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  • • Most hepatic masses are benign

    • Major diagnoses:

    • -Adenoma

      -Hemangioma

      -Focal nodular hyperplasia

      -Cysts

      -Angiomyolipoma

      -Regenerative nodules

    • Estrogens or anabolic steroids can be associated with adenomas, hemangioma growth, and focal nodular hyperplasia

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Epidemiology

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  • • Adenomas occur primarily in women 20-40 years of age

    • Hemangioma most common benign tumor of liver, affecting 7%

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Symptoms and Signs

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  • • Most asymptomatic and seen on imaging studies performed for other reasons

    • Pain (right upper quadrant or epigastric)

    • Early satiety

    • Hemorrhage

    • Jaundice

    • Kasabach-Merritt syndrome (consumptive coagulopathy in infantile hemangiomatosis)

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Laboratory Findings

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  • • Mostly normal

    • Occasionally, elevated transaminases, bilirubin, thrombocytopenia, or coagulopathy

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Imaging Findings

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  • Ademoma: Homogeneous hyperintense on T1 or T2 MRI or CT, but 10-20% with hemorrhagic areas making appearance heterogenous

    • -PET scan with decreased uptake when compared with hepatocellular carcinoma or metastatic disease

    Hemangioma: Early peripheral enhancement with IV contrast on CT, MRI, or tagged red cell scan followed by centripetal pooling (MRI and CT- lesion hypodense before contrast)

    Focal nodular hyperplasia: CT or MRI showing stellate scar and enhancement with IV contrast, sulfur colloid or superparmagnetic iron oxide uptake (with MRI)

    Cysts: Hypointense or water density on US, CT, or MRI with no septations

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  • • History of previous malignant disease

    • History of previous hepatitis or cirrhosis

    • History of other infections (eg, HIV)

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Rule Out

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  • • Malignant hepatic tumor with resection often being necessary to secure diagnosis

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  • • CBC

    • Liver function tests

    • Alpha-fetoprotein (AFP), CA 19-9, CA 125, carcinoembryonic antigen (CEA)

    • History and physical exam

    • US, CT, or MRI depending on overall suspicion of diagnosis

    • Intraoperative US if resection is planned

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When to Admit

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  • • Tumor with symptomatic hemorrhage

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Surgery

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  • • Enucleation if diagnosis is secure

    • Formal anatomic resection if diagnosis is in doubt

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Indications

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  • • Symptomatic lesions or when diagnosis in doubt

    • Adenomas over 5 cm

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Contraindications

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  • • Medical comorbidity associated with too high a risk for general anesthesia

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Medications

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  • • Discontinue estrogens or androgens for suspected adenomas, focal nodular hyperplasia, or hemangiomas

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Treatment Monitoring

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  • • Individualized based on recurrence of symptoms following resection

    • Serial CT scans to verify stability of lesion for presumed benign lesions for 2 years or when symptoms change

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Complications

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  • • Liver failure

    • Hemorrhage

    • Biliary injury

    • Perihepatic infection

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References

Bioulac-Sage P et al. Diagnosis of focal nodular hyperplasia: not so easy. Am J Surg Pathol. 2001;25:1322.  [PubMed: 11688469]
Terkivatan T et al. Indications and ...

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