• Clinical science

Benign liver tumors and hepatic cysts

Summary

Benign liver tumors and hepatic cysts are common and may occur in all age groups. Benign liver tumors are especially frequent in young women and include hepatic hemangiomas, focal nodular hyperplasia (FNH), and hepatocellular adenoma (also known as liver cell adenoma). Use of oral contraceptives, especially those containing estrogen, and pregnancy are associated with an increased risk of hepatocellular adenoma. Hepatic cysts include solitary and hydatid (echinococcal) cysts. Benign liver tumors and cysts are mainly asymptomatic and are often incidental findings in patients undergoing abdominal imaging. However, in some cases (e.g., large lesions), symptoms like upper abdominal pain and postprandial fullness may occur. Diagnosis is usually based on imaging, but may require biopsy in unclear cases. Treatment is generally conservative; surgery is reserved for specific lesion types and the presence of symptoms or complications.

Benign liver tumors

General

The typical clinical picture of a hepatocellular adenoma is a young woman with a history of oral contraceptive or anabolic steroid use and upper right abdominal pain.

Additional diagnostic findings [11]

Diagnostic studies to differentiate benign liver tumors
Diagnostic studies Hepatic hemangioma Focal nodular hyperplasia (FNH) [3][12] Hepatocellular adenoma [13]

Ultrasonography

  • Usually well-demarcated, homogeneous, hyperechoic (pale)
  • Homogeneous, hypoechoic to isoechoic
  • Round/oval, sharply defined
  • Central, stellate scar
  • Mainly isoechoic
  • No characteristic vascularization
  • Inhomogenous due to bleeding
  • More frequent in the right lobe of the liver
Contrast-enhanced sonography
  • From the central artery, radial arrangement of the peripheral arteries with a typical spoke-like pattern [6]
  • Fast centripetal or mixed filling in the arterial phase [14]
  • Hypervascularity compared to the adjacent liver parenchyma
  • Sustained enhancement or weak washout in the delayed phase [15]
Contrast-enhanced CT scan
  • Well-demarcated
  • Early arterial phase discontinuous, nodular, or peripheral enhancement
  • Subsequent gradual centripetal enhancement (iris diaphragm phenomenon)
  • Delayed-phase hyperintensity due to retention of contrast
  • Early arterial phase enhancement
  • Hypoechoic to isoechoic and poorly visualized in the portal venous phase
  • Central scar (“nest of vessels”)
  • Well-demarcated
  • Heterogenous density due to the presence of fat, glycogen, and hemorrhagic products
  • Early arterial phase peripheral enhancement due to feeding arteries
  • Subsequent centripetal pattern of enhancement
  • No retention of contrast due to arteriovenous shunting on delayed-phase
Pathology
  • Possibly pedunculated, cystic lesions with a dark color
  • Cavernous vascular spaces of variable size, lined by flat endothelial cells
  • Light yellow color compared with the surrounding liver tissue
  • Localized hepatocyte nodules, with large malformed arterial branches and centralized fibrous tissue (central stellate scar)
  • May resemble macronodular cirrhosis [16]
  • Normal hepatic lobular architecture is absent.
  • Enlarged hepatocytes, with small and regular nuclei, cytoplasmic glycogen and lipid deposits
  • Arranged in sheets or 2-cell thick cords

Hepatic cysts

Simple hepatic cysts [17]

  • Etiology: congenital
  • Epidemiology
    • Peak incidence: > 50 years
    • Sex: slightly higher in females (1.5:1 female:male ratio) [18]
  • Clinical features
    • Usually asymptomatic
    • Patients with large cysts may present with dull abdominal pain located in the right upper quadrant, bloating, and early satiety.
  • Diagnostics
  • Treatment: laparoscopic resection if symptomatic

Congenital polycystic liver

See polycystic kidney disease.

Hydatid (echinococcal) cysts

See echinococcosis.

Differential diagnoses

  • 1. Reddy KR, Kligerman S, Levi J, et al. Benign and solid tumors of the liver: relationship to sex, age, size of tumors, and outcome. Am Surg. 2001; 67(2): pp. 173–178. pmid: 11243545.
  • 2. Bajenaru N, Balaban V, Săvulescu F, Campeanu I, Patrascu T. Hepatic hemangioma -review-. Journal of medicine and life. 2015; 8 Spec Issue: pp. 4–11. pmid: 26361504.
  • 3. Venturi A, Piscaglia F, Vidili G, et al. Diagnosis and management of hepatic focal nodular hyperplasia. Journal of Ultrasound. 2007; 10(3): pp. 116–127. doi: 10.1016/j.jus.2007.06.001.
  • 4. Jarnagin WR. Blumgart's Surgery of the Liver, Biliary Tract, and Pancreas. Elsevier; 2016.
  • 5. Luciani A. Focal nodular hyperplasia of the liver in men: is presentation the same in men and women?. Gut. 2002; 50(6): pp. 877–880. doi: 10.1136/gut.50.6.877.
  • 6. Kang HS, Kim BK, Shim CS. Focal nodular hyperplasia: with a focus on contrast enhanced ultrasound. Korean J Hepatol. 2010; 16(4): p. 414. doi: 10.3350/kjhep.2010.16.4.414.
  • 7. Rooks JB, Ory HW, Ishak KG, et al. Epidemiology of hepatocellular adenoma. The role of oral contraceptive use. JAMA. 1979; 242(7): pp. 644–8. pmid: 221698.
  • 8. Renzulli M, Clemente A, Tovoli F, Cappabianca S, Bolondi L, Golfieri R. Hepatocellular adenoma: An unsolved diagnostic enigma. World Journal of Gastroenterology. 2019; 25(20): pp. 2442–2449. doi: 10.3748/wjg.v25.i20.2442.
  • 9. Marrero JA, Ahn J, Reddy RK. ACG Clinical Guideline: The Diagnosis and Management of Focal Liver Lesions. Am J Gastroenterol. 2014; 109(9): pp. 1328–1347. doi: 10.1038/ajg.2014.213.
  • 10. Farges O, Ferreira N, Dokmak S, Belghiti J, Bedossa P, Paradis V. Changing trends in malignant transformation of hepatocellular adenoma. Gut. 2010; 60(1): pp. 85–89. doi: 10.1136/gut.2010.222109.
  • 11. Chiche L, Adam JP. Diagnosis and management of benign liver tumors. Semin Liver Dis. 2013; 33(3): pp. 236–247. doi: 10.1055/s-0033-1351779.
  • 12. Hussain SM, Terkivatan T, Zondervan PE, et al. Focal Nodular Hyperplasia: Findings at State-of-the-Art MR Imaging, US, CT, and Pathologic Analysis. RadioGraphics. 2004; 24(1): pp. 3–17. doi: 10.1148/rg.241035050.
  • 13. Hussain SM, van den Bos IC, Dwarkasing RS, Kuiper J-W, den Hollander J. Hepatocellular adenoma: findings at state-of-the-art magnetic resonance imaging, ultrasound, computed tomography and pathologic analysis. Eur Radiol. 2006; 16(9): pp. 1873–1886. doi: 10.1007/s00330-006-0292-4.
  • 14. Laumonier H, Cailliez H, Balabaud C, et al. Role of Contrast-Enhanced Sonography in Differentiation of Subtypes of Hepatocellular Adenoma: Correlation with MRI Findings. American Journal of Roentgenology. 2012; 199(2): pp. 341–348. doi: 10.2214/ajr.11.7046.
  • 15. Burrowes DP, Medellin A, Harris AC, Milot L, Wilson SR. Contrast-enhanced US Approach to the Diagnosis of Focal Liver Masses. RadioGraphics. 2017; 37(5): pp. 1388–1400. doi: 10.1148/rg.2017170034.
  • 16. Ferrell L. Liver pathology: cirrhosis, hepatitis, and primary liver tumors: Update and diagnostic problems. Mod Pathol. 2000; 13(6): pp. 679–704. doi: 10.1038/modpathol.3880119.
  • 17. Borhani AA, Wiant A, Heller MT. Cystic Hepatic Lesions: A Review and an Algorithmic Approach. American Journal of Roentgenology. 2014; 203(6): pp. 1192–1204. doi: 10.2214/ajr.13.12386.
  • 18. Rawla P, Sunkara T, Muralidharan P, Raj JP. An updated review of cystic hepatic lesions. Clinical and Experimental Hepatology. 2019; 5(1): pp. 22–29. doi: 10.5114/ceh.2019.83153.
  • 19. Calomeni GD, Ataíde EB, Machado RR, Escanhoela CAF, Costa LBE, Boin IFF. Hepatic inflammatory pseudotumor: A case series. International Journal of Surgery Case Reports. 2013; 4(3): pp. 308–311. doi: 10.1016/j.ijscr.2013.01.002.
  • 20. Yousaf MN, D’Souza RG, Chaudhary F, Ehsan H, Sittambalam C. Biloma: A Rare Manifestation of Spontaneous Bile Leak. Cureus. 2020. doi: 10.7759/cureus.8116.
  • 21. Sakamoto I, Iwanaga S, Nagaoki K, et al. Intrahepatic Biloma Formation (Bile Duct Necrosis) After Transcatheter Arterial Chemoembolization. American Journal of Roentgenology. 2003; 181(1): pp. 79–87. doi: 10.2214/ajr.181.1.1810079.
  • 22. Shankar S, vanSonnenberg E, Silverman SG, Tuncali K, Morrison PR. Diagnosis and Treatment of Intrahepatic Biloma Complicating Radiofrequency Ablation of Hepatic Metastases. American Journal of Roentgenology. 2003; 181(2): pp. 475–477. doi: 10.2214/ajr.181.2.1810475.
  • 23. Kwon H-J, Kim KW, Park JY, et al. Complications in Living Liver Donors After Partial Liver Procurement: An Illustrative Radiologic Review. American Journal of Roentgenology. 2007; 189(6): pp. W338–W343. doi: 10.2214/ajr.07.2586.
  • 24. Khalid TR, Casillas VJ, Montalvo BM, Centeno R, Levi JU. Using MR Cholangiopancreatography to Evaluate Iatrogenic Bile Duct Injury. American Journal of Roentgenology. 2001; 177(6): pp. 1347–1352. doi: 10.2214/ajr.177.6.1771347.
  • Herold G. Internal Medicine. Cologne, Germany: Herold G; 2014.
last updated 09/29/2020
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