgery and Liver Transplant Unit, Henri-Mondor Hospital, Université Paris-EstCréteil, France
| | - Alain Luciani
- Department of Radiology and Medical Imaging, Henri-Mondor Hospital, Université Paris-EstCréteil, France
| | - Alexis Laurent
- Digestive Surgery and Liver Transplant Unit, Henri-Mondor Hospital, Université Paris-EstCréteil, France
| | - Daniel Cherqui
- Hepatobiliary and Pancreatic Surgery and Liver Transplantation Unit, Paul Brousse HospitalParis, France
| | - Daniel Azoulay
- Digestive Surgery and Liver Transplant Unit, Henri-Mondor Hospital, Université Paris-EstCréteil, France,Correspondence, Daniel Azoulay, Digestive and Liver Transplant Surgery Unit, Henri-Mondor Hospital, Université Paris Est, 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France. Tel: + 33 1 4981 2348. Fax: + 33 1 4981 2432. E-mail:
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Abstract
Liver tumors bleed rarely; management has changed radically during the last 20years, advancing from emergency surgery with poor results to multidisciplinary management. The first steps are the diagnosis and control of bleeding. Abdominopelvic CT scan should be performed as soon as patient hemodynamics allow. When active bleeding is visualized, arterial embolization, targeted as selectively as possible, is preferable to surgery, which should be reserved for severe hemodynamic instability or failure of interventional radiology. When surgery is unavoidable, abbreviated laparotomy (damage control) with perihepatic packing is recommended. The second step is determination of the etiology and treatment of the underlying tumor. Adenoma and hepatocellular carcinoma (HCC) are the two most frequently encountered tumors in this context. Liver MRI after control of the bleeding episode generally leads to the diagnosis although sometimes the analysis can be difficult because of the hematoma. Prompt resection is indicated for HCC, atypical adenoma or lesions at risk for degeneration to hepatocellular carcinoma. For adenoma with no suspicion of malignancy, it is best to wait for the hematoma to resorb completely before undertaking appropriate therapy.
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Affiliation(s)
- B Darnis
- Service de chirurgie générale et digestive, transplantation hépatique et intestinale, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, 103, Grande Rue de la Croix-Rousse, 69004 Lyon, France.
| | - A Rode
- Service de radiologie, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, 103, Grande Rue de la Croix-Rousse, 69004 Lyon, France
| | - K Mohkam
- Service de chirurgie générale et digestive, transplantation hépatique et intestinale, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, 103, Grande Rue de la Croix-Rousse, 69004 Lyon, France
| | - C Ducerf
- Service de chirurgie générale et digestive, transplantation hépatique et intestinale, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, 103, Grande Rue de la Croix-Rousse, 69004 Lyon, France
| | - J-Y Mabrut
- Service de chirurgie générale et digestive, transplantation hépatique et intestinale, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, 103, Grande Rue de la Croix-Rousse, 69004 Lyon, France
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Ramia JM, Bernardo C, Valdivieso A, Dopazo C, Jover JM, Albiol MT, Pardo F, Fernandez Aguilar JL, Gutierrez Calvo A, Serrablo A, Diez Valladares L, Pereira F, Sabater L, Muffak K, Figueras J. [Multicentre study on hepatic adenomas]. Cir Esp 2014; 92:120-125. [PMID: 23827931 DOI: 10.1016/j.ciresp.2012.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 12/02/2012] [Accepted: 12/16/2012] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Hepatic adenomas (HA) are benign tumours which can present serious complications, and as such, in the past all were resected. It has now been shown that those smaller than 3 cm not expressing β-catenin only result in complications in exceptional cases and therefore the therapeutic strategy has been changed. MATERIAL AND METHOD Retrospective study in 14 HPB units. INCLUSION CRITERIA patients with resected and histologically confirmed HA. STUDY PERIOD 1995-2011. RESULTS 81 patients underwent surgery. Age: 39.5 years (range: 14-75). Sex: female (75%). Consumption of oestrogen in women: 33%. Size: 8.8 cm (range, 1-20 cm). Only 6 HA (7.4%) were smaller than 3 cm. The HA median was 1 (range: 1-12). Nine patients had adenomatosis (>10HA). A total of 51% of patients displayed symptoms, the most frequent (77%) being abdominal pain. Eight patients (10%) began with acute abdomen due to rupture and/or haemorrhage. A total of 67% of the preoperative diagnoses were correct. Surgery was scheduled for 90% of patients. The techniques employed were: major hepatectomy (22%), minor hepatectomy (77%) and one liver transplantation. A total of 20% were performed laparoscopically. The morbidity rate was 28%. There were no cases of mortality. Three patients had malignisation (3.7%). The follow-up period was 43 months (range 1-192). Two recurrences were detected and resected. DISCUSSION Patients with resected HA are normally women with large lesions and oestrogen consumption was lower than expected. Its correct preoperative diagnosis is acceptable (70%). The major hepatectomy rate is 25% and the laparoscopy rate is 20%. There was a low morbidity rate and no mortality.
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Affiliation(s)
- José Manuel Ramia
- Unidad Hepatobiliopancreática, Servicio de Cirugía, Hospital Universitario de Guadalajara, Guadalajara, España.
| | - Carmen Bernardo
- Sección Hepatobiliopancreática y de Trasplante Hepático, Servicio de Cirugía, Hospital Central de Asturias, Oviedo, España
| | - Andrés Valdivieso
- Unidad Hepatobiliopancreática y de Trasplante Hepático, Servicio de Cirugía, Hospital de Cruces, Bilbao, España
| | - Cristina Dopazo
- Unidad Hepatobiliopancreática y de Trasplante Hepático, Servicio de Cirugía, Hospital Vall d'Hebron, Barcelona, España
| | - José María Jover
- Unidad Hepatobiliopancreática, Servicio de Cirugía, Hospital de la Cruz Roja, Getafe, Madrid, España
| | - M Teresa Albiol
- Unidad Hepatobiliopancreática, Servicio de Cirugía, Hospital Josep Trueta, Girona, España
| | - Fernando Pardo
- Unidad Hepatobiliopancreática, Servicio de Cirugía, Clínica Universitaria de Navarra, Pamplona, España
| | - José Luis Fernandez Aguilar
- Unidad Hepatobiliopancreática, Unidad de Gestión Clinica de Cirugía General, Digestiva y Trasplantes, Servicio de Cirugía, Hospital Carlos Haya, Málaga, España
| | - Alberto Gutierrez Calvo
- Unidad Hepatobiliopancreática, Servicio de Cirugía, Hospital Príncipe de Asturias, Alcalá de Henares, Madrid, España
| | - Alejandro Serrablo
- Unidad Hepatobiliopancreática, Servicio de Cirugía, Hospital Miguel Servet, Zaragoza, España
| | - Luis Diez Valladares
- Unidad Hepatobiliopancreática, Servicio de Cirugía, Hospital Clínico San Carlos, Madrid, España
| | - Fernando Pereira
- Servicio de Cirugía, Hospital de Fuenlabrada, Fuenlabrada, Madrid, España
| | - Luis Sabater
- Unidad Hepatobiliopancreática, Servicio de Cirugía, Hospital Clínico Universitario, Valencia, España
| | - Karim Muffak
- Unidad Hepatobiliopancreática, Servicio de Cirugía, Hospital Virgen de las Nieves, Granada, España
| | - Joan Figueras
- Unidad Hepatobiliopancreática, Servicio de Cirugía, Hospital Josep Trueta, Girona, España
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Martinez-Mier G, Enriquez De los Santos H, Grube-Pagola P. Large hepatic adenoma in a 21-year-old male. BMJ Case Rep 2013; 2013:bcr-2013-202111. [PMID: 24306431 DOI: 10.1136/bcr-2013-202111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Hepatic adenoma is an uncommon benign lesion of the liver that occurs more frequently in women in their third and fourth decades. The female/male ratio is up to 11:1. Hepatic adenomas may be single or multiple occasionally reaching sizes up to 20 cm. They are non-cancerous lesions, however they can become malignant. We present a 21-year-old male patient with no medical history who presented with abdominal pain, a palpable abdominal mass, abnormal liver function tests and a 14 kg weight loss in a 2-year period. A CT scan was performed with a 17 cm tumour compressing intrahepatic bile ducts. The patient underwent a right hepatectomy with no complications. Histopathological analysis of the tumour revealed a hepatic adenoma with central necrosis. The patient is asymptomatic at 1-year follow-up.
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Affiliation(s)
- Gustavo Martinez-Mier
- Department of Organ Transplantation, Hospital General de Veracruz, Veracruz, Veracruz, Mexico
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25
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Focal nodular hyperplasia and hepatic adenoma: current diagnosis and management. Updates Surg 2013; 66:9-21. [DOI: 10.1007/s13304-013-0222-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 06/16/2013] [Indexed: 12/25/2022]
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26
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Zhan HC, Xu ZH, Zeng WH, Ding HM, Fu HQ. Surgical treatment of patients with traumatic liver rupture: An analysis of 23 cases. Shijie Huaren Xiaohua Zazhi 2012; 20:3277-3279. [DOI: 10.11569/wcjd.v20.i33.3277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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
AIM: To summarize our experience with surgical treatment of 23 patients with traumatic liver rupture.
METHODS: The clinical data for 23 patients with traumatic liver rupture who were surgically treated from 2006 to 2011 at our hospital were retrospectively analyzed.
RESULTS: Of 23 patients with traumatic liver rupture, 20 were cured and 3 died. One patient died of multiple organ injury. Rupture of the liver, spleen and kidney, and pelvic fracture occurred in this patient. One patient died of severe chest trauma with acute respiratory distress syndrome (ARDS), and the other patient died of multiple organ failure (MOF) after surgery for liver rupture. The death rate was higher in patients with serious liver rupture or with combined MOF. Early and accurate diagnosis and proper and timely surgical treatment are key to saving the lives of patients and improving the cure rate and death rate.
CONCLUSION: Proper and timely surgical treatment can improve survival and reduce complications in patients with traumatic liver rupture who require surgical treatment.
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27
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Vanounou T, Groeschl RT, Geller DA, Marsh JW, Gamblin TC. Economic model of observation versus immediate resection of hepatic adenomas. J Surg Oncol 2012; 106:491-7. [PMID: 22442008 DOI: 10.1002/jso.23099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Accepted: 02/24/2012] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES For small asymptomatic hepatic adenomas (HA), available data are insufficient to establish the superiority of either observation or surgery. We sought to investigate the cost-effectiveness of two initial management strategies. METHODS We performed a comparative analysis of two theoretical cohorts of 100 patients with small (<5 cm), asymptomatic HA. Discounted cash flow (DCF) models compared the net present value (NPV) of both treatment options at year 10 under three distinct progression rate scenarios. A break-even (BE) analysis was used to determine the BE point at which the NPV for observation and immediate surgery intersect. RESULTS The NPV for immediate surgery was $1,733,955. The NPV for observation varied between $2,065,315-$2,745,631 for computed tomography (CT), $2,264,575-$2,929,541 for magnetic resonance imaging (MRI), and $802,837-$1,580,413 for ultrasound (US). The BE point was between 6 and 8 years for CT and 5-7 years for MRI. The BE point for US was not reached except in the highest progression rate scenario (12 years). CONCLUSIONS This study highlights the importance of the underlying progression rate and the cost of imaging when following patients with asymptomatic HA. Overall, US surveillance is the most cost-efficient approach to observing small asymptomatic HA. If cross-sectional imaging is utilized, then immediate surgery is the most cost-effective decision at 5-8 years.
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Affiliation(s)
- Tsafrir Vanounou
- Department of Surgery, McGill University, Jewish General Hospital, Montreal, Quebec, Canada
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28
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"Incidentaloma" of the liver: management of a diagnostic and therapeutic dilemma. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2012; 2012:891787. [PMID: 22927707 PMCID: PMC3423934 DOI: 10.1155/2012/891787] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 04/20/2012] [Accepted: 05/05/2012] [Indexed: 12/15/2022]
Abstract
The continuous development of highly sensitive clinical imaging increased the detection of focal lesions of the liver. These accidentally detected liver tumors without liver-specific symptoms such as cholestasis have been named “incidentalomas.” Diagnostic tools such as sonography, computed tomography, or magnetic resonance imaging are used increasingly in asymptomatic individuals without defined suspected diagnoses in the setting of general prevention or followup after a history of malignancy. But despite continuous improvement of diagnostics, some doubt regarding the benign or malign behavior of a tumor remains. In case an asymptomatic hemangioma or FNH can be preoperatively detected with certainty, the indication for surgery must be very strict. In case of symptomatic liver lesions surgical resection should only be indicated with tumor-specific symptoms. In the remaining cases of benign lesions of the liver, a “watch and wait” strategy is recommended. In case of uncertain diagnosis, especially in patients with positive history of a malignant tumor or the suspected diagnosis of hepatocellular adenoma, surgical resection is indicated. Due to the continuous improvement of surgical techniques, liver resection should be done in the laparoscopic technique. Laparoscopic surgery has lower morbidity and shorter hospitalization than open technique.
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29
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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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30
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Battula N, Tsapralis D, Takhar A, Coldham C, Mayer D, Isaac J, Muiesan P, Sutcliffe RP, Marudanayagam R, Mirza DF, Bramhall SR. Aetio-pathogenesis and the management of spontaneous liver bleeding in the West: a 16-year single-centre experience. HPB (Oxford) 2012; 14:382-9. [PMID: 22568414 PMCID: PMC3384862 DOI: 10.1111/j.1477-2574.2012.00460.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Spontaneous liver bleeding (SLB) is a rare but potentially fatal complication. In contrast to the East, various benign pathologies are the source of SLB in the West. An accurate diagnosis and a timely implementation of appropriate treatment are crucial in the management of these patients. The present study presents a large Western experience of SLB from a specialist liver centre. METHODS A retrospective analysis of patients presented with SLB between January 1995 and January 2011. RESULTS Sixty-seven patients had SLB, 44 (66%) were female and the median age at presentation was 47 years. Abrupt onset upper abdominal pain was the presenting symptom in 65 (97%) patients. The aetiology for SLB was hepatic adenoma in 27 (40%), hepatocellular carcinoma (HCC) in 17 (25%) and various other liver pathologies in the rest. Emergency treatment included a conservative approach in 42 (64%), DSA and embolization in 6 (9%), a laparotomy and packing in 6 (9%) and a liver resection in 11 (16%) patients. Eleven (16%) patients had further planned treatments. Seven (10%) died during the same admission but the mortality was highest in patients with HELLP syndrome. At a median follow-up of 54 months all patients with benign disease are alive. The 1-, 3- and 5-year survival of patients with HCC was 59%, 35% and 17%, respectively. CONCLUSION SLB is a life-threatening complication of various underlying conditions and may represent their first manifestation. The management should include initial haemostasis followed by appropriate staging investigations to provide a definitive treatment for each individual patient.
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31
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van Aalten SM, de Man RA, IJzermans JNM, Terkivatan T. Systematic review of haemorrhage and rupture of hepatocellular adenomas. Br J Surg 2012; 99:911-6. [PMID: 22619025 DOI: 10.1002/bjs.8762] [Citation(s) in RCA: 121] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2012] [Indexed: 12/21/2022]
Abstract
BACKGROUND Although benign in itself, hepatocellular adenoma (HCA) can be complicated by hormone-induced growth, and subsequent haemorrhage and rupture. The exact risk of haemorrhage and rupture is not known. This systematic review of the literature was carried out with the aim of estimating the risk of haemorrhage and rupture in HCA. METHODS A systematic literature search of the PubMed and Embase databases was performed for all articles relevant to haemorrhage and/or rupture of HCA, published between 1969 and March 2011. RESULTS Twenty-eight articles met the selection criteria, containing a total of 1176 patients. Haemorrhage was reported with an overall frequency of 27·2 per cent among patients, and in 15·8 per cent of all HCA lesions. Rupture and intraperitoneal bleeding were reported in 17·5 per cent of patients. Bleeding was the first symptom in 68·5 per cent of patients with a bleeding HCA. Six of 13 articles reporting the size of HCA lesions in which bleeding occurred mentioned haemorrhage in HCAs smaller than 5 cm. CONCLUSION Haemorrhage and rupture are common in patients with HCA.
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Affiliation(s)
- S M van Aalten
- Department of Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands.
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32
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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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33
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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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34
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van Aalten SM, Thomeer MGJ, Terkivatan T, Dwarkasing RS, Verheij J, de Man RA, Ijzermans JNM. Hepatocellular adenomas: correlation of MR imaging findings with pathologic subtype classification. Radiology 2011; 261:172-81. [PMID: 21875850 DOI: 10.1148/radiol.11110023] [Citation(s) in RCA: 151] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE To investigate the correlation between magnetic resonance (MR) imaging findings and pathologic subtype classification of hepatocellular adenoma (HCA). MATERIALS AND METHODS This retrospective study was approved by the institutional review board, and the requirement for informed consent was waived. MR imaging studies of 61 lesions (48 patients; median age, 36 years) were available and were independently reviewed by two radiologists. Consensus readings on all morphologic and signal-intensity imaging features were obtained. Previously, these lesions had been classified on the basis of pathologic findings and immunohistochemical analysis. Fisher exact and χ² tests were performed to compare the results between the different subtypes. A Bonferroni correction was applied to correct for multiple testing (α < .0033). RESULTS MR imaging signs of diffuse intratumoral fat deposition were present in seven (78%) of nine liver-fatty acid binding protein (L-FABP)-negative HCAs compared with five (17%) of 29 inflammatory HCAs (P = .001). Steatosis within the nontumoral liver was present in 11 (38%) of 29 inflammatory HCAs compared with none of the L-FABP-negative HCAs (P = .038). A characteristic atoll sign was only seen in the inflammatory group (P = .027). Presence of a typical vaguely defined type of scar was seen in five (71%) of seven β-catenin-positive HCAs (P = .003). No specific MR imaging features were identified for the unclassified cases. CONCLUSION L-FABP-negative, inflammatory, and β-catenin-positive HCAs were related to MR imaging signs of diffuse intratumoral fat deposition, an atoll sign, and a typical vaguely defined scar, respectively. Since β-catenin-positive HCAs are considered premalignant, closer follow-up with MR imaging or resection may be preferred.
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Affiliation(s)
- Susanna M van Aalten
- Department of Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands.
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Abu Hilal M, Di Fabio F, Wiltshire RD, Hamdan M, Layfield DM, Pearce NW. Laparoscopic liver resection for hepatocellular adenoma. World J Gastrointest Surg 2011; 3:101-5. [PMID: 21860698 PMCID: PMC3158885 DOI: 10.4240/wjgs.v3.i7.101] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Revised: 07/12/2011] [Accepted: 07/18/2011] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the role of laparoscopy in the surgical management of hepatocellular adenoma (HA). METHODS We reviewed a prospectively collected database of consecutive patients undergoing laparoscopic liver resection for HA. RESULTS Thirteen patients underwent fifteen pure laparoscopic liver resections for HA (male/female: 3/10; median age 42 years, range 22-72 years). Two patients with liver adenomatosis required two different laparoscopic operations for ruptured adenomas. Indications for surgery were: symptoms in 12 cases, need to rule out malignancy in 2 cases and preoperative diagnosis of large HA in one case. Symptoms were related to bleeding in 10 cases, sepsis due to liver abscess following embolization of HA in one case and mass effect in one case (shoulder tip pain). Five cases with ruptured bleeding adenoma required emergency admission and treatment with selective arterial embolization. Laparoscopic liver resection was then semi-electively performed. Eight patients (62%) required major hepatectomy [right hepatectomy (n = 5), left hepatectomy (n = 3)]. No conversion to open surgery occurred. The median operative time for pure laparoscopic procedures was 270 min (range 135-360 min). The median size of the excised lesions was 85 mm (range 25-180 mm). One patient with adenomatosis developed postoperative bleeding requiring embolization. Mortality was nil. The median hospital stay was 4 d (range 1-18 d) with a median high dependency unit stay of 1 d (range 0-7 d). CONCLUSION The laparoscopic approach represents a safe option for the management of HA in a semi-elective setting and when major hepatectomy is required.
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Affiliation(s)
- Mohammed Abu Hilal
- Hepatobiliary and Pancreatic Surgical Unit, Southampton University Hospitals NHS Trust, Tremona Road, Southampton SO16 6YD, United Kingdom
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36
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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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Shanbhogue AK, Prasad SR, Takahashi N, Vikram R, Sahani DV. Recent advances in cytogenetics and molecular biology of adult hepatocellular tumors: implications for imaging and management. Radiology 2011; 258:673-93. [PMID: 21339346 DOI: 10.1148/radiol.10100376] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Focal nodular hyperplasia (FNH), hepatocellular adenoma (HCA), and hepatocellular carcinoma (HCC) compose hepatocellular neoplasms that occur in adults. These tumors demonstrate characteristic epidemiologic and histopathologic features and clinical and imaging manifestations. HCAs are monoclonal neoplasms characterized by increased predilection to hemorrhage or rupture and occasional transformation to HCC. On the other hand, FNH is a polyclonal tumorlike lesion that occurs in response to increased perfusion and has an indolent clinical course. Up to 90% of HCCs occur in the setting of cirrhosis. Chronic viral hepatitis (hepatitis B and hepatitis C) infection and metabolic syndrome are major risk factors that can induce HCCs in nonfibrotic liver. Recent advances in pathology and genetics have led to better understanding of the histogenesis, natural history, and molecular events that determine specific oncologic pathways used by these neoplasms. HCAs are now believed to result from specific genetic mutations involving TCF1 (transcription factor 1 gene), IL6ST (interleukin 6 signal transducer gene), and CTNNB1 (β catenin-1 gene); FNHs are characterized by an "imbalance" of angiopoietin. While the β catenin signaling pathway is associated with well- and moderately differentiated HCCs, mutations involving p53 (tumor protein 53 gene), MMP14 (matrix metalloproteinase 14 gene), and RhoC (Ras homolog gene family, member C) are associated with larger tumor size, higher tumor grade with resultant shortened tumor-free survival, and poor prognosis. Fibrolamellar carcinoma (FLC), a unique HCC subtype, exhibits genomic homogeneity that partly explains its better overall prognosis. On the basis of recent study results involving cytogenetics and oncologic pathways of HCCs, novel drugs that act against molecular targets are being developed. Indeed, sorafenib (a multikinase inhibitor) is currently being used in the successful treatment of patients with advanced HCC. Characterization of genetic abnormalities and genotype-phenotype correlations in adult hepatocellular tumors provides better understanding of tumor pathology and biology, imaging findings, prognosis, and response to molecular therapeutics.
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Affiliation(s)
- Alampady K Shanbhogue
- Department of Radiology, University of Texas Health Science Center-San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229, USA
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Hepatocellular adenomas: current update on genetics, taxonomy, and management. J Comput Assist Tomogr 2011; 35:159-66. [PMID: 21412084 DOI: 10.1097/rct.0b013e31820bad61] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Hepatocellular adenomas (HCAs) are uncommon, benign hepatocellular neoplasms that commonly occur in young women. Recent advances in pathology and cytogenetics have thrown fresh light on the pathogenesis of HCAs leading to classification of HCAs into 3 distinct subtypes, each with a characteristic epidemiology, histopathology, oncogenesis, and imaging findings. The aim of the article was to provide a comprehensive review of contemporary taxonomy of HCAs, with an emphasis on cross-sectional imaging findings and management.
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Abstract
One of the consequences of extensive use of abdominal imaging, and especially liver ultrasonography, is the detection of asymptomatic liver tumors. In the absence of underlying chronic liver disease, the vast majority of these lesions correspond to benign liver tumors including solid and cystic lesions. This article is dedicated to hepatocellular tumors and also addresses hemangiomas as the most common benign liver tumors, and angiomyolipomas as a rare tumor often misdiagnosed.
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Affiliation(s)
- Valérie Paradis
- Pathology Department, Beaujon Hospital, 100 bd du Général Leclerc, 92118 Clichy Cedex, France.
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40
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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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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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Di Bisceglie AM, Befeler AS. Tumors and Cysts of the Liver. SLEISENGER AND FORDTRAN'S GASTROINTESTINAL AND LIVER DISEASE 2010:1569-1592.e6. [DOI: 10.1016/b978-1-4160-6189-2.00094-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Dokmak S, Paradis V, Vilgrain V, Sauvanet A, Farges O, Valla D, Bedossa P, Belghiti J. A single-center surgical experience of 122 patients with single and multiple hepatocellular adenomas. Gastroenterology 2009; 137:1698-705. [PMID: 19664629 DOI: 10.1053/j.gastro.2009.07.061] [Citation(s) in RCA: 258] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2008] [Revised: 07/24/2009] [Accepted: 07/29/2009] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Hepatocellular adenoma (HA) is associated with risk of bleeding and malignancy, justifying resection. Patients with multiple forms of HA are difficult to manage. We evaluated the characteristics and outcome of 122 patients with single and multiple HAs after surgery. METHODS From 1990 to 2004, 122 patients (14 male) underwent surgical resection. Complications (hemorrhage and malignancy) were assessed according to size, number, and histologic subtype (steatotic, telangiectatic, and unclassified), with a mean follow-up period of 70 months. RESULTS Hemorrhagic HA occurred in 21% of cases and malignant HA occurred in 8%. Risk of complications was not related to the number of HAs but was associated with size (>5 cm), especially of telangiectatic and unclassified subtypes. Patients with steatotic HA had a low risk of complications. Malignant HA was more frequent in men (43%); all patients treated by partial resection survived, without recurrent malignancy, after a mean follow-up period of 78 months. After 109 patients with benign HA revealed recurrence or progression of HA in 8% and regression in 9% of cases. No complications were observed in 11 women who became pregnant during the follow-up period. CONCLUSIONS Patients with HAs greater than 5 cm, telangiectatic or unclassified subtypes, and men have an increased risk of complicated disease; resection should be restricted to these patients. The risk of complications was not related to the number of HAs, so patients with multiple HAs do not need liver transplantation.
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Affiliation(s)
- Safi Dokmak
- Department of HepatoBilioPancreatic Surgery, University of Paris 7 and Beaujon Hospital, Clichy, France
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van der Sluis FJF, Bosch JL, Terkivatan T, de Man RA, IJzermans JNM, Hunink MGM. Hepatocellular Adenoma: Cost-effectiveness of Different Treatment Strategies. Radiology 2009; 252:737-46. [DOI: 10.1148/radiol.2523082219] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Abstract
BACKGROUND With the routine use of improved imaging modalities, more benign liver lesions are detected nowadays. An accurate characterization of these incidental lesions may be a challenge, and frequently a biopsy or even unnecessary surgery is being performed. However, these interventions are not always to the benefit of the patient. METHODS A Medline search of studies relevant to imaging diagnosis and management of the most common, benign, solid and non-solid liver lesions was undertaken. References from identified articles were handsearched for further relevant articles. The authors' own experiences with benign liver lesions were also taken into account. RESULTS Although atypical imaging features are the exception rather than the rule, it is sometimes difficult to differentiate between benign and malignant lesions, and knowledge of their imaging features is essential if unnecessary work-up is to be avoided. The use of tissue-specific contrast media, which has clearly improved the accuracy of highly advanced radiological techniques, may be helpful during differential diagnosis. Once having established an accurate diagnosis, surgery is rarely indicated for a benign liver lesion because of its asymptomatic nature. CONCLUSION Knowledge of imaging features and a clear management strategy during diagnostic work-up, emphasizing the indications for surgery, will minimize the number of patients who have to undergo biopsy or unnecessary surgery.
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Affiliation(s)
- Türkan Terkivatan
- Department of Surgery, Erasmus University Medical Center Rotterdam, The Netherlands
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Coronel F, Navarro F. [Resection of a giant hepatic lymph node]. Cir Esp 2009; 85:253-4. [PMID: 19281970 DOI: 10.1016/j.ciresp.2008.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2008] [Accepted: 04/09/2008] [Indexed: 10/21/2022]
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Deneve JL, Pawlik TM, Cunningham S, Clary B, Reddy S, Scoggins CR, Martin RCG, D'Angelica M, Staley CA, Choti MA, Jarnagin WR, Schulick RD, Kooby DA. Liver cell adenoma: a multicenter analysis of risk factors for rupture and malignancy. Ann Surg Oncol 2009; 16:640-8. [PMID: 19130136 DOI: 10.1245/s10434-008-0275-6] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2008] [Revised: 11/04/2008] [Accepted: 11/07/2008] [Indexed: 12/23/2022]
Abstract
BACKGROUND Liver cell adenoma (LCA) is a benign hepatic tumor with poorly characterized risk for spontaneous rupture and malignant transformation. METHODS Records from five tertiary hepatobiliary centers were reviewed for all patients treated for LCA from 1997 to 2006. Clinicopathological data were collected and analyzed, and factors that were associated with rupture and/or malignant transformation were assessed by using multivariable logistic regression. RESULTS A total of 124 patients were analyzed, of which 8 (6.5%) were men; 119 patients underwent resection, and 5 patients had embolic therapy only. Mean patient age was 39+/-11 years, and 55% had history of hormone use. Rupture occurred in 31 (25%) cases. Ruptured tumors were larger (10.5+/-4.5 cm vs. 7.2+/-4.8 cm; p=0.001), and no tumor <5 cm ruptured. Patients with ruptured LCAs were more likely to require preoperative blood transfusion (32% vs. 9%, p=0.006), preoperative embolization (16% vs. 1%, p=0.021), and major (>or=3 segments) hepatic resection (65% vs. 32%, p=0.003). By multivariate analysis, increasing tumor size (odds ratio (OR), 7.8; 95% confidence interval (CI), 2.2-26.3; p<0.01) and recent (within 6 months) hormone use (OR, 4.5; 95% CI, 1.5-13.3; p<0.01) remained independently associated with risk of rupture. Five cases (4%) had evidence of underlying malignancy, but none had LCA <8 cm in diameter. CONCLUSION In this multicenter analysis of patients with LCAs, risk of rupture correlated with increasing tumor size and recent hormone use. Rupture is associated with greater need for preoperative blood transfusion and major hepatic resection. These data suggest that patients with asymptomatic LCAs approaching 4 cm and those requiring hormonal therapy should undergo surgical therapy.
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Affiliation(s)
- Jeremiah L Deneve
- Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
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Ribeiro Junior MAF, Chaib E, Saad WA, D’Albuquerque LAC, Cecconello I. Surgical management of spontaneous ruptured hepatocellular adenoma. Clinics (Sao Paulo) 2009; 64:775-779. [PMID: 19690662 PMCID: PMC2728191 DOI: 10.1590/s1807-59322009000800011] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Accepted: 05/20/2009] [Indexed: 02/08/2023] Open
Abstract
AIMS Spontaneous ruptured hepatocellular adenoma (SRHA) is a rare life-threatening condition that may require surgical treatment to control hemorrhaging and also stabilize the patient. We report a series of emergency surgeries performed at our institution for this condition. METHODS We reviewed medical records and radiology files of 28 patients (from 1989 to 2006) with a proven diagnosis of hepatocellular adenoma (HA). Three (10.7%) of 28 patients had spontaneous ruptured hepatocellular adenoma, two of which were associated with intrahepatic hemorrhage while one had intraperitoneal bleeding. Two patients were female and one was male. Both female patients had a background history of oral contraceptive use. Sudden abdominal pain associated with hemodynamic instability occurred in all patients who suffered from spontaneous ruptured hepatocellular adenoma. The mean age was 41.6 years old. The preoperative assessment included liver function tests, ultrasonography and computed tomography. RESULTS The surgical approaches were as follows: right hemihepatectomy for controlling intraperitoneal bleeding, and right extended hepatectomy and non-anatomic resection of the liver for intrahepatic hemorrhage. There were no deaths, and the postoperative complications were bile leakage and wound infection (re-operation), as well as intraperitoneal abscess (re-operation) and pleural effusion. CONCLUSION Spontaneous ruptured hepatocellular adenoma may be treated by surgery for controlling hemorrhages and stabilizing the patient, and the decision to operate depends upon both the patient's condition and the expertise of the surgical team.
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Affiliation(s)
- Marcelo Augusto Fontenelle Ribeiro Junior
- Department of Gastroeneterology, Liver and Portal Hypertension Unit, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil, E-mail:
, Tel: 55 11 3845.5820
| | - Eleazar Chaib
- Department of Gastroeneterology, Liver and Portal Hypertension Unit, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil, E-mail:
, Tel: 55 11 3845.5820
| | - William Abrão Saad
- Department of Gastroeneterology, Liver and Portal Hypertension Unit, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil, E-mail:
, Tel: 55 11 3845.5820
| | - Luiz Augusto Carneiro D’Albuquerque
- Department of Gastroeneterology, Liver and Portal Hypertension Unit, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil, E-mail:
, Tel: 55 11 3845.5820
| | - Ivan Cecconello
- Department of Gastroeneterology, Liver and Portal Hypertension Unit, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil, E-mail:
, Tel: 55 11 3845.5820
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Abstract
Hepatic surgery has made substantial advances in the last two decades due to technical developments and improvements in perioperative management. This has reduced surgery dependent mortality to less than 5%, and provides the possibility of carrying out more substantial hepatic resections and to interpret the indications more liberally, also for tumours localized unfavorably. A widely standardized surgical technique as well as new possibilities for organ conservation and, in particular, immunosuppression mean that given suitable indications, liver transplantation is today regarded as a routine procedure for the treatment of hepatocellular carcinoma. This work provides an overview of the current status of surgical therapy for the most frequent, benign liver tumours, as well as for hepatocellular and cholangiocellular carcinoma.
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Affiliation(s)
- H Lang
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, 45122, Hufelandstrasse 55, Essen, Germany.
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