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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
Liver tumours are benign or malignant; malignant tumours can be primary or secondary. In Europe and the USA, a solitary lesion in the liver is more likely to be a metastatic carcinoma than a primary liver tumour.
Risk factors for liver cancer
The major risk factors for liver cancer are infection with hepatitis B and C and heavy alcohol consumption, all of which can cause cirrhosis. Smokers and those with diabetes are also at increased risk, while consumption of foods contaminated with aflatoxin is a cause of liver cancer in many developing countries.
- The most common benign liver tumour in adults and children. They are more common in the right lobe of the liver than in the left lobe.
- Hepatic haemangiomas can occur as part of a clinical syndrome - eg, Klippel-Trénaunay-Weber syndrome, Osler-Weber-Rendu syndrome and Von Hippel-Lindau disease.
- The vast majority of hepatic haemangiomas are asymptomatic and most often discovered incidentally during imaging investigations for unrelated health concerns.
- Large cavernous haemangiomas may reach 8-10 cm in diameter.
- They are thought to be congenital and may enlarge under the influence of oral contraceptives. However, they usually regress when oral contraceptives are stopped. They can also grow during pregnancy.
- Hepatic haemangiomas may be seen in up to 10% of children aged 1 year but they usually regress within the first two years of life.
- Usually small and asymptomatic; they most often present as incidental findings at the time of imaging of the liver, laparotomy or post-mortem.
- Right upper quadrant pain or fullness is the most common symptom.
- Examination is usually normal but there may be hepatomegaly and/or an arterial bruit over the right upper quadrant.
- Rare presentations include a large abdominal mass, high-output cardiac failure, obstructive jaundice, gastrointestinal haemorrhage or fever. Thrombocytopenia, hypofibrinogenaemia and microangiopathic haemolytic anaemia may rarely occur.
- Large lesions may cause obstruction to gastric emptying and so present with vomiting.
- Rupture is rare but may occur spontaneously, following trauma or at the time of attempted biopsy.
- Imaging techniques include ultrasound, contrast-enhanced CT scanning, nuclear medicine studies using technetium 99m Tc-labelled red blood cells, MRI, hepatic arteriography and digital subtraction angiography.
- If asymptomatic they may be left alone. Surgical resection is the treatment of choice if necessary. Minimally invasive therapies include arterial embolisation, radiofrequency ablation and hepatic irradiation. Liver transplantation is required on rare occasions. Steroids and interferon treatment are other treatment options.
- Hepatic adenomas are rare, benign liver tumours. Approximately 90% of cases occur in females, mostly aged 15-45 years. They occur most often in women of childbearing age and are strongly associated with the use of oral contraceptives.
- Usually asymptomatic but may cause slight abdominal pain in the epigastrium and in the right hypochondrium, and also bloating. May cause elevations of gamma GT and alkaline phosphatase. The possibility of malignant transformation can be monitored with serum alpha-fetoprotein (AFP).
- Other conditions associated with hepatic adenomas include:
- Anabolic steroids.
- Type 1 diabetes mellitus.
- Glycogen storage diseases (types 1 and 3). Multiple hepatic adenomas are more common in glycogen storage disease.
- The risk of malignant transformation is not completely known and may be as high as 13%.
Hepatic adenoma symptoms
- Often asymptomatic and found incidentally on physical examination or during imaging for another reason.
- May present with pain in the right upper quadrant or the epigastric region.
- A palpable mass may be noticed by the patient.
- May present with severe, acute abdominal pain with bleeding into the abdomen, leading to shock.
- Other rare presentations include obstructive jaundice.
- Liver function is not usually affected but aminotransferase levels may be mildly elevated or there may be features suggestive of obstructive jaundice.
- The most appropriate imaging investigation is contrast-enhanced MRI.
- Immediate abdominal imaging is required for patients with hepatocellular adenomas who present with new or worsened abdominal pain or signs of haemodynamic instability.
Hepatic adenoma treatment
- Patients should be managed in referral centres with access to an MDT. They should be advised to stop using oral contraceptives or anabolic steroids. Pregnancy should be avoided until resection of the tumour because of the risk of growth and rupture.
- Symptomatic tumours should be resected. Due to the increased risk of spontaneous life-threatening haemorrhage and the possible malignant transformation associated with larger-sized tumours, asymptomatic hepatic adenomas approaching 4 cm and those requiring hormonal therapy should also be resected.
- Yearly ultrasound imaging and serum AFP levels for patients with hepatocellular adenomas who do not have a resection of the tumour.
- Emergency hepatic arteriography and embolisation should be considered to control bleeding in high-risk surgical candidates.
Focal nodular hyperplasia
- Focal nodular hyperplasia is the second most common benign liver tumour.
- It is a benign condition of the liver that is often discovered incidentally on radiological investigation. It is more common in women.
- It is not prone to malignant change.
- It is rarely symptomatic and surgical intervention is almost never required. However, symptomatic focal nodular hyperplasia does occur, may have rapid growth and may require resection.
- Duplex Doppler ultrasound may be sufficient but further confirmation may be required using CT, MRI, MR angiography or radionuclide imaging.
- Rupture and haemorrhage have occasionally been reported. Therefore, some authorities advocate excision but most patients can be monitored with imaging.
Other benign liver tumours
They are very rare. They include fibroma, lipoma, leiomyoma and cystadenoma.
Further reading and references
EASL Clinical Practice Guidelines on the management of benign liver tumours; European Association for the Study of the Liver (2016)
Oldhafer KJ, Habbel V, Horling K, et al; Benign Liver Tumors. Visc Med. 2020 Aug36(4):292-303. doi: 10.1159/000509145. Epub 2020 Aug 4.
Yang JD, Hainaut P, Gores GJ, et al; A global view of hepatocellular carcinoma: trends, risk, prevention and management. Nat Rev Gastroenterol Hepatol. 2019 Oct16(10):589-604. doi: 10.1038/s41575-019-0186-y. Epub 2019 Aug 22.
Bajenaru N, Balaban V, Savulescu F, et al; Hepatic hemangioma -review. J Med Life. 20158 Spec Issue:4-11.
Ponnatapura J, Kielar A, Burke LMB, et al; Hepatic complications of oral contraceptive pills and estrogen on MRI: Controversies and update - Adenoma and beyond. Magn Reson Imaging. 2019 Jul60:110-121. doi: 10.1016/j.mri.2019.04.010. Epub 2019 Apr 19.
Leon M, Chavez L, Surani S; Hepatic hemangioma: What internists need to know. World J Gastroenterol. 2020 Jan 726(1):11-20. doi: 10.3748/wjg.v26.i1.11.
Jia K, Gao Z, Li M, et al; Interventional treatments for hepatic hemangioma: A state-of-the-art review. J Interv Med. 2022 Feb 265(1):6-9. doi: 10.1016/j.jimed.2021.12.009. eCollection 2022 Feb.
Szor DJ, Ursoline M, Herman P; Hepatic adenoma. Arq Bras Cir Dig. 2013 Jul-Sep26(3):219-22.
Socas L, Zumbado M, Perez-Luzardo O, et al; Hepatocellular adenomas associated with anabolic androgenic steroid abuse in bodybuilders: a report of two cases and a review of the literature. Br J Sports Med. 2005 May39(5):e27.
Shreenath AP, Kahloon A; Hepatic Adenoma.
Renzulli M, Clemente A, Tovoli F, et al; Hepatocellular adenoma: An unsolved diagnostic enigma. World J Gastroenterol. 2019 May 2825(20):2442-2449. doi: 10.3748/wjg.v25.i20.2442.
Klompenhouwer AJ, de Man RA, Dioguardi Burgio M, et al; New insights in the management of Hepatocellular Adenoma. Liver Int. 2020 Jul40(7):1529-1537. doi: 10.1111/liv.14547. Epub 2020 Jun 11.
Deneve JL, Pawlik TM, Cunningham S, et al; Liver cell adenoma: a multicenter analysis of risk factors for rupture and malignancy. Ann Surg Oncol. 2009 Mar16(3):640-8. Epub 2009 Jan 8.
Hamad S, Willyard CE, Mukherjee S; Focal Nodular Hyperplasia.
Navarro AP, Gomez D, Lamb CM, et al; Focal nodular hyperplasia: a review of current indications for and outcomes of hepatic resection. HPB (Oxford). 2014 Jun16(6):503-11. doi: 10.1111/hpb.12169. Epub 2013 Oct 15.
Hsee LC, McCall JL, Koea JB; Focal nodular hyperplasia: what are the indications for resection? HPB (Oxford). 20057(4):298-302.