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Haring MPD, Cuperus FJC, Duiker EW, de Haas RJ, de Meijer VE. Scoping review of clinical practice guidelines on the management of benign liver tumours. BMJ Open Gastroenterol 2021; 8:bmjgast-2020-000592. [PMID: 34362758 PMCID: PMC8351490 DOI: 10.1136/bmjgast-2020-000592] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 07/18/2021] [Indexed: 12/18/2022] Open
Abstract
Objective Benign liver tumours (BLT) are increasingly diagnosed as incidentalomas. Clinical implications and management vary across and within the different types of BLT. High-quality clinical practice guidelines are needed, because of the many nuances in tumour types, diagnostic modalities, and conservative and invasive management strategies. Yet, available observational evidence is subject to interpretation which may lead to practice variation. Therefore, we aimed to systematically search for available clinical practice guidelines on BLT, to critically appraise them, and to compare management recommendations. Design A scoping review was performed within MEDLINE, EMBASE, and Web of Science. All BLT guidelines published in peer-reviewed, and English language journals were eligible for inclusion. Clinical practice guidelines on BLT were analysed, compared, and critically appraised using the Appraisal of Guidelines, Research and Evaluation (AGREE II) checklist regarding hepatic haemangioma, focal nodular hyperplasia (FNH), and hepatocellular adenoma (HCA). Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations (PRISMA) for scoping reviews were adhered to. Results The literature search yielded unique 367 papers, 348 were excluded after screening of title/abstract, and 16 after full-text screening. Three guidelines were included: the American College of Gastroenterology (ACG; 2014), Brazilian Society of Hepatology (SBH; 2015), and European Association for the Study of the Liver (EASL; 2016). There was no uniformity in the assessment methods for grading and gravity of recommendations between guidelines. Among observed differences were: (1) indications for biopsy in all three tumours; (2) advices on contraceptive pills and follow-up in FNH and HCA; (3) use of an individualised approach to HCA; (4) absence of recommendations for treatment of HCA in men; and (5) approaches to HCA subtype identification on magnetic resonance imaging. Conclusion Recognising differences in recommendations can assist in harmonisation of practice standards and identify unmet needs in research. This may ultimately contribute to improved global patient care.
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Affiliation(s)
- Martijn P D Haring
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Frans J C Cuperus
- Department of Hepatology and Gastroenterology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Evelien W Duiker
- Department of Medical Biology and Pathology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Robbert J de Haas
- Department of Radiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
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2
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Tsekouras K, Spartalis E, Mamakos N, Tsourouflis G, Nikiteas NI, Dimitroulis D. The Use of Robotics in Surgery of Benign Liver Diseases: A Systematic Review. Surg Innov 2021; 29:258-268. [PMID: 34275339 DOI: 10.1177/15533506211031414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Surgical treatment of benign liver diseases (BLD) remains a field of conflict, due to increased risk and high complication rate. However, the introduction of minimally invasive surgery has led to increased number of patients with BLD being treated surgically, with similar outcomes and fewer complications. Current data support the application of laparoscopic surgery (LS) and robotic surgery (RS) in surgical treatment of liver malignancies, but there are insufficient data concerning the application of robotic surgery in BLD. In the present systematic review, we aimed to evaluate the application of RS in BLD surgery. METHODS After a thorough search of Medline, Scopus, and Cochrane Library, 12 studies were considered eligible with a total number of 115 patients with BLD. DISCUSSION In brief, RS appears to be a safe and feasible option for BLD surgery. When compared to open surgery, RS is associated with lower blood loss, shorter length of stay, and fewer complication rate. Regarding LS, the peri- and postoperative outcomes were similar, but RS can overcome the technical limitations of LS. However, the cost of RS remains a major drawback in its widespread application. CONCLUSIONS Considering our findings, RS can be a safe and feasible option for BLD surgery, but further studies are needed to justify the introduction of RS in liver surgery and to define the type of patients that will benefit the most from it.
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Affiliation(s)
- Konstantinos Tsekouras
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens Medical School, 68989National and Kapodistrian University of Athens, Athens, Greece
| | - Eleftherios Spartalis
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens Medical School, 68989National and Kapodistrian University of Athens, Athens, Greece.,Second Department of Propaedeutic Surgery, Laiko Hospital, Athens Medical School, 68993National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Mamakos
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens Medical School, 68989National and Kapodistrian University of Athens, Athens, Greece
| | - Gerasimos Tsourouflis
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens Medical School, 68989National and Kapodistrian University of Athens, Athens, Greece.,Second Department of Propaedeutic Surgery, Laiko Hospital, Athens Medical School, 68993National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos I Nikiteas
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens Medical School, 68989National and Kapodistrian University of Athens, Athens, Greece.,Second Department of Propaedeutic Surgery, Laiko Hospital, Athens Medical School, 68993National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Dimitroulis
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens Medical School, 68989National and Kapodistrian University of Athens, Athens, Greece.,Second Department of Propaedeutic Surgery, Laiko Hospital, Athens Medical School, 68993National and Kapodistrian University of Athens, Athens, Greece
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Abstract
OBJECTIVE To describe the MRI findings of the effects of exogenous sex steroids on the liver. FINDINGS Estrogens, progesterone and synthetic testosterone are exogenous sex steroids that may result in a variety of liver diseases, including tumour formation and vascular disorders. These hormones are mainly administered in the form of the oral contraceptive pill (OCP) and anabolic steroids. Both are implicated in hepatic adenoma formation. The HNF-1α-mutated and inflammatory adenoma subgroups are more commonly seen in association with the OCP whereas there is an increased incidence of the β-catenin positive subtype with anabolic steroid use. Furthermore, anabolic steroids are associated with hepatocellular carcinoma resulting from malignant transformation of β-catenin positive adenomas. The oral contraceptive pill may also induce vascular disorders within the liver, some of which are related to the prothrombotic effect of the hormones, such as hepatic and portal vein thrombosis. Other hepatic vascular abnormalities resulting from exogenous sex steroids include veno-occlusive disease and peliosis hepatis.
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4
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Zhang G, Wang M, Duan F, Yuan K, Yan J, Chang Z. Early- and intermediate-term outcome of transarterial embolization for symptomatic hepatic focal nodular hyperplasia. J Interv Med 2019; 1:86-91. [PMID: 34805835 PMCID: PMC8586580 DOI: 10.19779/j.cnki.2096-3602.2018.02.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Purpose: To evaluate the early- and intermediate-term outcome in patients with symptomatic hepatic focal nodular hyperplasia (FNH) treated with transarterial embolization using bleomycin-iodinated oil and polyvinyl alcohol (PVA) particles. Materials and methods: In this two-center retrospective study between January 2005 and December 2013, 27 consecutive patients with symptomatic hepatic FNH underwent superselective catheterization by microcatheter techniques and embolization using bleomycin-iodinated oil combined with PVA. Early-term (3-41 months) follow-up of TAE was performed in terms of symptom control, changes in lesion size, and complications. Intermediate-term (45-112 months) follow-up was carried out to assess symptom control and reinterventions for recurrence. Results: Embolization was performed in 27 patients with 31 lesions. Technical success was achieved in all cases. The follow-up period ranged from three to 112 months. At early-term follow-up, mean lesion diameters were decreased significantly from 6.4±2.7 cm pre-intervention to 3.6±1.8 cm at 3-9 months after embolization (P<0.001). A total of 7 lesions had complete resolution during the whole follow-up period. At intermediate-term follow-up, local recurrence was found in 1 treated lesion at 54-months. Contrast-enhanced scans showed complete lack of residual arterial blood supply in the majority of lesions during the follow-up period. There was no major complication associated with the procedure. Conclusion: Transarterial embolization using bleomycin-iodinated oil and PVA is a feasible, safe and effective alternative in both early- and intermediate-terms for the treatment of symptomatic hepatic FNH.
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Affiliation(s)
- Guodong Zhang
- Department of Interventional Radiology, Chinese PLA General Hospital, 28# Fuxing RD, Beijing 100853, China,Department of Interventional Radiology, Shandong medical imaging research institute, Shandong University, 324# Jingwu Rd, Jinan 250021, China
| | - Maoqiang Wang
- Department of Interventional Radiology, Chinese PLA General Hospital, 28# Fuxing RD, Beijing 100853, China,Correspondence: Wang MQ, M.D., Department of Interventional Radiology, Chinese PLA General Hospital, Beijing 100853, P.R. China.
| | - Feng Duan
- Department of Interventional Radiology, Chinese PLA General Hospital, 28# Fuxing RD, Beijing 100853, China
| | - Kai Yuan
- Department of Interventional Radiology, Chinese PLA General Hospital, 28# Fuxing RD, Beijing 100853, China
| | - Jieyu Yan
- Department of Interventional Radiology, Chinese PLA General Hospital, 28# Fuxing RD, Beijing 100853, China
| | - Zhongfei Chang
- Department of Interventional Radiology, Chinese PLA General Hospital, 28# Fuxing RD, Beijing 100853, China
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5
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Hoffmann K, Unsinn M, Hinz U, Weiss KH, Waldburger N, Longerich T, Radeleff B, Schirmacher P, Büchler MW, Schemmer P. Outcome after a liver resection of benign lesions. HPB (Oxford) 2015; 17:994-1000. [PMID: 26456947 PMCID: PMC4605338 DOI: 10.1111/hpb.12496] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 07/08/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Benign liver tumours represent a challenge in clinical management. There is considerable controversy with respect to the indications for surgery as the evidence for surgical treatment is variable. The aim of this retrospective study was to analyse the indication and outcome after resection of benign, solid liver lesions. METHODS Data of 79 patients, who underwent liver resection between 2001 and 2012, were analysed for demographic and outcome parameters. RESULTS Thirty-eight patients with focal nodular hyperplasia (48%), 23 patients with haemangioma (29%) and 18 patients with hepatocellular adenoma (23%) underwent a hepatic resection. A major hepatic resection was performed in 23 patients (29%) and a minor resection in 56 patients (71%). The post-operative mortality rate was zero and the 30-day morbidity rate 13.9%. After a median follow-up of 64 months, 75 patients (95%) were alive, and no patient had developed recurrent disease. Fifty-four patients (68%) were pre-operatively symptomatic, of which, 87% had complete or partial relief of symptoms after a liver resection. The incidence of symptoms increased with the lesions' size. DISCUSSION The management of benign liver lesions necessitates an individualized therapy within a multidisciplinary, evidence-based, treatment algorithm. Resection of benign liver lesions can be performed safely in well-selected patients without mortality and low post-operative morbidity.
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Affiliation(s)
- Katrin Hoffmann
- Department of General and Transplant Surgery, University Hospital HeidelbergHeidelberg, Germany,Internal Medicine IV, University Hospital HeidelbergHeidelberg, Germany
| | - Michael Unsinn
- Department of General and Transplant Surgery, University Hospital HeidelbergHeidelberg, Germany,Internal Medicine IV, University Hospital HeidelbergHeidelberg, Germany
| | - Ulf Hinz
- Department of General and Transplant Surgery, University Hospital HeidelbergHeidelberg, Germany
| | - Karl Heinz Weiss
- Internal Medicine IV, University Hospital HeidelbergHeidelberg, Germany,Department of Radiology, University Hospital HeidelbergHeidelberg, Germany
| | - Nina Waldburger
- Internal Medicine IV, University Hospital HeidelbergHeidelberg, Germany,Institute of Pathology, University Hospital HeidelbergHeidelberg, Germany
| | - Thomas Longerich
- Internal Medicine IV, University Hospital HeidelbergHeidelberg, Germany,Institute of Pathology, University Hospital HeidelbergHeidelberg, Germany
| | - Boris Radeleff
- Internal Medicine IV, University Hospital HeidelbergHeidelberg, Germany,Liver Cancer Center Heidelberg, University Hospital HeidelbergHeidelberg, Germany
| | - Peter Schirmacher
- Internal Medicine IV, University Hospital HeidelbergHeidelberg, Germany,Institute of Pathology, University Hospital HeidelbergHeidelberg, Germany
| | - Markus W Büchler
- Department of General and Transplant Surgery, University Hospital HeidelbergHeidelberg, Germany,Internal Medicine IV, University Hospital HeidelbergHeidelberg, Germany
| | - Peter Schemmer
- Department of General and Transplant Surgery, University Hospital HeidelbergHeidelberg, Germany,Internal Medicine IV, University Hospital HeidelbergHeidelberg, Germany
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Hau HM, Atanasov G, Tautenhahn HM, Ascherl R, Wiltberger G, Schoenberg MB, Morgül MH, Uhlmann D, Moche M, Fuchs J, Schmelzle M, Bartels M. The value of liver resection for focal nodular hyperplasia: resection yes or no? Eur J Med Res 2015; 20:86. [PMID: 26494164 PMCID: PMC4619214 DOI: 10.1186/s40001-015-0181-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 10/08/2015] [Indexed: 12/21/2022] Open
Abstract
Background Focal nodular hyperplasia (FNH) are benign lesions in the liver. Although liver resection is generally not indicated in these patients, rare indications for surgical approaches indeed exist. We here report on our single-center experience with patients undergoing liver resection for FNH, focussing on preoperative diagnostic algorithms and quality of life (QoL) after surgery. Methods Medical records of 100 consecutive patients undergoing liver resection for FNH between 1992 and 2012 were retrospectively analyzed with regard to diagnostic pathways and indications for surgery. Quality of life (QoL) before and after surgery was evaluated using validated assessment tools. Student’s t test, one-way ANOVA, χ2, and binary logistic regression analyses such as Wilcoxon–Mann–Whitney test were used, as indicated. Results A combination of at least two preoperative diagnostic imaging approaches was applied in 99 cases, of which 70 patients were subjected to further imaging or tumor biopsy. In most patients, there was more than one indication for liver resection, including tumor-associated symptoms with abdominal discomfort (n = 46, 40.7 %), balance of risk for malignancy/history of cancer (n = 54, 47.8 %/n = 18; 33.3 %), tumor enlargement/jaundice of vascular and biliary structures (n = 13, 11.5 %), such as incidental findings during elective operation (n = 1, 0.9 %). Postoperative morbidity was 19 %, with serious complications (>grade 2, Clavien–Dindo classification) being evident in 8 %. Perioperative mortality was 0 %. Liver resection was associated with a significant overall improvement in general health (very good–excellent: preoperatively 47.4 % vs. postoperatively 68.1 %; p = 0.015). Conclusions Liver resection remains a valuable therapeutic option in the treatment of either symptomatic FNH or if malignancy cannot finally be ruled out. If clinically indicated, liver resection for FNH represents a safe approach and may lead to significant improvements of QoL especially in symptomatic patients. Electronic supplementary material The online version of this article (doi:10.1186/s40001-015-0181-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hans Michael Hau
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany.
| | - Georgi Atanasov
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany. .,Department of General, Visceral, Vascular and Thoracic Surgery, Charité-University Hospital of Berlin, Berlin, Germany.
| | - Hans-Michael Tautenhahn
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany. .,Translational Centre for Regenerative Medicine, University of Leipzig, Leipzig, Germany.
| | - Rudolf Ascherl
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany.
| | - Georg Wiltberger
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany.
| | - Markus Bo Schoenberg
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany.
| | - Mehmet Haluk Morgül
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany.
| | - Dirk Uhlmann
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany.
| | - Michael Moche
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig, Germany.
| | - Jochen Fuchs
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig, Germany.
| | - Moritz Schmelzle
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany. .,Translational Centre for Regenerative Medicine, University of Leipzig, Leipzig, Germany. .,Department of General, Visceral, Vascular and Thoracic Surgery, Charité-University Hospital of Berlin, Berlin, Germany.
| | - Michael Bartels
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany.
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7
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Kim Y, Amini N, He J, Margonis GA, Weiss M, Wolfgang CL, Makary M, Hirose K, Spolverato G, Pawlik TM. National trends in the use of surgery for benign hepatic tumors in the United States. Surgery 2015; 157:1055-64. [PMID: 25769697 DOI: 10.1016/j.surg.2015.01.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 12/16/2014] [Accepted: 01/22/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND The widespread use of diagnostic imaging has led to an increase in the incidence and diagnosis of benign liver tumors. The objective of this study was to define the overall use and temporal trends of operative procedures for benign liver tumors using a nationally representative cohort. METHODS All patients who underwent liver surgery for benign liver tumors between 2000 and 2011 were identified from the Nationwide Inpatient Sample database. Trends in annual volume of liver procedures were analyzed using the average annual percent change (AAPC) assessed by joinpoint analysis. RESULTS There were 2,489 open (94.5%) and 144 (5.5%) minimally invasive surgical (MIS) procedures. Partial hepatectomy accounted for 43.8% of all cases (n = 1,153). Surgery for patients with benign liver tumors increased from 156 in 2000 to 272 in 2011 (AAPC, 5.8%; 95% CI, 3.2-8.6%). There was decline in the relative use of open operative procedures from 98.1% in 2000 to 92.3% in 2011 (AAPC, -0.4%; 95% CI, -0.7 to -0.1%). In contrast, the proportion of MIS procedures increased from 1.9% in 2000 to 7.7% in 2011 (AAPC, 7.4%; 95% CI, 1.9-13.3%). The median duration of stay among all patients was 5 days (interquartile range, 4-7; 5 days [open] vs 3 days [MIS]; P < .001). Inpatient mortality was 0.6% (n = 15 [open] vs n = 0 [MIS]; P = .43) and did not change during the study period (P > .05). CONCLUSION Overall volume of surgical management of benign liver tumors has increased substantially over the past decade. There has been a relative shift away from open procedures toward MIS procedures.
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Affiliation(s)
- Yuhree Kim
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Neda Amini
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jin He
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Georgios A Margonis
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Matthew Weiss
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Martin Makary
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kenzo Hirose
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Gaya Spolverato
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
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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: 64] [Impact Index Per Article: 6.4] [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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Navarro AP, Gomez D, Lamb CM, Brooks A, Cameron IC. Focal nodular hyperplasia: a review of current indications for and outcomes of hepatic resection. HPB (Oxford) 2014; 16:503-11. [PMID: 24127684 PMCID: PMC4048071 DOI: 10.1111/hpb.12169] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 06/28/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Focal nodular hyperplasia (FNH) is a common benign disease of the liver with no recognized potential for malignant transformation. The term describes an entity of lobular proliferation of normally differentiated hepatocytes, frequently around a central fibrous scar. Two key issues influence surgical decision making in FNH: diagnostic certainty, and symptomatic assessment. METHODS A systematic review of studies reporting hepatic resections of FNH was performed. Indications and outcomes in adult populations were examined with a focus on diagnostic workup, patient selection and operative mortality and morbidity. RESULTS Diagnostic modalities in the majority of studies involved ultrasound and computed tomography. Fewer than half employed magnetic resonance imaging (MRI). In instances in which MRI was not available, diagnostic accuracy was inferior. CONCLUSIONS Percutaneous biopsy should be avoided to prevent the risk for tumour seeding. Patients presenting with asymptomatic definitive FNH can be safely managed conservatively. In symptomatic patients surgical resection is a safe and effective treatment for which acceptable rates of morbidity (14%) and zero mortality are reported. However, evidence of symptom resolution is reported with conservative strategies. Diagnostic uncertainty remains the principal valid indication for FNH resection, but only in patients in whom contrast-enhanced MRI forms part of preoperative assessment.
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Affiliation(s)
- Alex P Navarro
- Department of Hepatobiliary and Pancreatic Surgery, Queen's Medical Centre, Nottingham University Hospitals National Health Service (NHS) Trust, Nottingham, UK
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10
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Bieze M, Busch ORC, Tanis PJ, Verheij J, Phoa SSKS, Gouma DJ, van Gulik TM. Outcomes of liver resection in hepatocellular adenoma and focal nodular hyperplasia. HPB (Oxford) 2014; 16:140-9. [PMID: 23509949 PMCID: PMC3921009 DOI: 10.1111/hpb.12087] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 02/01/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The clinical management of hepatocellular adenoma (HCA) and focal nodular hyperplasia (FNH) is still subject to controversy, especially with respect to patient selection for surgery. The aim of this prospective cohort study was to assess the outcomes of surgical intervention. METHODS Between January 2008 and September 2012, patients diagnosed with FNH or HCA based on magnetic resonance imaging or computed tomography were enrolled in this prospective study. Resection was undertaken in patients with HCA of > 5 cm or symptomatic lesions. Lesion characteristics, extent of liver resection (minor: fewer than three segments; major: three or more segments), morbidity (by Dindo-Clavien class), mortality, postoperative length of stay and symptoms [McGill Pain Questionnaire, including a visual analogue scale (VAS)] were evaluated. RESULTS A total of 110 patients (106 female; median age: 39 years) were included; 51 patients had HCA and 59 had FNH. Of the 110 patients, 49 underwent resection (33 HCA patients; 16 FNH patients). Laparoscopic minor resection was performed in five HCA and five FNH patients; open minor resection was performed in 19 HCA and seven FNH patients, and open major resection was performed in nine HCA and four FNH patients. Severe postoperative complications were observed in four patients (Grade III, n = 3; Grade IV, n = 1). Median baseline scores on the VAS were 6 in FNH patients and 7 in HCA patients; the median VAS score after resection was 0 (P = 0.008). CONCLUSIONS If patients with HCA and FNH require surgery, limited resection can be carried out with low morbidity and without mortality. Patients with preoperative symptoms show a high rate of postoperative symptom relief.
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Affiliation(s)
- Matthanja Bieze
- Department of Surgery, Academic Medical CentreAmsterdam, the Netherlands,Matthanja Bieze, Academic Medical Centre, IWO 1-A1-132, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands. Tel: + 31 20 566 6653. Fax: + 31 20 697 6621. E-mail:
| | - Olivier R C Busch
- Department of Surgery, Academic Medical CentreAmsterdam, the Netherlands
| | - Pieter J Tanis
- Department of Surgery, Academic Medical CentreAmsterdam, the Netherlands
| | - Joanne Verheij
- Department of Pathology, Academic Medical CentreAmsterdam, the Netherlands
| | - Saffire S K S Phoa
- Department of Radiology, Academic Medical CentreAmsterdam, the Netherlands
| | - Dirk J Gouma
- Department of Surgery, Academic Medical CentreAmsterdam, the Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Academic Medical CentreAmsterdam, the Netherlands
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11
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MR Imaging of Hepatocellular Adenomas and Differential Diagnosis Dilemma. Int J Hepatol 2013; 2013:374170. [PMID: 23606972 PMCID: PMC3623472 DOI: 10.1155/2013/374170] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2012] [Accepted: 01/24/2013] [Indexed: 12/22/2022] Open
Abstract
HEPATOCELLULAR ADENOMAS (HCAS) ARE CURRENTLY CATEGORIZED INTO DISTINCT GENETIC AND PATHOLOGIC SUBTYPES AS FOLLOWS: inflammatory hepatocellular adenoma, hepatocyte-nuclear-factor-1-alpha (HNF-1 α -mutated) hepatocellular adenoma, and β -catenin-mutated hepatocellular adenomas; the fourth, defined as unclassified subtype, encompasses HCAs without any genetic abnormalities. This classification has accepted management implications due to different risks of haemorrhage and malignant transformation of the four subtypes. Imaging guided biopsy and/or surgical resection very important in obtaining definitive characterization; nevertheless, MRI with intra-extravascular and hepatobiliary (dual phase) agents, is an important tool not only in differential subtypes definition but even in surveillance with early identification of complications and discovery of some signs of HCA malignant degeneration. Inflammation, abnormal rich vascularisation, peliotic areas, and abundant fatty infiltration are pathologic findings differently present in the HCA subtypes and they may be detected by multiparametric MRI approach. Lesion enlargement and heterogeneity of signal intensity and of contrast enhancement are signs to be considered in malignant transformation. The purpose of this paper is to present the state of the art of MRI in the diagnosis of HCA and subtype characterization, with particular regard to morphologic and functional information available with dual phase contrast agents, and to discuss differential diagnosis with the most common benign and malignant lesions mimicking HCAs.
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Focal nodular hyperplasia--a review of myths and truths. J Gastrointest Surg 2011; 15:2275-83. [PMID: 21959783 DOI: 10.1007/s11605-011-1680-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2011] [Accepted: 09/07/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Focal nodular hyperplasia (FNH) is a benign hyperplastic lesion of the liver with no known malignant potential. It has generated much interest due to the frequency with which it presents with atypical features on radiological imaging. Often resulting in misdiagnosis. Moreover, the understanding of particular subtypes of this lesion at a molecular level has changed in recent years. This may have implications on how certain subtypes should be managed. PURPOSE This review aims to analyse current literature pertaining to FNH and to provide clinically relevant advice regarding diagnosis and management.
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Gadoxetate disodium-enhanced MRI of the liver: part 1, protocol optimization and lesion appearance in the noncirrhotic liver. AJR Am J Roentgenol 2010; 195:13-28. [PMID: 20566794 DOI: 10.2214/ajr.10.4392] [Citation(s) in RCA: 250] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The purpose of this article is to review the pharmacokinetic and pharmacodynamic properties of gadoxetate disodium (Gd-EOB-DTPA), to describe a workflow-optimized pulse sequence protocol, and to illustrate the imaging appearance of focal lesions in the noncirrhotic liver. CONCLUSION Gd-EOB-DTPA allows a comprehensive evaluation of the liver with the acquisition of both dynamic and hepatocyte phase images. This provides potential additional information, especially for the detection and characterization of small liver lesions. However, protocol optimization is necessary for improved image quality and workflow.
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Sclerosing haemangiomas of the liver: two cases of mistaken identity. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2009; 2009:473591. [PMID: 20066166 PMCID: PMC2804040 DOI: 10.1155/2009/473591] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2009] [Revised: 08/26/2009] [Accepted: 11/09/2009] [Indexed: 11/26/2022]
Abstract
We describe two cases where patients undergoing hepatic resection for metastatic disease of colorectal origin were found to have concomitant sclerosing haemangiomas. The typical radiological and histological appearances of these lesions are discussed.
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Assy N, Assy N, Samuel N, Lerman A, Nseir W. Approach to Solid Liver Masses in the Cirrhotic Patient. Gastroenterology Res 2009; 2:259-267. [PMID: 27956969 PMCID: PMC5139772 DOI: 10.4021/gr2009.10.1314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/17/2009] [Indexed: 12/27/2022] Open
Abstract
Liver masses in cirrhosis are increasingly being recognized with the use of new imaging modalities. The majority of these lesions are detected by ultrasound, enhanced CT and MRI. The most likely diagnosis of a solid liver lesion in a cirrhotic liver is hepatocellular carcinoma, followed by high grade or low grade dysplastic nodule, and cholangiocarcinoma. Lymphoma and liver metastasis are extremely rare. Diagnosis is made by contrast enhanced ultrasound, multi detector (MDCT) and MRI. Fine needle core biopsy (FNCB) or aspiration (FNAB) or both may be required in doubtful cases. If uncertainty persists on the nature of the lesion, surgical liver resection is recommended. This review discusses the main characteristics of the most common solid liver masses in cirrhotic patient.
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Affiliation(s)
- Nimer Assy
- Liver Unit, Ziv Medical Center, Safed, Israel; Technion Institute, Haifa, Israel
| | - Najib Assy
- Liver Unit, Ziv Medical Center, Safed, Israel
| | - Nir Samuel
- Liver Unit, Ziv Medical Center, Safed, Israel
| | - Aracdi Lerman
- Department of Radiology, Ziv Medical Centre, Safed, Israel
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Diener MK, Wolff RF, von Elm E, Rahbari NN, Mavergames C, Knaebel HP, Seiler CM, Antes G. Can decision making in general surgery be based on evidence? An empirical study of Cochrane Reviews. Surgery 2009; 146:444-61. [DOI: 10.1016/j.surg.2009.02.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2008] [Accepted: 02/20/2009] [Indexed: 10/20/2022]
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Assy N, Nasser G, Djibre A, Beniashvili Z, Elias S, Zidan J. Characteristics of common solid liver lesions and recommendations for diagnostic workup. World J Gastroenterol 2009; 15:3217-27. [PMID: 19598296 PMCID: PMC2710776 DOI: 10.3748/wjg.15.3217] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Due to the widespread clinical use of imaging modalities such as ultrasonography, computed tomography and magnetic resonance imaging (MRI), previously unsuspected liver masses are increasingly being found in asymptomatic patients. This review discusses the various characteristics of the most common solid liver lesions and recommends a practical approach for diagnostic workup. Likely diagnoses include hepatocellular carcinoma (the most likely; a solid liver lesion in a cirrhotic liver) and hemangioma (generally presenting as a mass in a non-cirrhotic liver). Focal nodular hyperplasia and hepatic adenoma should be ruled out in young women. In 70% of cases, MRI with gadolinium differentiates between these lesions. Fine needle core biopsy or aspiration, or both, might be required in doubtful cases. If uncertainty persists as to the nature of the lesion, surgical resection is recommended. If the patient is known to have a primary malignancy and the lesion was found at tumor staging or follow up, histology is required only when the nature of the liver lesion is doubtful.
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Abstract
Benign liver tumors are being detected more frequently due to the widespread use of ultrasound and complementary methods and due to improvements in diagnostic accuracy. In the case of a reliable diagnosis of asymptomatic hemangioma or focal nodular hyperplasia surgery is not indicated. Hepatic adenoma of considerable size should be resected primarily based on the risk of rupture. Improvements in diagnostic imaging as well as the optimization of surgical procedures with extremely low complication rates permit an individualized management strategy founded on evidence-based algorithms. In the case of an equivocal diagnosis, we advocate low-risk tumor resection instead of tumor biopsy due to the inherent complication rates of hemorrhage or tumor-cell dissemination and possible misleading histology.
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Affiliation(s)
- M Loss
- Klinik und Poliklinik für Chirurgie, Klinikum der Universität Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Deutschland.
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Zülke C, Schlitt HJ. [Incidentalomas of the liver and gallbladder. Evaluation and therapeutic procedure]. Chirurg 2007; 78:698-712. [PMID: 17661000 DOI: 10.1007/s00104-007-1388-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The expanding use of ultrasound in general practice is leading to an ever increasing rate of detection of true hepatic incidentaloma. The correct diagnosis of hepatic incidentaloma may be made in over 90% with non-invasive means. The questionable diagnosis of "symptomatic" incidentaloma should undergo close scrutiny prior to a decision in favour of surgery. With regard to more recent literature, the former "absolute" requirement for surgical resection in all cases of liver cell adenoma may have to be reappraised. Final inability to rule out malignancy represents an unquestionable indication for surgery in the light of low rates of morbidity and lack of mortality in this otherwise healthy patient group. Percutaneous biopsies should not be performed due to oncological hazards, indeterminate results and potential for acute complications.The stage-oriented radical re-resection following diagnosis of an incidentally detected gallbladder cancer may lead to significantly improved long-term survival, especially in the early tumour stages T1b and T2, which represents the most common stage of gallbladder cancer in incidentaloma. Patients at elevated risk for incidental gallbladder cancer should undergo thorough instruction with regard to the potential hazards of laparoscopic cholecystectomy. Multimodal therapeutic strategies directed at advanced stages of incidentally detected gallbladder cancer should be evaluated in prospective multicentre studies.
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Affiliation(s)
- Carl Zülke
- Chirurgische Klinik und Poliklinik, Universitätsklinikum Regensburg.
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Sandonato L, Cipolla C, Graceffa G, Bartolotta TV, Li Petri S, Ciacio O, Cannizzaro F, Latteri MA. Giant hepatocellular adenoma as cause of severe abdominal pain: a case report. J Med Case Rep 2007; 1:57. [PMID: 17662116 PMCID: PMC1950307 DOI: 10.1186/1752-1947-1-57] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2007] [Accepted: 07/27/2007] [Indexed: 11/29/2022] Open
Abstract
The authors describe the case of a large hepatocellular adenoma diagnosed in a 30-year old woman who came to us complaining of acute pain in the upper abdominal quadrants. The patient had been taking an oral contraceptive pill for the last ten years. We present the clinical features, the diagnostic work-up and the treatment prescribed.
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Affiliation(s)
- Luigi Sandonato
- Department of Oncology, Division of General and Oncological Surgery, University of Palermo, Palermo, Italy
| | - Calogero Cipolla
- Department of Oncology, Division of General and Oncological Surgery, University of Palermo, Palermo, Italy
| | - Giuseppa Graceffa
- Department of Oncology, Division of General and Oncological Surgery, University of Palermo, Palermo, Italy
| | - Tommaso V Bartolotta
- Department of Radiology Interdepartmental Unit for Hepatic Neoplasia Group, University of Palermo, Palermo, Italy
| | - Sergio Li Petri
- Department of Oncology, Division of General and Oncological Surgery, University of Palermo, Palermo, Italy
| | - Oriana Ciacio
- Department of Oncology, Division of General and Oncological Surgery, University of Palermo, Palermo, Italy
| | - Fabio Cannizzaro
- Department of Radiology Interdepartmental Unit for Hepatic Neoplasia Group, University of Palermo, Palermo, Italy
| | - Mario A Latteri
- Department of Oncology, Division of General and Oncological Surgery, University of Palermo, Palermo, Italy
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