hepatic adenoma – can we do more?

Hepatic Adenoma– Can we do more?

Joint Hospital Grand Round2011-02-19

TWO CASES PRESENTATIONProfessional Challenge You May Face of…

April, 2007

• F/25• History of Acute Leukemia with Bone Marrow

Transplant in 1994• On Hormonal Replacement Therapy

• Presented sudden onset of upper abdominal pain with guarding

• Clinically suggested peritonitis

Emergency Laparoscopy Performed

• Intra-operative Findings– Haemoperitoneum with 1L old blood and clots– Large subcapsular haematoma occupying most

inferior surface of right lobe of liver– Small capsular tear with slow oozing– Stomach, Gallbladder, small bowel and ovary

normal

• Oozing stopped with Surgicel packing

• Computer Tomography– Enhancing lesion with haemorrhage in segment

VI/VII, suggestive hepatic adenoma with haemorrhage

November, 2010

• F/19• Good Past Health, No history of use of oral

contraceptive pills

• Presented sudden onset of right upper quadrant pain and tachycardia

• Computer Tomography– Circumscribed 10cm intrahepatic mass in right

lobe of liver with contrast leakage right anterior and posterior aspect of lesion suggestive haemorrage in hepatic adenoma

Uncommon but You May Want to Know More

HEPATIC ADENOMA

Hepatic Adenoma

• Reported incidence 3-4 per 100,000 per year(1), (2)

• Increased case reported since 1970s as introduction of OCP in 1960s– Real incidence maybe underestimated as many patients

are asymptomatic

• Most common in women in their third and fourth decades(3)

• Female/Male Ratio 11:1(3)

(1) Rooks JB et al, JAMA 242(1979):644-648(2) Leese T et al, Ann Surg 208(1988):558-564

(3)Joseph F et al, Surg Clin N Am 90(2010):719-315

Risk Factors• Oral Contraception

– 10 times higher incidence when used for more than 2 years (1), but these estimations were performed in 1970s

– Lower risk was suggested in 2nd and 3rd generation OCP with lower dose of estrogen (4)

– Cessation of OCP was reported to cause regression of hepatic adenoma(5-10)

(1) Rooks JB et al, JAMA 242(1979):644-648(4)Edmondson HA et al. N Engl J Med. 1976;294(9):470-2

(5) Anderson PH et al, Arch Surg 1976; 111:898–900.(6) Aseni P et al. J Clin Gastroenterol 2001; 33:234–6.

(7) Steinbrecher UP et al, Dig Dis Sci 1981; 26:1045–50.(8). Buhler H et al, Gastroenterology

1982; 82:775–82.(9) Edmondson HA et al, Ann Intern Med 1977; 86:180–2.

(10) Ramseur WL et al, JAMA 1978; 239:1647–8.

Risk Factors

• Use of anabolic steroids• Glycogen Storage

Disease

Presentation

• Asymptomatic – Incidental findings in imaging• Right Upper Quadrant Pain or mass in 25-50% (3)

• Complications– Spontaneous Rupture– Malignant Transformation

(3) Joseph F et al, Surg Clin N Am 90(2010)

Imaging• Computer Tomography

– Typically as a discrete, hypodense lesion that shows arterial-phase enhancement and may become iso-dense on delayed images (3)

– Sometime differentiating hepatic adenoma from HCC is difficult

– With the evidence of portal hypertension, cirrhosis and elevated AFP, the diagnosis of HCC is favored.

(3) Joseph F et al, Surg Clin N Am 90(2010)

Imaging

• Magnetic Resonance Imaging– Isointense or hyperintense on T1

weighted images– Variable hyperintensity in T2

weighted images

– Most HCC are characteristically hypointense on T1 W and hyperintense on T2 W images

COMPLICATIONS

1/ Spontaneous Rupture2/ Malignant Transformation to Hepatocellular Carcinoma

• Incidence of haemorrhage was reported upto 30%

• Risk Factors for rupture– Size >7cm– Contraceptive use

Malignant Transformation to Hepatocellular Carcinoma

• Overall frequency of malignant transformation rate was 4.2%.

• Risk Factors– Risk analysis of size was

difficult because studies report only mean size

– 3 cases size less than 5cm– Contraceptive use, anerobic

steriod and glycogen storage disease were high risk group.

CAN WE DO MORE TO PREVENT COMPLICATIONS?

With advance in hepatectomy and new interventions to liver tumors…

Surgery - Hepatectomy

• Classically hepatic adenoma was treated conservatively if size less then 5cm.

• Because there were only scanty reports of rupture and malignant transformation in this size.

The median diameter was 9 cm (range, 1–18 cm).

Other Modalities – TAE and RFA

Other Modalities – TAE and RFA

TWO CASES PRESENTATIONProfessional Challenge You May Face of…

Outcomes of The Two Young Ladies

• Both of them were treated conservatively initially.• Elective hepatectomy were done with no

complication.• Follow up well with no recurrence.

Right Hepatectomy Segment 5/6 Bisegmentectomy

Conclusion

• Hepatic Adenoma may present in complications as rupture or malignant transformation.

• The most common risk factor is use of oral contraceptive pills.

• With advance in surgical techniques, open and laparoscopic hepatectomy, indication of surgery for hepatic adenoma may be extended.

• Other modalities such as TAE and RFA may be future alternative treatments.