Focal nodular hyperplasia in children

Hepatic focal nodular hyperplasia after pediatric hematopoietic stem cell transplantation: The impact of hormonal replacement therapy and iron overload

BACKGROUND

The advent of techniques for the assessment of iron overload (liver T2*-MRI) has led to the awareness that focal nodular hyperplasia (FNH) represents a possible incidental finding after hematopoietic stem cell transplantation (HSCT), though its pathogenesis is still unclear.

METHODS

We performed a retrospective analysis of the liver T2*-MRI scans performed between 2013 and 2018 in a single pediatric HSCT Unit and recorded the number of patients with FNH (group A). Patients incidentally diagnosed with FNH at imaging performed for different clinical indications were included in group B.

RESULTS

Nine of 105 (8.6%) patients from group A were diagnosed with FNH. Group B included three patients. Overall, 12 patients were diagnosed 4.4 ± 3.1 years after HSCT. At univariate analysis, female gender (odds ratio [OR] 3.77, P = .03), moderate-to-severe iron overload (OR 6.97, P = .01), and hormone replacement therapy (HRT) administered for at least 6 months (OR 18.20, P = .0002) exposed patients to a higher risk of developing FNH. The detrimental effect of HRT was significant also at multivariate analysis (OR 7.93, P = .024). MRI-T2* values in affected patients were statistically lower than healthy controls (P < .001).

CONCLUSIONS

We confirm the high incidence of FNH among transplanted pediatric patients and demonstrate the potential pathogenic role of HRT and iron overload.

Focal nodular hyperplasia in children: an institutional experience with review of the literature

BACKGROUND

Focal nodular hyperplasia (FNH) is uncommonly diagnosed in pediatric patients and may be difficult to distinguish from a malignancy. We present a review of all children with a tissue diagnosis of FNH at our institution, describe the diagnostic modalities, and provide recommendations for diagnosis and follow-up based on our experience and review of the literature.

METHODS

A retrospective review of children <18years of age diagnosed with FNH at a single institution was performed from 2000 to 2013.

RESULTS

Twelve patients were identified with a tissue diagnosis of FNH. Two patients required surgical resection of their lesion owing to concern for malignancy. Ten patients were managed expectantly with imaging surveillance after biopsy confirmed a diagnosis of FNH. All patients who underwent MRI had very typical findings including hypointensity on T1 weighted sequences, hyperintensity on T2, and homogenous uptake of contrast on the arterial phase. On follow-up all patients had either a stable lesion or reduction in size.

CONCLUSIONS

Focal nodular hyperplasia presents typically in children with liver disease, have undergone chemotherapy, and adolescent females. Young children, particularly <5years of age, without underlying liver disease or history of chemotherapy can pose a diagnostic dilemma. In this unique subgroup of children with FNH, MRI and/or needle biopsy should be adequate diagnostic modalities for these lesions.

Benign hepatocellular tumors in children: focal nodular hyperplasia and hepatocellular adenoma

Benign liver tumors are very rare in children. Most focal nodular hyperplasia (FNH) remain sporadic, but predisposing factors exist, as follows: long-term cancer survivor (with an increasing incidence), portal deprivation in congenital or surgical portosystemic shunt. The aspect is atypical on imaging in two-thirds of cases. Biopsy of the tumor and the nontumoral liver is then required. Surgical resection will be discussed in the case of large tumors with or without symptoms. In the case of associated vascular disorder with portal deprivation, restoration of the portal flow will be discussed in the hope of seeing the involution of FNH. HepatoCellular Adenoma (HCA) is frequently associated with predisposing factors such as GSD type I and III, Fanconi anemia especially if androgen therapy is administered, CPSS, and SPSS. Adenomatosis has been reported in germline mutation of HNF1- α . Management will depend on the presence of a predisposing factor and may include metabolic control, androgen therapy withdrawn, or closure of the shunt when appropriate. Surgery is usually performed on large lesions. In the case of adenomatosis or multiple lesions, surgery will be adapted. Close followup is required in all cases.

Focal nodular hyperplasia of the liver after intensive treatment for pediatric cancer: is hematopoietic stem cell transplantation a risk factor?

Focal nodular hyperplasia (FNH) is a benign hepatic lesion very rarely described in the pediatric population. It has been reported more frequently in patients treated for pediatric cancers with chemotherapy or hematopoietic stem cell transplantation. The use of high dosage of alkylating agents, the occurrence of venous occlusive disease, graft-versus-host disease, and other variables linked to the hematopoietic stem cell transplantation procedure can represent risk factors for the development of FNH in the pediatric age. The discovery of hepatic nodules in the follow-up of patients treated for malignancies suggests recurrence of disease and raises a diagnostic dilemma. Here we describe possible risk factors, clinical and radiological findings of eight pediatric patients who developed focal nodular hyperplasia after hematopoietic stem cell transplantation. The aim of this report is to provide useful diagnostic tools to facilitate accurate diagnosis of FNH and suggest a correct management of this benign lesion during postcancer follow-up.

Focal nodular hyperplasia in children: clinical features and current management practice

BACKGROUND

Although nonoperative management is an accepted practice for most adults with focal nodular hyperplasia (FNH), questions remain about the safety and feasibility of this strategy in children. Our aim was to review the clinical features of children with FNH and determine current management patterns.

METHODS

We reviewed records of all children and adolescents with FNH managed at our institution from 1999 to 2009 and performed a MEDLINE search to identify all published cases of FNH in the pediatric population.

RESULTS

A total of 172 patients with FNH were identified, including 11 at our institution. The median age at diagnosis was 8.7 years and 66% were female. Median tumor size was 6 cm, and 25% had multiple lesions. Thirty-six percent were symptomatic at presentation. Twenty-four percent had a history of malignancy. Management included resection (61%), biopsy followed by observation (21%), and observation alone (18%). Indications for resection included symptoms (48%), inability to rule out malignancy (24%), tumor growth (15%), and biopsy-proven concurrent malignancy (9%).

CONCLUSIONS

Although FNH is a benign lesion that is typically managed nonoperatively in adults, most children with FNH currently undergo resection because of symptoms, increasing size, or inability to confidently rule out malignancy.

Management and surgical treatment for focal nodular hyperplasia in children

Focal nodular hyperplasia (FNH) is rare in pediatric liver tumor. To investigate the experience in the appropriate management of pediatric FNH, the records of consecutive children who were managed at our institute from 2000 to 2007were reviewed for FNH. There were four males and nine females whose ages ranged from 26 months to 18 years with a mean of 11.7 years. FNH in most children was detected by medical examination for abdominal pain (61.5%) or other symptoms. All the 13 pediatric patients underwent liver resection. There was no operative death or postoperative complications. The children were regularly followed up ranging from 2 to 85 months and they were healthy without recurrence. For pediatric FNH patients with clinical symptoms or indefinite diagnosis, it is suggested that active surgical treatment by hepatectomy should be performed.

Focal nodular hyperplasia of the liver: usefulness of superparamagnetic iron oxide-enhanced magnetic resonance imaging

This report describes the use of superparamagnetic iron oxide-enhanced magnetic resonance imaging to diagnose fibronodular hyperplasia of the liver in a 12-year-old girl.