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Hassine HB, Chaouch MA, Jallali M, Zenati H, Gafsi B, Noomen F. Arterial embolization of focal nodular hyperplasia of the liver: A case report. Int J Surg Case Rep 2024; 116:109473. [PMID: 38447522 PMCID: PMC10926115 DOI: 10.1016/j.ijscr.2024.109473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 02/28/2024] [Accepted: 02/29/2024] [Indexed: 03/08/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Focal nodular hyperplasia (FNH) is a benign liver lesion that can pose diagnostic and management dilemmas, especially when distinguishing it from other hypervascular hepatic lesions. The benign nature of FNH often makes conservative management a priority; however, intervention may be necessary in symptomatic cases or when diagnostic uncertainty exists. CASE PRESENTATION A 19-year-old male presenting with abdominal pain, found to have a large 25 cm FNH lesion in the right lobe of the liver. Initial diagnosis was achieved through ultrasonography and contrast-enhanced computed tomography (CECT), with histopathological confirmation via core needle biopsy. Given the lesion's size and the patient's symptomatic presentation, we opted for arterial embolization, a less invasive surgical approach, over traditional resection methods. This technique not only led to symptom resolution but also resulted in a significant reduction in lesion size. CLINICAL DISCUSSION Our approach to managing this FNH case involved a multidisciplinary team. The decision to employ arterial embolization over more invasive surgical options was based on the lesion's characteristics, the patient's age, and the potential for significant morbidity associated with traditional surgery. Arterial embolization of the FNH lesion resulted in complete resolution of symptoms and a significant reduction in lesion size, from 25 cm to 12 cm, demonstrating the effectiveness of this technique in managing large FNH lesions. CONCLUSION Our findings contribute to the scientific literature by showcasing the potential of less invasive surgical techniques in the management of FNH, offering valuable insights for clinicians faced with similar diagnostic and therapeutic challenges.
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Affiliation(s)
- Hiba Ben Hassine
- Department of Visceral and Digestive Surgery, Monastir University Hospital, Monastir, Tunisia
| | - Mohamed Ali Chaouch
- Department of Visceral and Digestive Surgery, Monastir University Hospital, Monastir, Tunisia.
| | - Maissa Jallali
- Department of Visceral and Digestive Surgery, Monastir University Hospital, Monastir, Tunisia
| | - Hanen Zenati
- Department of Visceral and Digestive Surgery, Monastir University Hospital, Monastir, Tunisia
| | - Besma Gafsi
- Department of Anesthesia, Monastir University Hospital, Monastir, Tunisia
| | - Faouzi Noomen
- Department of Visceral and Digestive Surgery, Monastir University Hospital, Monastir, Tunisia
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Tsalikidis C, Mitsala A, Pappas-Gogos G, Romanidis K, Tsaroucha AK, Pitiakoudis M. Pedunculated Focal Nodular Hyperplasia: When in Doubt, Should We Cut It Out? J Clin Med 2023; 12:6034. [PMID: 37762973 PMCID: PMC10532121 DOI: 10.3390/jcm12186034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 09/10/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
Focal nodular hyperplasia (FNH) is the second most common benign hepatic tumor and can rarely present as an exophytic solitary mass attached to the liver by a stalk. Most FNH cases are usually detected as incidental findings during surgery, imaging or physical examination and have a high female predominance. However, the pedunculated forms of FNH are particularly rare and commonly associated with severe complications and diagnostic challenges. Hence, our study aims to provide a comprehensive summary of the available data on the pedunculated FNH cases among adults and children. Furthermore, we will highlight the role of different therapeutic options in treating this clinical entity. The use of imaging techniques is considered a significant addition to the diagnostic toolbox. Regarding the optimal treatment strategy, the main indications for surgery were the presence of symptoms, diagnostic uncertainty and increased risk of complications, based on the current literature. Herein, we also propose a management algorithm for patients with suspected FNH lesions. Therefore, a high index of suspicion and awareness of this pathology and its life-threatening complications, as an uncommon etiology of acute abdomen, is of utmost importance in order to achieve better clinical outcomes.
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Affiliation(s)
- Christos Tsalikidis
- Second Department of Surgery, University General Hospital of Alexandroupolis, Democritus University of Thrace Medical School, 68100 Alexandroupolis, Greece; (C.T.); (A.M.); (G.P.-G.); (K.R.); (M.P.)
| | - Athanasia Mitsala
- Second Department of Surgery, University General Hospital of Alexandroupolis, Democritus University of Thrace Medical School, 68100 Alexandroupolis, Greece; (C.T.); (A.M.); (G.P.-G.); (K.R.); (M.P.)
| | - George Pappas-Gogos
- Second Department of Surgery, University General Hospital of Alexandroupolis, Democritus University of Thrace Medical School, 68100 Alexandroupolis, Greece; (C.T.); (A.M.); (G.P.-G.); (K.R.); (M.P.)
| | - Konstantinos Romanidis
- Second Department of Surgery, University General Hospital of Alexandroupolis, Democritus University of Thrace Medical School, 68100 Alexandroupolis, Greece; (C.T.); (A.M.); (G.P.-G.); (K.R.); (M.P.)
| | - Alexandra K. Tsaroucha
- Laboratory of Experimental Surgery & Surgical Research, Democritus University of Thrace Medical School, 68100 Alexandroupolis, Greece
| | - Michail Pitiakoudis
- Second Department of Surgery, University General Hospital of Alexandroupolis, Democritus University of Thrace Medical School, 68100 Alexandroupolis, Greece; (C.T.); (A.M.); (G.P.-G.); (K.R.); (M.P.)
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Sato H, Monden K, Iwasaki T, Hioki M, Sadamori H, Takakura N. Large focal nodular hyperplasia of the liver treated with transcatheter arterial embolization and laparoscopic resection: A case report. Asian J Endosc Surg 2023. [PMID: 37037454 DOI: 10.1111/ases.13188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/03/2023] [Accepted: 03/23/2023] [Indexed: 04/12/2023]
Abstract
Focal nodular hyperplasia (FNH) is a rare benign hepatic tumor which is frequently observed in women of reproductive age, and therapeutic intervention needs to be considered in cases wherein the tumor has a risk of rupture. The laparoscopic approach is beneficial, especially for young women, but is often challenging because the tumor is large and hemorrhagic. Herein, we report a case of large FNH in a 22-year-old woman. The patient was asymptomatic; however, the tumor was approximately 15 cm in diameter and protruded from the liver. Given the risk of rupture, we decided to perform surgical resection. Preoperative transcatheter arterial embolization led to rapid shrinkage of the tumor and control of intraoperative bleeding, which enabled us to safely perform laparoscopic liver resection. The combination of surgical resection with intravascular embolization may be a promising therapeutic option for hypervascular tumors such as FNH.
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Affiliation(s)
- Hiroki Sato
- Department of Surgery, Fukuyama City Hospital, 5-23-1 Zao, Fukuyama, 721-8511, Japan
| | - Kazuteru Monden
- Department of Surgery, Fukuyama City Hospital, 5-23-1 Zao, Fukuyama, 721-8511, Japan
| | - Toshimitsu Iwasaki
- Department of Surgery, Fukuyama City Hospital, 5-23-1 Zao, Fukuyama, 721-8511, Japan
| | - Masayoshi Hioki
- Department of Surgery, Fukuyama City Hospital, 5-23-1 Zao, Fukuyama, 721-8511, Japan
| | - Hiroshi Sadamori
- Department of Surgery, Fukuyama City Hospital, 5-23-1 Zao, Fukuyama, 721-8511, Japan
| | - Norihisa Takakura
- Department of Surgery, Fukuyama City Hospital, 5-23-1 Zao, Fukuyama, 721-8511, Japan
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Chambers G, Zarfati A, Aderotimi T, Branchereau S, Humphrey T, Woodley H, Franchi-Abella S. Imaging strategy for focal nodular hyperplasia in children: long-term experience from two specialist European centres. Pediatr Radiol 2023; 53:46-56. [PMID: 35773358 DOI: 10.1007/s00247-022-05420-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/10/2022] [Accepted: 06/02/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Focal nodular hyperplasia (FNH) in children is a rare but benign tumour, which must be differentiated from malignant entities to avoid unnecessary treatment, leading to potential morbidity. OBJECTIVES To provide data on imaging findings of these lesions with a suggested algorithm for diagnosis, sampling and follow-up. MATERIALS AND METHODS This retrospective review evaluated imaging of all patients diagnosed with FNH in two tertiary referral centres in Europe between 1975 and 2018. RESULTS One hundred and four patients with 137 tumours were reviewed. The mean age at presentation was 8.2 years. The median tumour size was 5 cm (range: 0.3-29 cm). Multiple lesions were seen in 16.3% of patients. The male-to-female ratio was 1:2. CONCLUSION FNH with typical features on imaging can be safely followed up once the diagnosis has been established. The use of contrast-enhanced ultrasound and magnetic resonance imaging allows accurate characterisation in most cases. Histological sampling is only advised when there is diagnostic doubt. Atypical arterial enhancement of FNH should prompt the search for a congenital portosystemic shunt.
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Affiliation(s)
- Greg Chambers
- Department of Paediatric Radiology, Leeds General Infirmary, Great George Street, LS1 3EX, Leeds, UK.
| | - Angelo Zarfati
- Department of Pediatric Surgery, Bambino Gesù Pediatric Hospital, Piazza di Sant'Onofrio, 4, Rome, Italy.,Residency School of Pediatric Surgery, Via University of Rome Tor Vergata, Cracovia, 50, Rome, Italy
| | - Tobi Aderotimi
- Royal Alexandra Children's Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Sophie Branchereau
- Department of Pediatric Surgery, AP-HP Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Terry Humphrey
- Department of Paediatric Radiology, Leeds General Infirmary, Great George Street, LS1 3EX, Leeds, UK
| | - Helen Woodley
- Department of Paediatric Radiology, Leeds General Infirmary, Great George Street, LS1 3EX, Leeds, UK
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Abstract
The etiologic association between focal nodular hyperplasia (FNH) and estrogen has been a subject of doubt and controversy. We present a case of a female patient with FNH that had been monitored for several years with noted size stability and later regression, who developed tumor growth during pregnancy. This case suggests that a subset of FNH is indeed hormone sensitive, as opposed to what has been frequently suggested by many other reports that question the association, a finding that may have clinical implications, in terms of monitoring of patients with high estrogen statuses.
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Zarfati A, Chambers G, Pio L, Guerin F, Fouquet V, Franchi-Abella S, Branchereau S. Management of focal nodular hyperplasia of the liver: Experience of 50 pediatric patients in a tertiary center. J Pediatr Surg 2020; 55:1885-1891. [PMID: 32057440 DOI: 10.1016/j.jpedsurg.2020.01.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 11/13/2019] [Accepted: 01/09/2020] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Angelo Zarfati
- Department of Pediatric Surgery, Hôpitaux Universitaires Paris-Sud (AP-HP), Hôpital Bicêtre, 78, avenue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.
| | - Greg Chambers
- Department of Pediatric Radiology, Hôpitaux Universitaires Paris-Sud (AP-HP), Hôpital Bicêtre, 78, avenue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.
| | - Luca Pio
- Department of Pediatric Surgery, Hôpitaux Universitaires Paris-Sud (AP-HP), Hôpital Bicêtre, 78, avenue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.
| | - Florent Guerin
- Department of Pediatric Surgery, Hôpitaux Universitaires Paris-Sud (AP-HP), Hôpital Bicêtre, 78, avenue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.
| | - Virginie Fouquet
- Department of Pediatric Surgery, Hôpitaux Universitaires Paris-Sud (AP-HP), Hôpital Bicêtre, 78, avenue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.
| | - Stéphanie Franchi-Abella
- Department of Pediatric Radiology, Hôpitaux Universitaires Paris-Sud (AP-HP), Hôpital Bicêtre, 78, avenue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.
| | - Sophie Branchereau
- Department of Pediatric Surgery, Hôpitaux Universitaires Paris-Sud (AP-HP), Hôpital Bicêtre, 78, avenue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.
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Vernuccio F, Ronot M, Dioguardi Burgio M, Lebigot J, Allaham W, Aubé C, Brancatelli G, Vilgrain V. Uncommon evolutions and complications of common benign liver lesions. Abdom Radiol (NY) 2018; 43:2075-2096. [PMID: 29260281 DOI: 10.1007/s00261-017-1427-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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