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Hepatocellular Adenoma

Adenoma Liver Cell

Hepatocellular adenomas are benign tumors of liver closely linked to oral contraceptive and anabolic steroid use that usually involve the right hepatic lobe. Cases have also been described in type I and III glycogen storage diseases and men with metabolic syndrome. Often clinically silent, this condition may be found incidentally or as a result of complications like rupture, hemorrhage or malignant transformation to hepatocellular carcinoma.


Presentation

Patients may be asymptomatic or may have non-specific complaints if the disease is not complicated, such as abdominal pain that is diffuse or located in the liver projection area or they might notice a palpable mass [1].

Tumor rupture leads to hemoperitoneum, with various degrees of blood loss, leading to severe abdominal pain accompanied by thirst, tachycardia, hypotension, diaphoresis, signs of hypovolemic shock. If left untreated, this complication causes death.

Jaundice appears if the biliary duct is compressed by the tumor, and this happens more often if several hepatocellular adenomas coexist. Some patients may present with pallor and asthenia, symptoms of chronic anemia. If malignant transformation occurs, symptoms resemble those of hepatocellular carcinoma [2], such as weight loss, pruritus, encephalopathy symptoms, splenomegaly, variceal bleeding, increasing abdominal girth due to ascites.

Abdominal Pain
  • Patients may be asymptomatic or may have non-specific complaints if the disease is not complicated, such as abdominal pain that is diffuse or located in the liver projection area or they might notice a palpable mass.[symptoma.com]
  • Twenty-nine months after the initial presentation, the patient was admitted with acute upper abdominal pain and abdominal tenderness.[ncbi.nlm.nih.gov]
Nausea
  • Solitary-uncomplicated HA Multiple HA Ruptured HA Total Cases ( n ) 9 6 10 25 No. of HA 1 9 39 2 10 58 Symptoms (no. of cases) None 3 3 0 6 Pain 6 3 10 19 Nausea/vomiting 3 0 5 8 Diarrhea 0 0 2 2 Asthenia 1 1 0 2 Median duration of symptoms (wk) 3 8 ([doi.org]
  • : oral contraceptives and anabolic steroids Hepatic hemangioma : possible hormonal component ; estrogen therapy associated with increased growth in size Symptoms/clinical findings Usually asymptomatic Large tumors upper abdominal pain, fullness, and nausea[amboss.com]
  • Sometimes it causes mild symptoms, though, such as pain, nausea, or a full feeling. This typically occurs when the tumor is large enough to put pressure on neighboring organs and tissues.[healthline.com]
  • Or, if there are symptoms, they are very mild and can be confused with everyday complaints such as discomfort, nausea or a feeling of fullness.[liverandpancreassurgeon.com]
  • Table 1 Clinical presentation of different forms of HA Solitary-uncomplicated HA Multiple HA Ruptured HA Total Cases ( n ) 9 6 10 25 No. of HA 1 9 39 2 10 58 Symptoms (no. of cases) None 3 3 0 6 Pain 6 3 10 19 Nausea/vomiting 3 0 5 8 Diarrhea 0 0 2 2[web.archive.org]
Hepatic Mass
  • An ultrasound showed a hypoechoic hepatic mass.[ncbi.nlm.nih.gov]
  • The unenhanced image of multiphase helical computed tomography (CT) revealed a heterogenous solid exophytic hepatic mass with intratumoral hemorrhage ( Fig. 2A ).[kjim.org]
  • mass that proved to be a hepatic adenoma Hepatic adenoma: Liver adenoma Hepatic adenoma: Liver adenoma in a patient with a fatty liver Hepatic adenoma: Hypoechoic liver lesion that proved to be a liver adenoma Hepatic adenoma: Incidentally found liver[ultrasoundcases.info]
  • FLC characteristically manifests as a 10-20 cm large hepatic mass in adolescents or young adults. The typical risk factors for HCC such as cirrhosis, elevated alphafetoprotein, viral hepatitis, alcohol abuse are absent.[radiologyassistant.nl]
  • mass and a very high serum alpha-fetoprotein, definitive diagnosis usually is made on examination of a biopsy or resection specimen.[nature.com]

Workup

Clinical examination should look for direct tumor symptoms (right hypochondrium mass or hepatomegaly), acute or chronic bleeding signs (tachycardia, orthostatic or permanent hypotension, pallor), compression signs (jaundice) and indications for tumor rupture: severe abdominal pain with peritoneal signs or fluid wave sign.

Blood workup should include the determination of aspartate aminotransferase, alanine aminotransferase (likely to be elevated due to the compression exerted by the tumor on the rest of the hepatocytes), gamma-glutamyl transferase and alkaline phosphatase, that might also be mildly elevated, complete blood cell count and inflammatory markers such as C-reactive protein and serum amyloid A that might also be high, alpha-fetoprotein that should be normal (if abnormal, consider carcinoma), carcinoembryonic antigen (if high, consider colon metastasis) and entamoeba histolytica and echinococcus granulosus tests.

Abdominal ultrasonography describes a well delineated, hypoechoic mass with venous flow patterns, better described by contrast-enhanced echography [3]. Computer tomography (CT) and magnetic resonance imaging (MRI) scans may describe necrosis and calcification.

Classic histology techniques performed on a needle aspiration specimen may be non-diagnostic (usually showing normal hepatocytes with abnormal lobular arrangement or peliosis hepatis), but immunohistochemistry may be useful: glutamine synthetase staining [4], E-cadherin, matrix metalloproteinases 1, 2, 7 and 9 [5], agrin and CD 34 [6], glycipan-3 [7] and cytokeratin 7 and 9 [8] may be valuable markers. Still, percutaneous biopsy of a presumed hepatocellular adenoma should not be routinely performed, as it might induce bleeding and dissemination. Immunohistochemical techniques can also be applied to excised masses if there is doubt about their nature.

Tc99m sulfur colloid scans show a photopenic center with a high uptake rim or a homogenous high uptake lesion [9]. Angiographic studies describe a well-irrigated periphery, different from the pattern seen in focal nodular hyperplasia [10].

Hepatocellular Carcinoma
  • Hussain SM, Semelka RC, Mitchell DG (2002) MR imaging of hepatocellular carcinoma. Magn Reson Imaging Clin N Am 10:31–52, v PubMed CrossRef Google Scholar 14.[doi.org]
Liver Biopsy
  • KEYWORDS: Differential diagnosis; Focal nodular hyperplasia; Hepatocellular adenoma; Hepatocellular carcinoma; Liver biopsy[ncbi.nlm.nih.gov]
  • Romil Saxena presents interpretation of liver biopsies according to a pattern-based approach that begins with recognition of the predominant histological pattern of injury, followed by identification of secondary features and appropriate work-up that[books.google.com]
  • The use of liver biopsy, therapeutic options and follow-up are decided by the presentation of the lesion and associated patient characteristics.[ijhpd.com]

Treatment

  • This case report suggests that the indication for IRE may extend to the treatment of benign liver tumors that cannot be treated safely otherwise.[ncbi.nlm.nih.gov]

Prognosis

  • The prognosis is not well established yet and malignant transformation has been recently associated with β-catenin activation.[ncbi.nlm.nih.gov]
  • Prognosis Malignant transformation is rare and the long-term prognosis is good. The documents contained in this web site are presented for information purposes only.[orpha.net]
  • Their appearance and prognosis are different from other subtypes. They are the second most common (30-35%) hepatic adenoma, after the inflammatory subtype. They occur only in female patients, most with a history of oral contraceptive (OCP) use.[radiopaedia.org]

Etiology

  • The etiological factors of HCA are known to relate to the contraceptive pill usage in female and the anabolic-androgenic-steroid administration in male.[ncbi.nlm.nih.gov]
  • Etiology In most cases, adenomas develop for unclear reasons in an otherwise healthy liver.[orpha.net]
  • It is no identifiable etiologic factor. It is, however, associated with a conditions having local or systemic vascular anomalies.[ijhpd.com]

Epidemiology

  • Abstract This educational review focuses on the epidemiology and radiological evaluation of the various subtypes of hepatic adenomas (HCAs).[ncbi.nlm.nih.gov]
  • "Epidemiology of hepatocellular adenoma. The role of oral contraceptive use". JAMA. 242 (7): 644–8. doi : 10.1001/jama.242.7.644. PMID 221698. a b c d "Hepatocellular Adenoma: eMedicine Gastroenterology". a b c Anthony S.[en.wikipedia.org]
  • Anthony P (2002) Tumours and tumour-like lesions of the liver and biliary tract: aetiology, epidemiology and pathology. In: MacSween RNM BA, Portmann BC (eds) Pathology of the liver. Churchill Livingstone, pp 711–775 Google Scholar 11.[doi.org]
Sex distribution
Age distribution

Pathophysiology

  • Herein, we review how molecular classification has modified our understanding of the pathophysiology and risk factors of HCA development, analysing its impact on clinical care in the field of diagnosis and therapeutic stratification.[ncbi.nlm.nih.gov]
  • […] contraceptive pills, approximately 3 per 100,000 ( N Engl J Med 1976;294:470 ) Additional risk factors include anabolic steroids, noncontraceptive estrogen supplements, obesity and metabolic syndrome Mean age 37 - 41 years Rare in pediatric patients Pathophysiology[pathologyoutlines.com]
  • Jump to: navigation, search Adenoma Microchapters Home Patient Information Overview Classification Pathophysiology Causes Differentiating Adenoma from other Diseases Epidemiology & Demographics Risk Factors Screening Natural History, Complications & Prognosis[wikidoc.org]
  • Although the pathophysiology is not yet fully known, malignant transformation of HA into hepatocellular carcinoma (HCC) has been reported [ 8 - 10 ].[kjim.org]

Prevention

  • We herein report the case of a 52-year-old woman presenting with severe multiple typical IHCA that regressed dramatically on treatment with fenofibrate, a PPAR agonist known to prevent IL6-induced inflammation experimentally and in humans.[ncbi.nlm.nih.gov]
  • When doctors discover a large adenoma, they may recommend that it be surgically removed to prevent that possibility.[liverfoundation.org]
  • Secondary Prevention Cost-Effectiveness of Therapy Future or Investigational Therapies Case Studies Case #1 Adenoma historical perspective On the Web Most recent articles Most cited articles Review articles CME Programs Powerpoint slides Images American[wikidoc.org]

References

Article

  1. Dokmak S, Paradis V, Vilgrain V, et al. A single-center surgical experience of 122 patients with single and multiple hepatocellular adenomas. Gastroenterology. 2009;137:1698–1705.
  2. Bioulac-Sage P, Taouji S, Possenti L, Balabaud C. Hepatocellular adenoma subtypes: the impact of overweight and obesity. Liver Int. 2012;32:1217–1221.
  3. van den Esschert JW, van Gulik TM, Phoa SS. Imaging modalities for focal nodular hyperplasia and hepatocellular adenoma. Dig Surg. 2010. 27(1):46-55.
  4. Hechtman JF, Raoufi M, Fiel MI, et al. Hepatocellular carcinoma arising in a pigmented telangiectatic adenoma with nuclear ß-catenin and glutamine synthetase positivity: case report and review of the literature. Am J Surg Pathol. 2011 Jun. 35(6):927-32
  5. Tretiakova MS, Hart J, Shabani-Rad MT, Zhang J, Gao ZH. Distinction of hepatocellular adenoma from hepatocellular carcinoma with and without cirrhosis using E-cadherin and matrix metalloproteinase immunohistochemistry. Mod Pathol. 2009 Aug. 22(8):1113-20.
  6. Tatrai P, Somoracz A, Batmunkh E, et al. Agrin and CD34 immunohistochemistry for the discrimination of benign versus malignant hepatocellular lesions. Am J Surg Pathol. 2009 Jun. 33(6):874-85.
  7. Wang HL, Anatelli F, Zhai QJ, et al. Glypican-3 as a useful diagnostic marker that distinguishes hepatocellular carcinoma from benign hepatocellular mass lesions. Arch Pathol Lab Med. 2008 Nov. 132(11):1723-8.
  8. Ahmad I, Iyer A, Marginean CE, et al. Diagnostic use of cytokeratins, CD34, and neuronal cell adhesion molecule staining in focal nodular hyperplasia and hepatic adenoma. Hum Pathol. 2009 May. 40(5):726-34.
  9. Lubbers PR, Ros PR, Goodman ZD, et al. Accumulation of technetium-99m sulfur colloid by hepatocellular adenoma: scintigraphic-pathologic correlation. AJR Am J Roentgenol. 1987;148 (6): 1105-8.
  10. Grazioli L, Federle MP, Brancatelli G, Ichikawa T, Olivetti L, Blachar A. Hepatic adenomas: imaging and pathologic findings. Radiographics. 2001;21:877–892; discussion 892-894.

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Last updated: 2019-07-11 20:52