Hepatic resection for benign tumours of the liver

Percutaneous ultrasound-guided 'three-step' radiofrequency ablation for giant hepatic hemangioma (5-15 cm): a safe and effective new technique

Purpose: To evaluate the safety and efficacy of percutaneous ultrasound-guided 'three-step' radiofrequency ablation (RFA) for the treatment of giant hepatic hemangioma.Materials and methods: Patients with giant hepatic hemangioma who underwent percutaneous ultrasound-guided 'three-step' RFA (n = 52) and conventional RFA (n = 54) at our center from June 2013 to December 2017 were retrospectively analyzed. The 'three-step' RFA proceeds as follows. Step 1: Ablate the feeding artery of the hemangioma. Step 2: Aspirate blood from the tumor. Step 3: Ablation the lesion. Intraoperative information, postoperative recovery, therapeutic effects, and complications were compared between the two groups.Results: The duration of RFA was significantly shorter (19.2 ± 0.8 min versus 44.5 ± 2.8 min, p < 0.001), the number of punctures was significantly lower (3.2 ± 0.1 versus 4.7 ± 0.3, p = 0.002), and the duration of hospital stay was significantly shorter (9.0 ± 0.5 versus 11.5 ± 0.7, p = 0.013) in the TS-RFA group than in the C-RFA group. The complete ablation rate (86.5% versus 40.7%), the maximum postoperative pain score (2.5 ± 1.3 versus 4.1 ± 2.0) and symptom relief were also significantly better in the TS-RFA group than in the C-RFA group (p < 0.05). No postoperative death occurred in either group. There were no grade III or higher complications in the TS-RFA group, but one patient in the C-RFA group developed the grade III complication of postoperative abdominal bleeding.Conclusions: 'Three-step' RFA is a safe and effective minimally invasive treatment for giant hepatic hemangioma. It is worthy of further promotion and application.

Outcomes of ultrasound-guided percutaneous microwave ablation versus surgical resection for symptomatic large hepatic hemangiomas

Purpose: Microwave ablation (MWA) has become increasingly popular as a minimally invasive treatment for benign and malignant liver tumors. However, few studies have demonstrated the benefits and disadvantages of MWA compared to surgical resection (SR) for large hepatic hemangiomas. This study aimed to evaluate the safety and effectiveness of MWA compared to SR for large (5-10 cm) hepatic hemangiomas. Methods and materials: This retrospective comparative study included 112 patients with large, symptomatic hepatic hemangiomas who had been treated with MWA (n = 44) or SR (n = 68) and followed up for a median of 44 months using enhanced computed tomography (CT) or magnetic resonance imaging (MRI). Intraoperative information, postoperative recovery time, postoperative discomfort and complications and treatment effectiveness between groups were compared using a chi-square test or an independent t-test. Results: The operative time was significantly shorter (31.3 ± 21.76 versus 148.1 ± 59.3 min, p < .001) and the blood loss (10.2 ± 60.6 versus 227.9 ± 182.9 mL, p < .0001) and rate of prophylactic abdominal drainage [1 (2.3%) versus 57 (83.8%), p < .001] were significantly lower in the MWA group than in the SR group. Postoperative recovery of the MWA group in regard to indwelling catheter time, normal diet time, incision cicatrization time and hospital stay (p < .001) was significantly better than the SR group. However, no statistically significant difference in effectiveness was noted between the groups (p = .58). Conclusions: MWA may be as effective as SR, and potentially safer for treating large, symptomatic hepatic hemangiomas. To confirm our findings, large-sample, multicentered, randomized controlled trials are needed.

What is Changing in Indications and Treatment of Focal Nodular Hyperplasia of the Liver. Is There Any Place for Surgery?

Focal nodular hyperplasia (FNH) is a common benign liver tumor, which occurs in the vast majority of the cases in young women. FNH represents a polyclonal lesion characterized by local vascular abnormalities and is a truly benign lesion without any potential for malignant transformation. A retrospective single institution analysis of 227 FNH patients, treated from 1990 to 2016 and a review of studies reporting surgical therapy of overall 293 patients with FNH was performed. Indications for resection with a focus on diagnostic workup, patient selection, surgical mode and operative mortality and morbidity have been analysed. Ninety three patients underwent elective hepatectomy and 134 patients observation alone, where median follow-up was 107 months. Postoperative complications were recorded in 14 patients, 92% of patients reported an improvement with respect to their symptoms. Overall among 293 patients underwent surgery in the series, included to this review, there was a morbidity of 13%, where median follow-up was 53 months. Systematic follow-up remains the gold standard in asymptomatic patients with FNH. However elective surgery should be considered in symptomatic patients, in those with marked enlargement and in case of uncertainty of diagnosis. Surgery for FNH is a safe procedure with low morbidity and very good long term results as far as quality of life after surgery is concerned and surely an integral part of the modern management of FNH.

The value of liver resection for focal nodular hyperplasia: resection yes or no?

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.

Giant cavernous hepatic hemangioma shrunk by use of sorafenib

Here we report a case of a 76-year-old man with a giant cavernous hepatic hemangioma of more than 20 cm in diameter. Since the hepatic hemangioma was actually growing and might possibly rupture and he complained of abdominal symptoms, we decided to perform interventional therapy. First we performed transcatheter arterial embolization (TAE) of the hepatic arteries. However, since this was not sufficiently effective, we added sorafenib (600 mg/day). As a result, the tumor shrank with symptomatic improvement. Subsequently, an adverse event occurred, and we suspended the sorafenib therapy. Then, the tumor began to grow, and we resumed administering sorafenib at 400 mg/day. The tumor shrank again, and we continued the sorafenib therapy thereafter. The tumor shrinkage, although possibly induced by the effect of TAE, is considered primarily due to the effect of treatment with sorafenib, because (1) TAE did not sufficiently reduce the blood supply to the inside of the tumor; (2) other tumors shrank in the area not targeted by TAE; and (3) the tumor grew during suspension of sorafenib therapy and shrank again after resuming the treatment.

Management of the focal nodular hyperplasia of the liver: evaluation of the surgical treatment comparing with observation only

BACKGROUND

Long-term results of both surgery and observation for patients with focal nodular hyperplasia (FNH) in a large single-center experience do not exist. Accordingly, the aim of this study was to compare long-term outcomes in patients with FNH who underwent either elective hepatectomy or observation alone.

METHODS

A retrospective single-institution analysis of 185 patients with FNH, treated from 1990 to 2009, was performed.

RESULTS

Seventy-eight patients underwent elective hepatectomy and 107 patients observation alone, with a median follow-up period of 113 months. There was no perioperative mortality. Postoperative complications were recorded in 12 patients, and 92% of patients reported symptomatic reductions. Among observation patients, 9 (13%) developed additional symptoms; tumor enlargement was seen in 3 patients (4%).

CONCLUSIONS

Elective liver resection for FNH is a safe procedure at high-volume centers. This single-center experience showed that 13% of observed patients had protracted symptoms. This justifies the therapeutic algorithm that elective surgery should be considered in symptomatic patients or in those with marked enlargement.

Indications and Long-Term Outcome after Elective Surgery for Hepatocellular Adenoma

The management of hepatocellular adenoma (HA) is dependent on several parameters, which are influencing the decision for further management. The aim of this study was to evaluate the clinical presentation, indications, and long-term outcome of surgical treatment in a single-institution analysis. Forty-nine patients underwent elective hepatectomy for HA between 1990 and 2007. Analysis parameters included demographic data, lesion number and size, diagnostic method, mode of surgery, and postoperative outcome. Mean follow-up was 108 months. Thirty-six patients underwent hormone therapy and four patients had a history of cancer before surgical treatment. The mean tumor diameter was 9.8 cm. Mild or moderate postoperative complications were recorded in 16 patients. There was no perioperative mortality. Symptoms were relieved in 95 per cent of the patients. Intratumoral hemorrhage was detected in 21 specimens (43%); malignant transformation was detected in zero specimens. Among patients with HA with clinical symptoms, tumor diameter greater than 5 cm and in male patients the indication for surgery should be given because of the high risk of tumor-related complications. Elective liver resection for HA is a safe procedure and results in a good long-term outcome.

Diagnosis and treatment of benign focal liver lesions

BACKGROUND

With the routine use of improved imaging modalities, more benign liver lesions are detected nowadays. An accurate characterization of these incidental lesions may be a challenge, and frequently a biopsy or even unnecessary surgery is being performed. However, these interventions are not always to the benefit of the patient.

METHODS

A Medline search of studies relevant to imaging diagnosis and management of the most common, benign, solid and non-solid liver lesions was undertaken. References from identified articles were handsearched for further relevant articles. The authors' own experiences with benign liver lesions were also taken into account.

RESULTS

Although atypical imaging features are the exception rather than the rule, it is sometimes difficult to differentiate between benign and malignant lesions, and knowledge of their imaging features is essential if unnecessary work-up is to be avoided. The use of tissue-specific contrast media, which has clearly improved the accuracy of highly advanced radiological techniques, may be helpful during differential diagnosis. Once having established an accurate diagnosis, surgery is rarely indicated for a benign liver lesion because of its asymptomatic nature.

CONCLUSION

Knowledge of imaging features and a clear management strategy during diagnostic work-up, emphasizing the indications for surgery, will minimize the number of patients who have to undergo biopsy or unnecessary surgery.

Incidental reduction in the size of liver hemangioma following use of VEGF inhibitor bevacizumab

BACKGROUND/AIMS

Hepatic cavernous hemangioma is the second most common liver tumor after metastases. Vascular endothelial growth factor (VEGF) is recognized as an essential regulator of blood vessel growth. High VEGF expression leads to increased angiogenic activity in cavernous hemangioma endothelial cells. The use of specific antibodies directed against VEGF abolishes this vascular endothelial growth-promoting activity in vitro. Bevacizumab is a recombinant humanized monoclonal antibody directed against VEGF which is used for the treatment of metastatic colorectal cancer in combination with 5-fluorouracil-based regimens.

METHODS

We report a patient with invasive colorectal adenocarcinoma and suspected liver metastasis on radiological examination, who showed a significant decrease in the size of his liver lesions after bevacizumab treatment. Histology of the liver lesions revealed hemangioma with a strong staining for VEGF and anti-VEGFr2 antibody in the hemangioma endothelial cells. To date, surgical resection provides the only consistently effective method for treatment of hepatic hemangioma.

CONCLUSIONS

This is the first documented case of hepatic hemangioma responsive to antiangiogenic therapy, suggesting a possible use for these agents in treating symptomatic patients without surgery. VEGF-signaling blockade including bevacizumab use poses a potential new treatment modality for vascular neoplasms in the liver and other sites.

Accurate differentiation of focal nodular hyperplasia from hepatic adenoma at gadobenate dimeglumine-enhanced MR imaging: prospective study

PURPOSE

To prospectively determine the accuracy of differentiating benign focal nodular hyperplasia (FNH) from hepatic adenoma (HA) and liver adenomatosis (LA) by using gadobenate dimeglumine-enhanced magnetic resonance (MR) imaging.

MATERIALS AND METHODS

The ethics committee at each center approved the study, and all patients provided informed consent. Seventy-three patients with confirmed FNH and 35 patients with confirmed HA (n = 27) or LA (n = 8) underwent MR imaging before (T2-weighted half-Fourier rapid acquisition with relaxation enhancement or T2-weighted fast spin-echo and T1-weighted gradient-echo [GRE] sequences) and at 25-30 seconds (arterial phase), 70-90 seconds (portal venous phase), 3-5 minutes (equilibrium phase), and 1-3 hours (delayed phase) after (T1-weighted GRE sequences only, with or without fat suppression) bolus administration of 0.1 mmol per kilogram of body weight gadobenate dimeglumine. The enhancement of 235 lesions (128 FNH, 32 HA, and 75 LA lesions) relative to the normal liver parenchyma was assessed. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy for the differentiation of FNH from HA and LA were determined.

RESULTS

Hyper- and isointensity on T2-weighted and iso- and hypointensity on T1-weighted GRE images were noted for 177 (88.9%) of 199 lesions visible on unenhanced images. On dynamic phase images after contrast material administration, 231 (98.3%) of 235 lesions showed rapid strong enhancement during the arterial phase and appeared hyper- to isointense during portal venous and equilibrium phases. Accurate differentiation of FNH from HA and LA was not possible on the basis of precontrast or dynamic phase images alone. At 1-3 hours after contrast material enhancement, 124 (96.9%) of 128 FNHs appeared hyper- or isointense, while 107 (100%) HA and LA lesions appeared hypointense. The sensitivity, specificity, PPV, NPV, and overall accuracy for the differentiation of FNH from HA and LA were 96.9%, 100%, 100%, 96.4%, and 98.3%, respectively.

CONCLUSION

Accurate differentiation of FNH from HA and LA is achievable on delayed T1-weighted GRE images after administration of gadobenate dimeglumine.