A case of progressive multiple focal nodular hyperplasia with alteration of imaging studies

Living donor liver transplantation for idiopathic portal hypertension with focal nodular hyperplasia

The patient was a 61-year-old woman with a history of diabetes mellitus who had undergone ileocecal resection for ascending colon carcinoma 5 years earlier, followed by a postoperative adjuvant chemotherapy with XELOX (capecitabine + oxaliplatin). During follow-up, the liver gradually atrophied, and radiological imaging showed suspicious findings of 20 × 14 mm hepatocellular carcinoma (HCC) in the right lobe of the liver. The patient also underwent endoscopic variceal ligation for the esophageal varices. She was referred to our hospital for living donor liver transplantation (LDLT) due to decompensated liver cirrhosis with HCC. The patient did not have hepatitis B or C, and history of alcohol, suggesting that her liver cirrhosis was caused by a non-alcoholic steatohepatitis. The Child-Pugh score was 10 points (class C) and the Model for End-Stage Liver Disease (MELD) score was 8 points. The possibility of HCC could not be ruled out, and LDLT was performed. Postoperative pathological examination revealed idiopathic portal hypertension (IPH), and the mass lesion was diagnosed as focal nodular hyperplasia (FNH). The postoperative course was uneventful and the patient was discharged on postoperative day 14. This is the first case of liver transplantation for IPH with FNH.

Management of focal nodular hyperplasia of the liver: Experience of 50 pediatric patients in a tertiary center

BACKGROUND

Focal nodular hyperplasia (FNH) is a rare benign hepatic lesion in children. No management guidelines for pediatric population exist because of limited evidence.

OBJECTIVE

To review the experience of a large tertiary liver center, providing additional clinical data to help formulate management guidelines for FNH in the pediatric population.

METHODS

We analyzed data of children <18 years diagnosed with FNH from 1996 to 2018 at our hospital, detailing management and long-term clinical outcome.

RESULTS

50 patients were identified. The median age was 10 years old (range 0.75-15.5 years old). The mean diameter of FNH was 5.9 cm (±3.1 cm). 10 patients had multiple lesions. First-line management: watchful waiting with serial checks (n = 37), surgery (n = 13). Of the watchful waiting patients, 10 required eventual second-line surgery. After a median follow-up of 4.7 years (range 0.5-20 years), 46 patients were asymptomatic, with no significant difference in clinical outcome (p = 0.962) between the two first-line management approaches. Lesions demonstrated growth in 13 cases: 5 of these required second-line surgery. In these patients, there was no significant difference in clinical outcome (p = 0.188) compared to nonoperative patients. Considering all surgically treated patients, there was no significant difference between first-line and second-line surgery for clinical outcome (p = 0.846), hospital stay (p = 0.410), complications (p = 0.510) and severe complications (p = 0.385).

CONCLUSIONS

Our data support the hypothesis that watchful waiting is a safe initial approach to pediatric FNH management in patients with no major symptoms or complications. Surgery should be reserved for patients with diagnostic doubt, persistent symptoms and/or biological or significant anatomical abnormalities. FNH growth alone should not be considered as an indication for surgery.

TYPE OF STUDY

Therapeutic study.

LEVEL OF EVIDENCE

Level III.

Fluctuation of Hepatic Focal Nodular Hyperplasia Size with Oral Contraceptives Use

Patient: Female, 44

Final Diagnosis: Focal nodular hyperplasia

Symptoms: Liver masses

Medication: —

Clinical Procedure: CT • MRI • Pathology

Specialty: General and Internal Medicine

Uncommon evolutions and complications of common benign liver lesions

Frequently encountered on abdominal imaging studies, the majority of common benign liver lesions are asymptomatic, confidently diagnosed by imaging, and do not require further workup, follow-up, or treatment. The increasing use of multimodality liver imaging, has allowed the recognition of uncommon evolutions of common benign liver lesions such as size changes, fibrotic regression, and content and vascularization changes, and their complications such as rupture, hemorrhage, thrombosis, extrinsic compression, and malignancy. The purpose of this pictorial review is to describe and illustrate the incidence and diagnostic features of these uncommon evolutions and complications on cross-sectional imaging, mainly on computed tomography and magnetic resonance imaging, with emphasis on those imaging clues which are helpful in the differential diagnosis or indicate the need for treatment.

A case of progressing focal nodular hyperplasia and its molecular expression pattern

We report the case of an adult male with progressing focal nodular hyperplasia (FNH). Although imaging studies suggested that the tumor was a classical FNH, the tumor biopsy showed glutamine synthetase expression and heat shock protein 70 in part of the tumor. As we could not definitely distinguish this case of FNH from early hepatocellular carcinoma (HCC), we performed laparoscopic partial hepatectomy. The surgical resected specimen showed that the tumor had a central scar with vascular and cholangiolar proliferation, which is compatible with FNH. Immunohistochemical analysis showed that the molecular expression pattern was compatible with FNH in the center of the tumor, whereas it partly resembled early HCC in the periphery of the tumor. FNH progression is occasionally found, and the molecular pattern of the progressing area in FNH might resemble that of early HCC due to morphologic and phenotypic changes induced by the regenerative mechanism and the alteration of blood flow. We should carefully observe progressing FNH.

Arrival time parametric imaging using Sonazoid-enhanced ultrasonography is useful for the detection of spoke-wheel patterns of focal nodular hyperplasia smaller than 3 cm

It is considered difficult to make a definitive diagnosis of focal nodular hyperplasia (FNH) of <3 cm when using conventional diagnostic imaging modalities. Typical FNH imaging findings are: i) central scar formation, ii) nutrient vessels extending radially from the center and iii) the presence of Kupffer cells. In a clinical setting, identification of a spoke-wheel pattern formed by nutrient vessels extending radially is a key feature in the diagnosis of FNH. In this study, we investigated the detection rate of spoke-wheel patterns of FNH <3 cm using arrival time parametric imaging (At-PI) technology with Sonazoid-enhanced ultrasonography (US). Five patients with FNH <3 cm who had undergone Sonazoid-enhanced US at the Toho University Omori Medical Center between February 2008 and March 2009 were included in the study. The mean tumor diameter was 20.2±7.2 mm. Lesions were enhanced with 0.5 ml Sonazoid US contrast agent and a video of the procedure was saved and used for At-PI analysis of contrast agent dynamics in FNH. Three ultrasonographic specialists examined the images and made a diagnosis of FNH based on the findings of spoke-wheel patterns. Similarly, micro-flow imaging (MFI) was performed to evaluate the contrast agent dynamics in FNH. Using MFI, FNH was diagnosed in 3 of the 5 cases by the three specialists, whereas At-PI enabled the identification of spoke-wheel patterns in all 5 cases. At-PI using Sonazoid-enhanced US is superior for detecting spoke-wheel patterns of FNH <3 cm.

Multiple progressive focal nodular hyperplasia lesions of liver in a patient with hemosiderosis

Focal nodular hyperplasia (FNH) is the second most common benign lesion of the liver. It is a solitary lesion and usually does not enlarge. We present the magnetic resonance imaging findings of multiple progressive FNH lesions in a patient with hemosiderosis using Gadolinium-EOB-DTPA (Eovist) as a hepatobiliary contrast agent. The possible mechanisms underlying the occurrence and progression of FNH lesions and the potential value of Eovist in characterizing the lesions were discussed.

Distinguishing benign from malignant liver tumours

Liver masses are very common and most are benign. It is therefore important to avoid unnecessary interventions for benign lesions, while at the same time ensuring accurate diagnosis of hepatic malignancies. Many cancer patients, like the general population, have incidental benign liver lesions. In planning treatment for cancer patients, it is critical to avoid inappropriate treatment decisions based on misdiagnosis of a benign lesion as a metastasis or primary liver malignancy. This article describes the salient imaging features of the common benign liver masses and outlines a general approach to distinguishing between benign and malignant hepatic lesions.

A case of rapidly expanding and increasing focal nodular hyperplasia

We report a case of 14-year-old male patient who underwent bile-duct-to-jejunum anastomosis because of congenital biliary atresia at the age of 2 months. A 15 mm hypervascular nodule was detected for the first time in the S1 region of the liver at the age of 9 years. Two years later, 6 hypervascular nodules were found in the liver. A tumor biopsy was performed. It was diagnosed as a focal nodular hyperplasia (FNH). However, the number of nodules increased from 6 to 12 and those diameters were enlarged two to seven times one year later; the tumor biopsy was performed again. Histologically, the findings were consistent with those obtained previously, which indicated FNH. We consider that this is a very rare case of FNH in which both the number of nodules and the size were increased in a short period of time. We present it here as a valuable case report.

Clinical, morphologic, and molecular features defining so-called telangiectatic focal nodular hyperplasias of the liver

BACKGROUND & AIMS

Telangiectatic focal nodular hyperplasia (TFNH) of the liver is generally believed to belong to the focal nodular hyperplasia (FNH) family. The aim of this study was to use molecular markers, in addition to morphologic features, to better characterize TFNH.

METHODS

Thirteen patients with TFNH were compared with 28 patients with FNH and 17 patients with hepatocellular adenoma. Full clinical and morphologic data were analyzed. Molecular markers included determination of clonality by examining the active X chromosome, genome-wide allelotyping, a search for hepatocyte nuclear factor 1alpha (HNF1alpha) mutations, and determination of ANGPT1/ANGPT2 transcript levels.

RESULTS

No clinical differences were evident between patients with TFNH and adenoma; in particular, bleeding was observed in 77% and 53% of the cases, respectively. Patients with TFNH were more likely to experience nodule recurrence and the presence of multiple nodules than those with either FNH or adenoma. All TFNH and adenoma samples that were available for analysis were monoclonal, in contrast to 40% of the FNH samples. Chromosome losses confirmed monoclonality and were significantly less frequent in TFNH and FNH (22% and 26%) than in adenoma (53%). HNF1alpha mutations were found exclusively in half of the adenomas. ANGPT2 was overexpressed in TFNH and down-regulated in adenoma (P < .01) and FNH (P < .0005).

CONCLUSIONS

TFNHs are monoclonal lesions frequently subject to bleeding that are similar to adenomas not carrying HNF1alpha mutations and require a similar type of treatment. However, morphologic and molecular data support the hypothesis that TFNH is a separate entity.

Multiple focal nodular hyperplasia of the liver in a 21-year-old woman

Focal nodular hyperplasia (FNH) is a relatively common condition, the diagnosis of which is now regularly made with diagnostic imaging. Cases of multiple FNH (more than four lesions) are rare, however, and the presence of numerous lesions may complicate the workup and diagnosis. We recently treated a young woman with multiple FNH. We report this case to highlight the clinical issues presented by this rare variant of a common benign hepatic disease.

Hepatic lesion differentiated from accessory spleen by a heat-damaged red blood cell scan

A 34-year-old woman referred for evaluation of an abdominal mass underwent a computed tomographic portagram that showed a large mass in the region of the left hepatic lobe and adjacent to the spleen. A liver-spleen scan with sulfur colloid did not clearly show whether the mass originated in the liver or the spleen. To evaluate the possibility of an accessory spleen, a selective spleen scan using Tc-99m-labeled heat-damaged red blood cells was performed and showed intense uptake in the region of the spleen only. The patient underwent surgical exploration and excision of the lesion, which proved to be focal nodular hyperplasia of the liver. Thus, the heat-damaged red blood cell scan ruled out an accessory spleen as a cause for the mass.

Focal nodular hyperplasia: natural course observed with CT and MRI

PURPOSE

The purpose of this work was to assess the natural course of biopsy-proven focal nodular hyperplasia (FNH).

METHOD

Eighteen biopsy-proven FNHs in 14 patients (12 women and 2 men) who were followed for at least 6 months with CT and/or MRI were included in the study. The volume of the lesions was calculated twice by two observers using the summation of areas method. Intra- and interobserver variability was assessed by intraclass correlation coefficients. Longitudinal data analysis was performed with generalized estimating equations.

RESULTS

The volume of FNH was stable in 6 cases, decreased in 10 cases, and increased in 2 cases. Intra- and interobserver variability in size measurements was 5-10%. Intraclass correlation coefficients were >0.992. Longitudinal data analysis showed that there was a general trend of lesion regression.

CONCLUSION

Long-term follow-up and objective measurements performed in patients with biopsy-proven lesions show that the natural course of FNH is variable. In particular, lesion regression is not rare.