Benign bile duct tumours, non-parasitic liver cysts and liver damage in males

WFUMB Review Paper. Incidental Findings in Otherwise Healthy Subjects, How to Manage: Liver

An incidental focal liver lesion (IFLL) is defined as a hepatic lesion identified in a patient imaged for an unrelated reason. They are frequently encountered in daily practice, sometimes leading to unnecessary, invasive and potentially harmful follow-up investigations. The clinical presentation and the imaging aspects play an important role in deciding if, and what further evaluation, is needed. In low-risk patients (i.e., without a history of malignant or chronic liver disease or related symptoms), especially in those younger than 40 years old, more than 95% of IFLLs are likely benign. Shear Wave liver Elastography (SWE) of the surrounding liver parenchyma should be considered to exclude liver cirrhosis and for further risk stratification. If an IFLL in a low-risk patient has a typical appearance on B-mode ultrasound of a benign lesion (e.g., simple cyst, calcification, focal fatty change, typical hemangioma), no further imaging is needed. Contrast-Enhanced Ultrasound (CEUS) should be considered as the first-line contrast imaging modality to differentiate benign from malignant IFLLs, since it has a similar accuracy to contrast-enhanced (CE)-MRI. On CEUS, hypoenhancement of a lesion in the late vascular phase is characteristic for malignancy. CE-CT should be avoided for characterizing probable benign FLL and reserved for staging once a lesion is proven malignant. In high-risk patients (i.e., with chronic liver disease or an oncological history), each IFLL should initially be considered as potentially malignant, and every effort should be made to confirm or exclude malignancy. US-guided biopsy should be considered in those with unresectable malignant lesions, particularly if the diagnosis remains unclear, or when a specific tissue diagnosis is needed.

Focal Liver Lesions other than Hepatocellular Carcinoma in Cirrhosis: Diagnostic Challenges

Liver cirrhosis is associated with regenerative nodules and an increased risk of developing hepatocellular carcinoma (HCC). However, other benign and malignant liver lesions may also occur. Differentiating the other lesions from HCC is important for further therapeutic decisions. This review discusses the characteristics of non-HCC liver lesions in cirrhosis and their consequent appearance on contrast-enhanced ultrasonography (CEUS) with consideration of other imaging. Knowledge of this data would be helpful in avoiding misdiagnoses.

Prevalence of benign focal liver lesions and non-hepatocellular carcinoma malignant lesions in liver cirrhosis

Liver cirrhosis is associated with an increased risk of developing hepatocellular carcinoma (HCC). However, other benign and malignant liver lesions may co-exist or may be the only focal liver lesion (FLL) detected. Compared to HCC, comparatively little is known about the frequency and natural history of benign FLL in patients with established liver cirrhosis.

This review analyses the prevalence and frequency of benign and malignant FLL others than hepatocellular carcinoma (HCC) in liver cirrhosis including imaging and autopsy studies. Understanding these data should be helpful in avoiding misdiagnoses.

Focal hepatic solid lesions incidentally detected on initial ultrasonography in 542 asymptomatic patients

PURPOSE

The purpose of this study is to evaluate the clinical significance of focal hepatic solid lesions incidentally detected on initial ultrasonography in asymptomatic patients.

METHODS

From January 2009 to December 2009, 2670 initial ultrasonographies were performed in asymptomatic population. Of these 2670 initial examinations, 681 focal hepatic solid lesions in 542 patients (mean 39.4 years, range 23-73 years) were detected. Clinical information, ultrasonography features, and the outcome of these lesions were analyzed.

RESULTS

Six hundred and seventy four lesions (99.0%) in 539 patients (99.4%) were benign, while seven lesions (1.0%) in three patients (0.6%) proved to be malignant. Risk factors significantly associated with malignant focal hepatic solid lesions were known history of malignancy, history of hepatitis, a positive result for the hepatitis B surface antigen, and abnormally elevated tumor markers. No malignancy was identified in patients without any one of these four risk factors. Ultrasonographic features of internal heterogeneous echotexture with peripheral hypoechoic rim showed significant associations with malignancy.

CONCLUSIONS

Focal hepatic solid lesions incidentally detected on initial ultrasonography were rarely malignant, especially in patients without these risk factors. Therefore, the knowledge of these risk factors and US features is important in order to make a differential diagnosis between benign and malignant focal hepatic lesions.

"Incidentaloma" of the liver: management of a diagnostic and therapeutic dilemma

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.

[Surgical therapy of benign liver tumors]

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.

Solitary bile duct hamartoma of the liver

Bile duct hamartomas, also known as von Meyenburg complexes, are benign liver malformations which usually present as multiple small nodules scattered in both lobes of the liver. We report a unique case of bile duct hamartoma. An asymptomatic 30-year-old man who had a solitary cystic lesion underwent partial hepatectomy. Macroscopically, the lesion, measuring 3.6 cm in diameter, was composed of a number of small grayish-white cysts measuring 0.1 to 1.2 cm in diameter. Histologically, the constituent cysts were embedded in a fibrous stroma and were lined by low columnar or cuboidal epithelium. By immunohistochemistry, the MIB-1 index was below 1%, and p53 and carcinoembryonic antigen (CEA) were negative. These findings lead us to conjecture that the lesion was a bile duct hamartoma, although its solitary nature and large size differed from those of typical bile duct hamartoma.

Liver resection and cyst fenestration in the treatment of severe polycystic liver disease

BACKGROUND/AIMS

There is limited information on treatment options for massive, highly symptomatic polycystic liver disease. The aim of the study was to analyze the immediate and long-term outcome of combined liver resection and fenestration.

METHODS

Information was abstracted from medical records. Follow-up was obtained by mailed questionnaire. Liver volume was quantified by computed tomography.

RESULTS

Thirty-one patients underwent liver resection and fenestration between July 1985 and June 1993. Mean liver volume was 9357 mL before and 3567 mL after surgery. There was one death from postoperative intracerebral bleed. Eighteen patients experienced complications, usually transient pleural effusions or transient ascites. Twenty-eight of 29 surviving patients with adequate follow-up have experienced immediate and sustained relief of symptoms and improvement in quality of life. After median follow-up of 2.4 years (range, 0.2 to 7.9 years), most patients have not had clinically significant enlargement of the liver. Sequential computed tomography scans before and after surgery suggest that hepatic enlargement in the age range of the patients in the study mainly resulted from the expansion of existing cysts rather than from the development of new cysts.

CONCLUSIONS

Selected patients with severe symptomatic polycystic liver disease and favorable anatomy benefit from liver resection and fenestration with acceptable morbidity and mortality. The extent of hepatic resection and fenestration is important for the long-term effectiveness of this procedure.

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.

Magnetic resonance imaging of von Meyenburg complexes: report of a pathologically documented case

Von Meyenburg complexes (VMC) are rare malformations of the bile ducts. They are usually associated with adult dominant polycystic disease (ADPCD). Although generally benign, they may give rise to cholangiocarcinomas. Herein, we report the third MR documented case of VMC. The comparative diagnostic value of ultrasound (US), computed tomography (CT), and magnetic resonance (MR) examinations is discussed.

Cystic disease of the liver and biliary tract

The widespread availability of ultrasound imaging has led to more frequent recognition of cystic disease affecting the liver and biliary tract. There is a wide range of possible causes. Cystic disease of infective origin is usually caused by an Echinococcal species, or as the sequel of a treated amoebic or pyogenic abscess. The clinical and radiological features are often then distinctive and will not be dwelt upon in this review, except in respect of their contribution to the differential diagnosis of non-infective disorders. The principal non-infective cysts can be conveniently divided between the simple cyst, the polycystic syndromes (usually with coexistent renal disease), Caroli's syndrome, and choledochal cysts. The overlap between constituent members of these groups, and the association of cystic disease with hepatic fibrosis (especially with congenital hepatic fibrosis) has attracted considerable attention, and it has been suggested that they may all be considered to belong to a hepatobiliary fibrocystic continuum. In addition there are a variety of cystic neoplasms and a miscellany of unusual forms.

Maternal and paternal alcohol consumption and miscarriage

To explore the role of parental alcohol consumption in miscarriage we interviewed 80 women who miscarried about their own and their partners' drinking habits. A control group of 81 gestational-age-matched women whose pregnancy ended in the delivery of a healthy infant at term were similarly questioned. The use of alcohol by women and men was equally frequent in both groups. Before pregnancy, the mean alcohol consumption per week had been about 1-2 drinks for the women and 4-5 drinks for the men. During the presumed day of conception, 13% of the women who miscarried and 11% of the women in the control group had drunk on average 3-4 drinks; the other women had been abstinent at this time. Of the partners, 13% and 15%, respectively, had taken a mean of 4-5 drinks. In both groups 58% of the subjects continued to consume alcohol during pregnancy. The mean consumption was about one drink a week by the women who miscarried and half a drink a week in the control group. Of women who miscarried, 36 had a blighted ovum and in this subgroup alcohol consumption in both women and men was similar to that in the other women who miscarried and their partners, suggesting that alcohol is not causally related to the development of a blighted ovum. These results suggest that moderate maternal or paternal alcohol consumption does not increase the risk of miscarriage.

Adult polycystic liver disease and biliary microhamartomas (von Meyenburg's complexes)

The relationship between adult polycystic liver disease (PLD) and biliary microhamartomas (von Meyenburg's complexes) was studied in a series of ten autopsy cases in which the size of the cysts varied from microscopic to 10 cm. Biliary microhamartomas, found in every case, were the most abundant (p less than 0.001) in livers with cyst size of 1 cm or less and had almost disappeared in cases with the largest cysts. The number of microhamartomas had no significant correlation with age or liver weight. The results indicate that biliary microhamartoma (von Meyenburg's complex) is coupled with adult-type polycystic liver disease, and, probably, is the histopathological lesion that transforms into cysts. The number of microhamartomas is the highest in the early phase of the disease.

Adult polycystic liver and kidney diseases are separate entities

In 22 cases of either adult polycystic liver (PLD) or polycystic kidney (APCD) disease, considered as one dominantly inherited entity, both diseases occurred together only once. Early microscopical cystic lesions that are typical of PLD were found in another case of APCD. In this medicolegal autopsy series the incidence of PLD was 0.05% and that of APCD 0.08%. Cerebral haemorrhage or cerebral aneurysms were found in 50% of APCD cases but in none of the cases with only PLD (p less than 0.01). Of the cases with PLD, 50% had associated renal cysts and 10% of the cases with APCD had associated liver cysts. The same medicolegal autopsy material yielded a prospective series of 95 male cases, where, however, kidney cysts were normally present in over 50% and liver cysts in about 20% of the cases of similar age. Thus, a part of the association between cystic disease of the liver and kidney may have been based on the common occurrence of cysts in old age. V. Meyenburg's complex was the microscopic alteration associated with cysts in PLD. It was associated as well with liver cysts in APCD suggesting that an intricate relation between PLD and APCD does occur in part of the cases, in this series characterized by large size APCD kidneys. The results indicate that in adults PLD is an entity of its own, expressed in most of the cases independently of APCD.

Occurrence of benign hepatocellular tumors in alcoholic men

Focal nodular hyperplasia (FNH) and liver cell adenoma (LCA) are benign hepatocellular tumors, found mainly in females in association with the use of oral contraceptives. In adult male clinical patients and in retrospective male autopsy cases, both tumors were often found in association with chronic abuse of alcohol. This association was also found (p less than 0.025) in a prospective autopsy series on alcoholic and non-alcoholic males, in which a family member or close friends of the deceased were interviewed for estimating the consumption of alcohol. Nine of the 12 tumors found in males were FNH and three were LCA. In the average males with FNH were as old (51.0 years) as those with LCA (48.7 years). In two of the FNH cases two tumors were found. In the prospective autopsy series the weight of the liver of males with FNH was significantly (p less than 0.001) higher than that of non-alcoholic controls. A correlation (p less than 0.05), independent of age or liver weight, was found between the size of cavernous hemangioma, another hepatic tumor suggested to respond to estrogens, and daily alcohol dose. It is suggested that alcohol-induced liver cell hypertrophy or the feminizing effect of chronic use of alcohol on male sex hormone metabolism might contribute to the growth of pre-existing benign hepatocellular tumors in males.