Hepatic Neoplasms, Benign

• • 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

Epidemiology

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

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

Symptoms and Signs

• • 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)

Laboratory Findings

• • Mostly normal

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

Imaging Findings

• • 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

• • History of previous malignant disease

  • History of previous hepatitis or cirrhosis

  • History of other infections (eg, HIV)

Rule Out

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

• • 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

When to Admit

• • Tumor with symptomatic hemorrhage

Surgery

• • Enucleation if diagnosis is secure

  • Formal anatomic resection if diagnosis is in doubt

Indications

• • Symptomatic lesions or when diagnosis in doubt

  • Adenomas over 5 cm

Contraindications

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

Medications

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

Treatment Monitoring

• • 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

Complications

• • Liver failure

  • Hemorrhage

  • Biliary injury

  • Perihepatic infection

References