Huge Hepatocellular Adenoma
A B S T R A C T
Hepatocellular adenoma (HCA) is generally uncommon benign liver tumor with potential to become malignant. Its prevalence has been increasing steadily secondary to wide use of oral contraceptives and due to the increased use of imaging for a variety of unrelated reasons. Large adenomas may present with chronic abdominal pain. As HCA become larger it is prone to rupture and hemorrhage due to central necrosis because the vascular supply is limited to the surface of the tumor. If left untreated HCA can undergo transformation into hepatocellular carcinoma which can be as high as in 10% of cases1 or even higher. Surgical excision is a preferred method of treatment. Other modalities include embolization of bleeding tumors and ablative modalities in selected cases.
Hepatocellular, adenoma, liver tumour
We describe a case of a large hepatocellular adenoma (HCA) diagnosed in a 51 years old Caucasian female. She was referred to us with a 1-year history of constant mild RUQ pain for which she initially underwent ultrasound investigation. It revealed large neoplasm at the upper pole of the right kidney, deforming liver, without signs of invasion, presumably originating from the right adrenal gland or retroperitoneum. She had no significant past medical history. She denied usage of oral contraceptives. Clinical examination of the abdomen did not reveal any palpable mass. Laboratory tests including full blood count, U&E, liver function tests and coagulation profile were all within normal limits, markers for hepatitis B and C were negative, a-fetoprotein was 4.0 ng/ml, CA 19-9- 1.59 U/ml.
A contrast enhanced triphasic abdominal computer tomography (CT) scan confirmed the presence of a nodular lesion of about 15 cm in diameter in the right lobe of the liver, compressing on the upper pole of the right kidney but without any signs of invasion (Figure 1). There were dilated segmental biliary ducts noted within the lesion. She underwent a robotic CT-guided translumbar core needle biopsy of the tumor using Robio EX Perfint navigation tool (Figure 2). It confirmed the diagnosis of hepatocellular adenoma based on both histological and immunochemistry appearance. On the basis of the clinical, histological and CT scan findings she was subjected to laparotomy and liver resection. The optimal approach to the tumor was attained by Mersedes Benz incision. The patient underwent removal of the tumor with resection of SVII-VIII of the liver along with right adrenalectomy.
The resection required meticulous mobilization of the tumor from diaphragm, IVC, duodenum and pancreas which was accompanied by bleeding from dilated blood vessels in retroperitoneum and resulted in 2000 ml blood loss. Post-operative course was uneventful. The pathological examination showed a mass of 17 cm in a maximum dimension with a smooth, regular external surface; there were an area of necrotic, haemorrhagic tissue centrally (Figure 3). The capsule of normal adrenal gland was fused with tumor capsule. Microscopic examination confirmed the diagnosis of HCA.
Hepatocellular adenoma (HCA) is generally uncommon benign liver tumor with potential to become malignant1. Its prevalence has been increasing steadily secondary to wide use of oral contraceptives and due to the increased use of imaging for a variety of unrelated reasons [1, 2]. Other possible etiologies of liver cell adenoma include Klinefelter's syndrome Types I, III and IV glycogen storage disease and familial adenomatous polyposis [3-6]. Our patient denied usage of oral contraceptives, she was not tested for other possible causes of HCA. Small uncomplicated HCAs in majority of cases are asymptomatic and can only be incidentally picked up on imaging or during laparoscopy . Large adenomas may present with chronic abdominal pain [1, 7]. As HCA become larger it is prone to rupture and hemorrhage due to central necrosis because the vascular supply is limited to the surface of the tumor [1, 8]. Rupture of adenoma causes massive haemorrhage with shock and acute abdominal pain [1, 7]. If left untreated HCA can undergo transformation into hepatocellular carcinoma (HCC) which can be as high as in 10% of cases or even higher [1, 4]. Therefore, surgical resection is advocated in most patients with presumed adenomas.
Figure 1: Computer tomography showing large liver tumor.
Figure 2: Robotic CT-guided core needle biopsy of the large liver tumor.
HCA sometimes can mimic other liver lesions such as focal nodular hyperplasia, benign liver lesion of vascular origin or well-differentiated HCC tumors . In our case after initial ultrasound assessment the tumor was thought to originate from right adrenal gland or to be retroperitoneal tumor. Although, the ultrasonographic features of HCA are known to be non-specific . However, with advent of modern cross-sectional imaging the diagnosis can be established rather accurately [1, 8]. The classical CT appearance of HCA is early phase peripheral contrast enhancement with subsequent central enhancement, whereas, in focal nodular hyperplasia the enhancement starts centrally due to vascular supply from artery which arises centrally .
Figure 3: The specimen of resected hepatocellular adenoma.
Hepatocellular adenoma was first described by Edmondson in 1958 as an encapsulated liver tumor that does not contain bile ducts . In our case the CT report stated that the lesion contained dilated segmental bile ducts which did not support the diagnosis of adenoma and therefore the biopsy was warranted. Unfortunately, percutaneous core needle biopsy not always accurate and does not rule out HCC even if no malignancy is found . There is also risk of bleeding and tumor dissemination associated with biopsy, therefore, excision biopsy is the gold standard method for diagnosis . Surgical excision is also a preferred method of treatment. Other modalities include embolization of bleeding tumors and radiofrequency ablation in selected cases . They were not feasible in our case.
Conflicts of interest
Article TypeCase Report
Publication historyReceived: Thu 21, Nov 2019
Accepted: Mon 06, Jan 2020
Published: Fri 10, Jan 2020
Copyright© 2019 Tomas Urbonas. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Hosting by Science Repository. All rights reserved.
Corresponding AuthorTomas Urbonas
Department of Emergency Surgery, Oxford University Hospitals Foundation Trust, United Kingdom
Figures & Tables
- Ludger Barthelmes, Iain S (2005) Liver cell adenoma and liver cell adenomatosis. HPB (Oxford) 7: 186-196. [Crossref]
- Edmondson H, Henderson B, Benton B (1976) Liver cell adenomas associated with the use of the oral contraceptive. N Engl J Med 294: 470-472. [Crossref]
- Beuers U, Richter WO, Ritter MM, Wiebecke B, Schwandt P (1991) Klinefelter's syndrome and liver adenoma. J Clin Gastroenterol 13: 214-216. [Crossref]
- AD Baheti, MM Yeh, R O'M, N Lalwani (2015) Malignant Transformation of Hepatic Adenoma in Glycogen Storage Disease Type-1a: Report of an Exceptional Case Diagnosed on Surveillance Imaging. J Clin Imaging Sci 5: 47. [Crossref]
- Labrune P, Trioche P, Duvaltier I, Chevalier P, Odievre M (1997) Hepatocellular adenomas in glycogen storage disease type I and III: a series of 43 patients and review of the literature. J Pediatr Gastroenterol Nutr 24: 276-279. [Crossref]
- Bala S, Wunsch PH, Ballhausen WG (1997) Childhood hepatocellular adenoma in familial adenomatous polyposis: mutations in adenomatous polyposis coli gene and p53 Gastroenterology 112: 919-922. [Crossref]
- Sandonato L, Cipolla C, Graceffa G, Bartolotta TV, Li Petri S et al. (2007) Giant hepatocellular adenoma as cause of severe abdominal pain: a case report. J Med Case Rep 1: 57. [Crossref]
- Van Hoe L, Baert AL, Gryspeerdt S, Vandenbosh G, Nevens F et al. (1997) Dual-phase helical CT of the liver: value of an early-phase acquisition in the differential diagnosis of noncystic focal lesions. AJR Am J Roentgenol 168: 1185-1192. [Crossref]
- Edmondson HA (1958) Tumors of the liver and intrahepatic bile ducts. Section 7, fascicle 25, Atlas of Tumor Pathology. Washington: Armed Forces Institute of Pathology.
- Charny CK, Jarnagin WR, Schwartz LH, Frommeyer HS, DeMatteo RP et al. (2001) Management of 155 patients with benign liver tumours. Br J Surg 88: 808-813. [Crossref]