Simultaneous occurrence of hepatic adenoma and focal nodular hyperplasia: report of a case and review of the literature

Patient with a novel syndrome with multiple benign hepatic lesions and extrahepatic neoplasms

Simultaneous occurrence of benign hepatic lesions of different types is a sporadic phenomenon. To the best of our knowledge, we report the first clinical case of a syndrome with simultaneous manifestations of three different entities of benign liver tumors (hepatocellular adenoma, focal nodular hyperplasia and hemangioma) with a novel mutation detected in the liver adenoma and in the presence of a number of further extrahepatic organ neoplasms. Furthermore, we describe for the first time the presence of liver epithelial cells of hepatocytic phenotype expressing cytokeratin 7 (CK7) at the border of the adenoma. These findings may be important for explaining pathogenesis of benign as well as malignant tumors based on genetic and histopathological features.

Hepatic adenomatosis: a rare but important liver disease with severe clinical implications

A 56-year-old white female presented to the emergency room (ER) with acute onset of right upper quadrant abdominal pain, nausea, and vomiting, and she was found to have a sudden drop in hemoglobin. Abdominal computed tomography (CT) with and without intravenous contrast revealed multiple bilobar focal hepatic hypervascular lesions, one of them demonstrating spontaneous rupture with active intraperitoneal bleeding. A moderate hemoperitoneum was present. The patient underwent exploratory laparotomy for right hepatic posterior segmentectomy (right posterior sectionectomy) and peritoneal lavage. The histopathology evaluation revealed multiple liver adenomas. Hepatic adenomatosis is a clinical entity characterized by 10 or more hepatic adenomas. It must be distinguished from isolated hepatic adenoma as it bears a much higher risk of complications, such as spontaneous rupture, hemorrhage and malignant transformation. Here we discuss the radiologic and histopathologic findings of the current case along with a review of the English language medical literature.

A new long term hepatic complication in survivors of childhood haematological malignancy

Hepatic abnormalities have been documented in survivors of childhood malignancies and a spectrum of liver diseases has been described in this group The risk factors for liver disease include: hepatic surgery; radiotherapy to field including liver; total body irradiation (TBI); chemotherapy, multiple blood transfusions and use of hematopoietic cell transplantation. We report three cases of hepatic adenomatosis (HA) in young women who had been treated for haematological malignancy as children and had bone marrow transplant. These women were on estrogen and growth hormone replacement. They had mild abnormalities of liver function tests. The diagnosis of HA was made on liver imaging and confirmed by liver biopsy. We also propose a hypothesis for the pathogenesis of hepatic adenomatosis in these patients which vascular damage, estrogen replacement and growth hormone deficiency.

Hepatitis B virus surface antigen-negative and hepatitis C virus antibody-negative hepatocellular carcinoma: clinical characteristics, outcome, and risk factors for early and late intrahepatic recurrence after resection

BACKGROUND

Although the incidence of hepatitis B virus surface antigen (HBsAg)-negative/hepatitis C virus antibody (HCVAb)-negative hepatocellular carcinoma (NBNC-HCC) is gradually increasing, it has been mostly ignored in previous studies. The objective of this exploratory study was to investigate the clinicopathologic characteristics and prognostic factors that influence recurrence and survival in patients with NBNC-HCC.

METHODS

A retrospective analysis was performed of 675 patients with NBNC-HCC and 3529 patients with HBsAg-positive/HCVAb-negative HCC (BNC-HCC) who underwent curative resection between 1997 and 2009. Intrahepatic recurrences were classified into early (≤1 year) and late (>1 year) recurrences. Multivariate competing risks analyses with Bonferroni correction were used to evaluate independent prognostic factors.

RESULTS

There were no significant differences between the NBNC-HCC and BNC-HCC groups regarding overall survival, cumulative incidence of HCC-specific death, and recurrence. However, the patients with NBNC-HCC were much older (P < .001), were associated less often with cirrhosis or elevated α-fetoprotein levels (P < .001), and had a much lower ratio of men to women (P < .001). NBNC-HCC tumors were larger (P < .001), but were involved less often with vascular invasion (P = .004). Women, serum γ-glutamyl transpeptidase level, tumor size, tumor capsule, and tumor differentiation were identified as independent risk factors for HCC-specific survival in patients with NBNC-HCC. The cumulative incidence of HCC-specific death for women with NBNC-HCC was significantly greater than for men with NBNC-HCC (P < .001).Tumor capsule and vascular invasion were identified as independent risk factors for early recurrence of NBNC-HCC, whereas tumor differentiation was identified as the only significant risk factor for late recurrence.

CONCLUSIONS

Patients who had NBNC-HCC had characteristics and prognostic factors that differed from those in patients who had BNC-HCC. Women with NBNC-HCC should be more closely monitored, and it may be worthwhile to evaluate estrogen administration for the maintenance of sex hormone balance and to improve these poor outcomes.

Diagnosis and management of hepatic focal nodular hyperplasia

Focal nodular hyperplasia (FNH) is the second most common benign tumor of the liver, after hemangioma. It is generally found incidentally and is most common in reproductive-aged women, but it also affects males and can be diagnosed at any age. Patients are rarely symptomatic, but FNH sometimes causes epigastric or right upper quadrant pain. The main clinical task is to differentiate it from other hypervascular hepatic lesions such as hepatic adenoma, hepatocellular carcinoma, or hypervascular metastases, but invasive diagnostic procedures can generally be avoided with the appropriate use of imaging techniques. Magnetic resonance (MR) imaging is more sensitive and specific than conventional ultrasonography (US) or computed tomography (CT), but Doppler US and contrast-enhanced US (CEUS) can greatly improve the accuracy in the diagnosis of FNH. Once a correct diagnosis has been made, in most cases there is no indication for surgery, and treatment includes conservative clinical follow-up in asymptomatic patients.

Focal nodular hyperplasia: Intraindividual comparison of dynamic gadobenate dimeglumine- and ferucarbotran-enhanced magnetic resonance imaging

PURPOSE

To intraindividually compare the enhancement pattern of focal nodular hyperplasia (FNH) after dynamic administration of two bolus-injectable liver-specific MR contrast agents, ferucarbotran and gadobenate dimeglumine.

MATERIALS AND METHODS

A total of 19 patients with 24 FNHs underwent gadobenate dimeglumine- and ferucarbotran-enhanced MRI during the hepatic arterial-dominant phase (HAP; 25 seconds), the portal-venous phase (PVP; 60 seconds), and the equilibrium phase (EP; 180 seconds). Hepatospecific phases were acquired on T1-weighted images 120 minutes after gadobenate dimeglumine administration, and on T2-weighted images 10 minutes after ferucarbotran administration. Lesion enhancement was independently analyzed by two observers. The kappa statistic was determined to evaluate the agreement between the enhancement patterns of the lesions.

RESULTS

On gadobenate dimeglumine-enhanced MR images during HAP, PVP, and EP, FNHs were: hyperintense (24/20/13); isointense (0/4/11); and hypointense (0/0/0). On ferucarbotran-enhanced MR images during HAP, PVP, and EP, FNHs were: hyperintense (2/0/0); isointense (16/9/14); and hypointense (6/15/10). Overall, poor agreement between both contrast agents was observed. During the hepatospecific phases, most (20/24; 83%) FNHs showed a typical enhancement pattern during the delayed hepatospecific phase.

CONCLUSION

The dynamic enhancement pattern of FNHs is significantly different between gadobenate dimeglumine- and ferucarbotran-enhanced MRI. With respect to hepatospecific phase, the majority of FNHs showed a typical behavior on both contrast agents.

A case of hepatocellular carcinoma arising within large focal nodular hyperplasia with review of the literature

Focal nodular hyperplasia (FNH) is a relatively rare benign hepatic tumor, usually presenting as a solitary lesion; however, multiple localizations have also been described. The association of FNH with other hepatic lesions, such as adenomas and haemangiomas has been reported by various authors. We herein report a case of a hepatocellular carcinoma arising within a large focal nodular hyperplasia, in a young female patient.

Association of adenoma and focal nodular hyperplasia: experience of a single French academic center

BACKGROUND: We report our experience of the simultaneous occurrence of adenoma and focal nodular hyperplasia (FNH). Liver cell adenoma together with FNH was found in five out of 30 cases of "multiple benign hepatocytic nodules" collected in our files of the Department of Pathology of the University Hospital of Bordeaux, during the last 12 years. All five cases were women on oral contraceptives. In all cases, the reason for surgery was the discovery, by imaging techniques, of an adenoma (4 cases) or of an unidentified benign tumor, possibly an adenoma. RESULTS: Four cases of FNH were discovered by imaging techniques, prior to surgery. Additional small nodules were diagnosed either during surgery or during the slicing of the specimen in 3 cases. Adenoma and the FNH cases identified by imaging techniques were confirmed as such by light microscopy. Some small nodules could not be categorized with certainty because they contained biliary structures without ductular reaction. In one case, the non-nodular liver was abnormal around the area in which there were multiple nodules: there was approximation of portal tracts with portal and hepatic venous thromboses, and portal tract remnants with arteries surrounded with a rim of fibrosis. In two cases, some large hepatic veins had thickened walls. CONCLUSIONS: The association of FNH and adenoma could be coincidental or secondary to shared causal mechanisms: a) systemic and local angiogenic abnormalities induced by oral contraceptives; b) tumor-induced growth factors; c) thrombosis and local arterio-venous shunting. A better recognition of the association of adenoma and FNH, particularly in the context of multiple nodules, could be useful in clinical practice.

Simultaneous occurrence of adenoma, focal nodular hyperplasia, and hemangioma of the liver: are they derived from a common origin?

The association between hepatic hemangioma (HH) and focal nodular hyperplasia (FNH) or the association between FNH and hepatic adenoma (HA) has been reported. The authors report a case in which FNH, HH, and HA simultaneously appear in the liver. A 25-year-old woman was admitted to the Department of Surgery of the University of Catania (Italy), after presenting pain in the right hypocondrium. No therapy with oral contraceptives, no pregnancy and no abnormalities of the laboratory tests were found. Ultrasonography and computed tomography scans revealed four masses with the characteristics of HH, HA, FNH, and a hydatid cyst located, respectively, in segments II, IV, IV, and V of the liver. The surgical procedures performed were hemangioma and adenoma enucleation and en bloc resection of the FNH, hydatid cyst and gallbladder. No complications were recorded in the postoperative period and the patient was discharged from the hospital after 1 week. A pathological examination confirmed the preoperative diagnosis. To the best of our knowledge, the association of HH, FNH, and HA has never been reported. A common pathogenesis has clearly been demonstrated for hepatocytes and other cell types. The simultaneous presence of these three different kinds of tumor suggest that HH, FNH and HA could be the different expression of the same malformative anomaly.

Liver cell adenoma in a 26-year-old man

This is a report of a case of liver cell adenoma (LCA) in a 26-year-old man with no prior history of liver disease or glycogen storage disease and no record of hormonal therapy. He was found to have an asymptomatic hepatic mass during a routine medical examination. The physical findings were unremarkable, and the results of routine laboratory studies were all within normal limits. Selective hepatic arteriography showed a hypervascular mass within the right lobe of the liver. Despite the radiological examination, the nature of the mass was unknown, and preoperative biopsy was unadvisable because of the risk of bleeding. Because of the difficulty of determining the malignancy of the hepatic tumor preoperatively, elective laparotomy for diagnosis and hepatectomy as treatment appeared to be the best available approach. Pathological examination of the surgical specimen resulted in a diagnosis of LCA. A review of the literature revealed that LCA unassociated with the use of oral contraceptives is rare.

Liver adenomatosis: clinical, histopathologic, and imaging findings in 15 patients

PURPOSE

To report and correlate the clinical, histopathologic, and imaging findings in 15 patients with liver adenomatosis.

MATERIALS AND METHODS

Fifteen adult patients had more than 10 hepatic adenomas each and no history of glycogen storage disease or anabolic steroid use. Ten of them underwent bolus-enhanced dynamic computed tomography (CT) with or without magnetic resonance (MR) imaging, ultrasonography, and/or angiography.

RESULTS

Clinical abnormalities included abdominal pain in 11 (73%) and hepatomegaly in 10 (67%) patients, and abnormal liver function in 10 (91%) of 11 patients. The number of adenomas in each patient was 10-50 at imaging, but many more lesions were found in the resected specimens. Hemorrhage was commonly found within adenomas at histopathologic analysis, but only four patients had clinical and imaging evidence of substantial hemorrhage. In all patients, the adenomas increased over time, and two patients developed hepatocellular carcinoma. CT and MR features of the adenomas included evidence of hypervascularity (63%), intratumoral fat (50% of patients at CT, 80% at MR), and decreased conspicuity at portal venous and delayed-phase imaging. Fifty percent of patients had congenital or acquired hepatic vascular abnormalities.

CONCLUSION

The imaging and histopathologic features of individual adenomatous lesions are similar to those reported in young women who are taking oral contraceptives. However, the lesions in liver adenomatosis are not steroid dependent but rather multiple, progressive, and symptomatic, and they are more likely to lead to impaired liver function, hemorrhage, and perhaps malignant degeneration.

Hepatocellular adenoma: multiphasic CT and histopathologic findings in 25 patients

PURPOSE

To evaluate multiphasic computed tomographic (CT) findings of hepatic adenomas and to correlate these findings with those of histopathologic analysis.

MATERIALS AND METHODS

Multiphasic helical CT was performed in 25 patients with 44 hepatic adenomas. Nonenhanced scans were obtained in all cases, along with hepatic arterial-dominant phase (HAP) and portal venous-dominant phase (PVP) images at 25-28 and 60-70 seconds after intravenous contrast material injection at 3-5 mL/sec. Twelve patients with 24 adenomas also underwent delayed-phase (5-10-minute) CT. Two independent readers retrospectively reviewed each case for the number of detectable lesions in each CT phase, morphologic features of tumors, and degrees of enhancement.

RESULTS

Thirteen patients had solitary adenomas; 12 patients had two or three adenomas. Both observers agreed on the numbers of lesions detected in all cases and in all phases of enhancement. The detection rate for all 44 adenomas per type of examination was as follows: nonenhanced, 86% (38 of 44); HAP, 100% (44 of 44); PVP, 82% (36 of 44), and delayed, 88% (21 of 24). Tumor margins were well defined in 38 adenomas (86%), and the surface was smooth in 42 adenomas (95%). The right hepatic lobe was the only site of adenoma or was a site along with the left lobe in 29 cases (66%). Tumor fat and calcifications were uncommon (three cases [7%] and two cases [5%], respectively). Other than areas of fat, hemorrhage, or necrosis, the adenomas enhanced nearly homogeneously, especially on PVP and delayed-phase scans. Five patients had coexistent hepatic masses, which were focal nodular hyperplasia (n = 3) or hepatocellular carcinoma (n = 2).

CONCLUSION

Hepatic adenomas often have characteristic features at multiphasic CT that may allow their distinction from other hepatic masses.

Focal nodular hyperplasia of the liver: a comprehensive pathologic study of 305 lesions and recognition of new histologic forms

Atypical histologic variants of focal nodular hyperplasia have been reported and are sometimes difficult to recognize. To characterize the morphologic spectrum of focal nodular hyperplasia, we studied 305 lesions surgically resected from 168 patients. Clinicomorphologic correlations were established by statistical analyses. The patients included 150 women and 18 men (sex ratio, 8:1; median age, 38 years). One hundred twenty-eight (76.2%) patients had solitary lesions, and 40 (23.8%) had 2 to 30 lesions. All 305 lesions measured 1 mm to 19 cm in diameter. Only 49% of these lesions had one to three macroscopic scars. Histologically, 245 (80.3%) lesions were of classical form, and 60 (19.7%) lesions were nonclassical. The latter were classified as focal nodular hyperplasia of telangiectatic form (47 lesions), of mixed hyperplastic and adenomatous form (five lesions), and with atypia of large cell type (eight lesions). Several benign or malignant tumors were found in association with these lesions. This large retrospective series of focal nodular hyperplasia shows the relative incidence of its classical and nonclassical forms. The absence of a central scar could explain the difficult preoperative diagnosis of some of the cases. The morphologic diagnostic criteria in this study require further prospective evaluation.

Benign hepatic tumors: focal nodular hyperplasia and hepatocellular adenoma

Focal nodular hyperplasia (FNH) and hepatocellular adenoma (HA) are uncommon benign hepatic tumors that continue to pose diagnostic and therapeutic challenges. An update of a recent Mayo Clinic experience is presented to highlight the management of patients harboring these neoplasms. A marked female predominance was seen. Incidental diagnosis was more prevalent with FNH, whereas symptomatic presentation was typical of HA. The frequency of oral contraceptive steroid use was similar regardless of tumor histology. Preoperative diagnosis remains difficult. Scintigraphy proved most specific, and ultrasonography and computed tomography were equally sensitive. Resection was employed in most patients. There was no mortality and minimal morbidity. Selective observation of FNH was uneventful, but resolution of HA after abstinence of oral contraceptive steroids was uncommon. These findings and data from the literature support selective management of benign liver tumors.

Hepatic neoformations

The aim of the paper is an accurate histologic description and illustration of those liver lesions that are usually summarized under the heading of "hepatic tumors and related subjects". For in some cases it may be unclear or at least controversial, whether the individual lesion is indeed an autonomous neoplasia or a malformation, regeneration or hyperplasia, the indifferent master term of neoformation is introduced, based on the fact that all of them are characterized by a cellular multiplication. According to common definitory practice the survey distinguishes between mesenchymal (angiomatous and non angiomatous) and epithelial neoformations. Among the latter hepatocellular and cholangiocellular types are distinguished, the criterium for differentiation being a phenomenological one, which is by no means identical with a histogenetical statement. The definition of subgroups mostly adheres to current nomenclatory usage; only occasionally--in the group of endothelial tumors--a novel term is employed, in view of brevity and coordination with the overall system of neoformations.

Liver tumours

Humans are remarkably resistant to many carcinogens that readily produce liver tumours in rodents, particularly the rat. The neoplastic process has been extensively studied in animal experiments, but little is known so far of how it evolves in humans. Few drugs have been shown to cause liver tumours in humans, and the risk appears to be low. The best-known examples are C17-alkylated or ethinylated gonadal sex steroids. Oral contraceptives have now been in use by millions for thirty years, but only a few hundred cases at most of liver cell adenoma have been observed. The role of these substances in liver cell carcinoma remains controversial, and the evidence is weaker still in relation to focal nodular hyperplasia and other tumour-like conditions. Anabolic-androgenic steroids stand out as the major cause of peliosis, but liver cell tumours induced by them seem to be adenomas and not carcinomas as originally suggested. The effect that both oral contraceptives and anabolic-androgenic steroids have on liver vasculature is of great clinical importance as the most important complication of liver tumours is rupture, leading to life-threatening haemorrhage. For this reason, liver tumours arising in users of these drugs should be removed whenever feasible. Thorium dioxide will remain a risk factor for the development of angiosarcoma, liver cell carcinoma and bile duct carcinoma for some time yet, and the number of patients who have been exposed is high--tens of thousands at least. The evidence of a carcinogenic role for many other drugs is anecdotal or weak. Neoplasia in the liver seems to be the least important side-effect of drugs in clinical use.

The spectrum of hepatotoxicity due to drugs

Drugs in common use can cause toxic effects on the liver which can mimic almost every naturally occurring liver disease in man. Drugs can have direct (metabolite-related) toxic effects; they can also cause deposition of microvesicular fat in hepatocytes; or they can provoke reactions resembling acute alcoholic hepatitis (phospholipidosis) or acute viral hepatitis. Hepatotoxicity can also be part of a general hypersensitivity reaction, or hepatic fibrosis or cholestasis can predominate. Drugs can lead to almost any type of vascular disease in the liver and to benign and malignant tumours.