Focal nodular hyperplasia contiguous with an echinococcal cyst

We report the first case of an Echinococcal cyst and focal nodular hyperplasia, two usually isolated hepatic lesions, in direct contiguity. The patient presented with right upper quadrant pain and subsequent imaging studies found a cystic and solid lesion. These studies suggested that this lesion was an hepatic adenoma, which had bled forming a hematoma. Pathological examination of the surgical resection showed Echinococcus multilocularis with contiguous focal nodular hyperplasia. Because focal nodular hyperplasia is a benign hepatic lesion the etiology of which is thought to be abnormal arterial blood flow, we postulate that the parasitic hepatic infection by E. multilocularis may have incited the formation of this contiguous hepatic lesion.     

Symptomatic focal nodular hyperplasia during pregnancy: a case report

A 30-year-old woman presented with hepatomegaly and an audible hepatic bruit at 24 weeks gestation. Non-contrast MRI demonstrated an exophytic 12.6 x 7.8 x 12.8 cm mass arising from the right lobe of the liver with a central scar, suggestive of focal nodular hyperplasia (FNH). Conservative management included monthly abdominal ultrasound examinations until the time of delivery, to assess growth of the mass and monitor for risk of rupture. Seven weeks post partum the patient experienced severe right upper quadrant pain. A CT angiogram of the liver demonstrated a stable mass with no evidence of bleed or rupture and multiple hypervascular masses throughout the liver. Surgical resection of the dominant lesion was performed. Histological examination of the lesion confirmed FNH. The patient is now 22 months post surgery with radiographic evidence of stable multifocal FNH.     

Thoracoabdominal wall tumour seeding after percutaneous radiofrequency ablation for recurrent colorectal liver metastatic lesion: a case report with a brief literature review

Radiofrequency is a safe and effective minimally invasive procedure in the treatment of liver and other organs neoplastic lesions. Percutaneous access of neoplastic liver tissue is the most common access and electrodes are placed with imaging guidance into the tumour to be ablated. Complications during and after radiofrequency ablation (RFA) are of major or minor severity. Tumour dissemination related to the percutaneous access seems to be very unusual. Herein, we present a rare case of thoracoabdominal tumour wall dissemination after RFA of a recurrent hepatic colorectal metastasis previously removed by surgery. A 64-year-old man with a recurrent hepatic metastatic lesion was treated with internally cooled radiofrequency (RF) for ablation of a 3x3 cm in size tumour mass. Two sessions of RFA in one-month period were performed. Computed tomography (CT) of the upper abdomen and carcinoembryonic (CEA) antigen were used for estimation of the disease progression in the patient's follow-up. Ten months after RFA the patient presented abdominal pain and a mass appeared on the right thoracoabdominal area with simultaneous lung metastases. In conclusion, a large size, bulky and superficial mass on the liver parenchyma adjacent to the thoracoabdominal wall as well as multiple RFA sessions, seem to represent risk factors for tumour dissemination through the needle electrode used during the RFA procedure in hepatic metastases of colorectal cancer.     

Application of radionics on primary and metastatic tumours of the liver

The aim of our study is to present our initial experience on the use of radiofrequency ablation (RFA) on hepatic tumours. Four patients with tumours of the liver were submitted to RFA. The first patient underwent an emergency left lobectomy due to rupture of a tumour of the left hepatic lobe. A synchronous tumour was detected on the right lobe. He has been submitted to four sessions of RFA. The second patient was submitted to transverse colon resection (adenocarcinoma) and a year later three metastatic tumours were detected. Two sessions of RFA have been applied in this case. The third patient, with adenocarcinoma of the sigmoid and one metastatic lesion on the right hepatic lobe, and the fourth patient with breast cancer and metastatic lesion of the liver, underwent one session of RFA each. The use of RFA on metastatic or primary tumours of the liver enriches the possibilities of therapeutic treatment.     

Complete spontaneous regression of giant focal nodular hyperplasia of the liver: Magnetic resonance imaging evaluation with hepatobiliary contrast media

Focal nodular hyperplasia(FNH) of the liver is a benign lesion occurring in 0.6%-3% of the general population that probably reflects a local hyperplastic response of hepatocytes to a vascular abnormality. Most lesions are diagnosed incidentally and the natural history of the disease remains largely unknown. It has been shown that most FNH remain stable, or even regress, over a long follow-up period. We present a patient with FNH of the liver who was followed up for 7 years. A 26-yearold woman with a 5-year history of oral contraceptive use was referred to our hospital in February 2005 for further examination of a liver tumour. The diagnosis of FNH was made using magnetic resonance(MR) imaging with hepatospecific contrast media; this technique allows a correct diagnosis, in particular distinguishing FNH from hepatic adenoma, avoiding an invasive procedure such as the lesion biopsy. After 7-year from the diagnosis, we observed the complete spontaneous regression of the lesion by enhanced MR scanning. In this patient, discontinuation of oral contraceptive use and two childbirths may have influenced the natural history of FNH. To our knowledge, in the English literature there is no report illustrating a complete regression of giant FNH but only studies of decreasing in size. The present case suggests that a young patient with giant FNH should be managed conservatively rather than by resection, because FNH has the potential for spontaneous regression.     

Hepatic adenoma. Timing for surgery

BACKGROUND/AIMS: Hepatic adenoma (HA) is a rare benign tumor of the liver. Tumor resection has been recommended for symptomatic or enlarging HA because of the risk of intraperitoneal, intrahepatic hemorrhage or even the development of hepatocellular carcinoma. From 1989 to 2003 we reviewed the medical records and radiology files of 28 patients with a proved diagnosis of hepatic adenoma. This article summarizes a single-center experience with surgical treatment of hepatic adenoma. METHODOLOGY: 24 patients were female and 4 were male. Twenty-two patients had a history of oral contraceptive use. Abdominal pain was presented in 19 patients and 3 of them had had an acute episode. The mean age was 36.3 years. Preoperative assessment included liver test, ultrasonography and computed tomography in all patients plus technetium (99mTc)-sulfur colloid and 99mTc-labeled DISIDA (dimethyliminoacetic acid) liver scintigraphy (n=19) and magnetic resonance imaging (n=22). RESULTS: Operative procedures included enucleation in 3 patients, two of them associated with hepatic segmentectomy; resection of one or two segments in 14 patients; left and right hemihepatectomy respectively in 7 and 3 patients; right extended hepatectomy in one patient and nonanatomic resection in one patient. There was no postoperative death and the complications were: bile leakage (re-operation) one patient, intraperitoneal abscess (re-operation) one patient, pleural effusion two patients, venous thrombosis one patient and wound infection one patient. CONCLUSIONS: We recommend that since the diagnosis has been well-established both enucleation or anatomically based resections of hepatic adenoma should be performed in all cases mainly in female patients taking oral contraceptives with tumors greater than 3cm for the risk of hepatic hemorrhage or even when malignancy cannot be excluded.     

Primary lipoma of the liver

A case of lipoma of the liver is reported in a 57-year-old woman with a 10-month history of non-insulin dependent diabetes mellitus and 3 days with abdominal pain, distention, nausea, and vomiting. On medical examination, the liver was palpable 5 cm below the right costal margin without splenomegaly or ascites. A CT scan revealed a well-defined fat attenuation tumor and an MR demonstrated a well-circumscribed lesion with bright signal intensity. An extended right hepatic lobectomy was performed. The resected specimen measured 28.6 x 18.3 x 8.2 cm and weighed 2,200 g. The yellow and well-circumscribed tumor measured 15 x 9.5 cm and was composed of mature adipose cells pushing the liver tissue at the periphery. The patient was asymptomatic 6 months after surgery.     

Cholangiocarcinoma, renal cell carcinoma and parathyroid adenoma found synchronously in a patient on long-term methotrexate

Cases of patients developing lymphoma and cutaneous neoplasms after long-term methotrexate therapy are well documented in the literature; however, there are no reported cases of other neoplasms resulting from methotrexate therapy. A 52-year-old woman who had been on methotrexate for 9 years for psoriatic arthritis was found to have abnormal liver function tests on screening. Investigation with ultrasound, CT scanning and MRCP showed a hilar cholangiocarcinoma and a synchronous right renal tumour. A left hemi-hepatectomy extended to segments 5 and 8 with the formation of a hepaticojejunostomy was performed for a poorly differentiated infiltrative hilar cholangiocarcinoma. This was combined with a right radical nephrectomy for a T1 renal cell adenocarcinoma. Postoperative vomiting was subsequently found to be due to hypercalcaemia and primary hyperparathyroidism. A parathyroid adenoma was later excised. It seems likely that treatment with methotrexate was causal in the development of these three non-cutaneous neoplasms-two malignant and one benign.     

Co-existence of hepatocellular adenoma and focal nodular hyperplasia in a young female

Focal nodular hyperplasia (FNH) and hepatocellular adenoma (HA) are both benign hepatocellular lesions, presenting mainly in women of childbearing age in non-cirrhotic, non-fibrotic livers. Simultaneous occur-rence of these two lesions is extremely rare. We herein report a case of a young female without any predis-posing risk factors who presented to our emergency department complaining of acute abdominal pain. Imaging studies revealed a 6 cm lesion in the right hepatic lobe and a 2.5 cm lesion in the left hepatic lobe, respectively. In view of the patient’s symptoms and lack of a confirmed diagnosis based on imaging, we performed a bisegmentectomy Ⅴ-Ⅵ and a wedge resection of the lesion in segment Ⅲ by laparotomy. Postoperative course was uneventful and the patient was discharged on the fourth postoperative day. The pathology report demonstrated an HA in segments Ⅴ-Ⅵ and FNH in segment Ⅲ, respectively. Six months later, the patient remains asymptomatic with normal liver function tests, ultrasound and magnetic reso-nance imaging follow-up. To our best knowledge, this is the first case to describe simultaneous occurrence of HA and FNH without the presence of any known risk factors for these entities. The uncertainty in diagnosis and acuteness of presenting symptoms were estab-lished criteria for prompt surgical intervention.     

Hepatocellular adenoma: an excellent indication for laparoscopic liver resection

Objectives

Laparoscopic resection for benign liver disease has gained wide acceptance in recent years and hepatocellular adenoma (HA) seems to be an appropriate indication. This study aimed to discuss diagnosis and treatment strategies, and to assess the feasibility, safety and outcomes of pure laparoscopic liver resection (LLR) in a large series of patients with HA.

Methods

Of 88 patients who underwent pure LLR, 31 were identified as having HA. Diagnosis was based on radiological evaluation and resections were performed for lesions measuring >5.0 cm.

Results

The sample included 29 female and two male patients. Their mean age was 33.2 years. A total of 27 patients had a single lesion, one patient had two and one had four lesions. The two remaining patients had liver adenomatosis. Mean tumour size was 7.5 cm. Three right hepatectomies, 17 left lateral sectionectomies and 11 wedge resections or segmentectomies were performed. There was no need for blood transfusion or conversion to open surgery. Postoperative complications occurred in two patients. Mean hospital stay was 3.8 days.

Conclusions

Hepatocellular adenoma should be regarded as an excellent indication for pure LLR. Pure LLR is safe and feasible and should be considered the standard of care for the treatment of HA when performed by surgeons with experience in liver and laparoscopic surgery.     

Budd-Chiari-like presentation of hepatic adenoma

Hepatic adenoma is a benign tumor characterized by its hypervascularity. Hepatic adenoma tends to occur more frequently in women and is related to the use of contraceptive hormones, androgenic/anabolic steroids, pregnancy, glycogen storage diseases and hemochromatosis. Hepatic venous obstruction, or Budd-Chiari syndrome, is a condition of hepatic vein occlusion that has many causes. A 35-year-old woman presented shortly after pregnancy with a huge cystic lesion in the liver. The lesion compressed the hepatic vein and created an early stage of Budd-Chiari syndrome. Tumor resection was carried out successfully. The final diagnosis of this case was multiple hepatic adenomas.     

Cystic mesenchymal hamartoma of the liver report of a case and review of the literature

Mesenchymal Hamartoma (MH) of the liver constitutes the third or the fourth most common tumour of the liver in childhood and occurs most commonly in the first two years of life. It is often misdiagnosed clinically as a malignant tumour because of its rapid increase in size within a short period of time, or as a hepatic collections or abscess because of its cystic appearance. Although a benign lesion, MH may cause heart failure due to arteriovenous shunts, or death as a result of respiratory complications. A typical case of MH was recently encountered in a 6-years-old-boy. The patient presented with progres sive abdominal distension; surgery revealed a large mass arising from the right lobe of the liver. The mass was predominantly formed by fluid collections. Loose mesenchymal tissue and branched, tortuous bile ducts were the key diagnostic features. When predominantly cystic, MH may mimic lymphangioma both grossly and microscopically. Prudent examination of the cystic structures can establish a correct diagnosis.     

Spontaneous rupture of hepatic metastasis from a thymoma: A case report

Bleeding resulting from spontaneous rupture of the liver is an infrequent but potentially life threatening complication that may be associated with an underlying liver disease. A hepatocellular carcinoma or hepatic adenoma is frequently reported is such cases. However, hemoperitoneum resulting from a hepatic metastatic thymoma is extremely rare. Here, we present a case of a 62-year-old man with hypovolemic shock induced by ruptured hepatic metastasis from a thymoma. At the first hospital admission, the patient had a 45-mm anterior mediastinal mass that was eventually diagnosed as a type A thymoma. The mass was excised, and the patient was disease-free for 6 years. He experienced sudden-onset right upper quadrant pain and was again admitted to our hospital. We noted large hemoperitoneum with a 10-cm encapsulated mass in S5/8 and a 2.3-cm nodular lesion in the right upper quadrant of the abdomen. He was diagnosed with hepatic metastasis from the thymoma, and he underwent chemotherapy and surgical excision.     

Hepatic adenoma mimicking a metastatic lesion on computed tomography-positron emission tomography scan

Positron emission tomography (PET) using 18F-fluorodeoxyglucose ( 18F-FDG) is an imaging modality which reflects cellular glucose metabolism. Most malignant cells accumulate and trap 18F-FDG, allowing the visualisation of increased uptake. It is hence widely used to differentiate malignant from benign lesions. "False positive" findings of hepatic lesions have been described in certain instances such as hepatic abscesses, but are rare in cases involving hepatocellular adenomas. To our knowledge, there have been only 7 reports in the English literature documenting PET-avid hepatocellular adenomas; 6 of the 7 reports were published in the last 3 years with the first report by Patel et al. We report the case of a 44-year-old Chinese female patient with a history of cervical adenocarcinoma, referred for a hepatic lesion noted on a surveillance computed tomography (CT) scan. A subsequent CT-PET performed showed a hypermetabolic lesion (standardized uptake value 7.9) in segment Ⅳb of the liver. After discussion at a multidisciplinary hepato-pancreato-biliary conference, the consensus was that of a metastatic lesion from her previous cervical adenocarcinoma, and a resection of the hepatic lesion was performed. Histology revealed features consistent with a hepatocyte nuclear factor-1 α inactivated steatotic hepatocellular adenoma.     

Robotic right hepatectomy for giant hemangioma in a Jehovah��s Witness

Background/purpose

The use of minimally invasive surgery for the resection of benign liver tumors has increased in recent years as results show decreased abdominal damage and significant cosmetic advantages. Herein, we describe the first reported application of minimally invasive surgery for the removal of a giant symptomatic hemangioma, using robotic surgery, in a Jehovah??s Witness (JW) patient.

Methods

A 32-year-old JW presented with abdominal discomfort and recent episodes of acute abdominal pain due to a giant cavernous hemangioma involving segments VI and VII of the liver. Because of the location and size of the lesion, a right hepatectomy was planned. After a careful preoperative evaluation, a robotic right hepatectomy was performed using the da Vinci Surgical System.

Results

The procedure was successfully completed in minimally invasive fashion with an operative time of 310?min and with an intraoperative blood loss of only 300?ml. The postoperative course was uneventful and the patient was discharged on postoperative day 10. At 30-month follow up the patient reported complete relief of symptoms and good esthetic results.

Conclusions

In experienced hands, a minimally invasive robotic major hepatic resection is a viable option that can be performed with minimal blood loss in a JW patient. A careful preoperative and intraoperative strategy is required and significant experience in liver and robotic surgery is mandatory.     

Adenomyoma of the common hepatic duct

BackgroundAdenomyoma occurs most commonly in the fundus of the gallbladder, seldom in other parts of the gallbladder and rarely in the extrahepatic biliary tree, where most lesions are localised to the common bile duct or papilla of Vater. Adenomyoma of the common hepatic duct is extremely rare. To the best of our knowledge, only three cases have been reported so far.Case outlineA 51-year-old woman was admitted with a three month history of attacks of right upper abdominal pain, nausea, vomiting and fever. Laboratory data, ultrasonography, ERCP and CT confirmed slight cholestasis and proximal bile duct dilatation due to a tumour within the common hepatic duct. Cholecystectomy was performed with excision of the suprapancreatic common bile duct including the convergence of the hepatic ducts plus lymphadenectomy and Roux-en-Y hepaticojejunostomy. Frozen section histology showed the benign nature of the lesion and a tumour-free resection line. Final histology showed adenomyoma. The patient has remained symptomfree for more than 30 months.DiscussionAlthough adenomyoma is a benign lesion and the surgical strategy has not been established, complete excision with frozen section is recommended to exclude small malignant foci and local recurrence as well as to avoid surgical over-treatment.     

Right hepatectomy with anterior approach for ruptured liver cell adenoma

We report a case of a 37-year-old woman who was referred to a peripheral hospital with severe abdominal pain, vomiting and hemorrhagic shock. Ultrasonography and CT scan showed a large ruptured adenoma of the right liver. Because of hemodynamic instability, she underwent laparotomy with gauze packing and then she was referred to our department with a bleeding persisting at a rate of about 100 mL per hour from the abdominal drain. She underwent relaparotomy and a ruptured liver cell adenoma with a huge hepatic hematoma completely involving the right liver and part of segment 4 was confirmed. Considering the size of the lesion and the presence of a large hematoma, a right hepatectomy with anterior approach was performed. In case of emergency liver resections, the anterior approach is preferable not only to avoid tumor manipulation and the risk of its rupture, but mainly to reduce liver bleeding and to prevent sudden fall of the blood pressure due to inferior vena cava twisting in a hemodynamically instable patient. Intraoperative blood loss was 1500 mL. The postoperative course was uneventful. The patient is doing well ten months after operation.     

Non-invasive diagnosis and follow-up of benign liver tumours

Hepatocellular benign liver tumours are mainly developed on normal liver and include hepatic hemangioma, focal nodular hyperplasia and hepatocellular adenoma from the most frequent to the less frequent. The diagnosis of hepatic hemangioma and of simple hepatic biliary cysts can be performed using non-invasive criteria using liver ultrasonography or contrast enhanced MRI. Most of the time the diagnosis of focal nodular hyperplasia can be achieved using contrast-enhanced ultrasonography or contrast enhanced MRI with an additional value of hepatobiliary contrast-agent in this setting. Rarely, if a doubt persists, a tumour and non-tumour liver biopsy can be required in order to establish the diagnosis. As hepatic hemangioma, simple hepatic biliary cysts and focal nodular hyperplasia are not associated with complications, they don't require any treatments or follow-up. Hepatocellular adenomas are mainly diagnosed at histology on surgical samples or liver biopsy even if some radiological features are highly suggestive of several subtypes of hepatocellular adenomas. Finally, the management of hepatocellular adenomas should be guided according to the tumour size, gender but also to the molecular subtypes.     

Hepatocellular carcinoma in a liver-cell adenoma within a non-cirrhotic liver

Liver-cell adenomas are benign lesions of the liver occurring predominantly in young women. Hepatocellular carcinomas in most of the cases arise in a cirrhotic liver during the fifth or sixth decade. We describe the case of a 40-year-old woman in whom work-up for epigastric pain revealed a peptic ulcer and a large hepatic mass. Tests for chronic liver diseases were negative. Imaging findings and biopsy specimens of the tumour were inconclusive. The tumour was surgically removed and a hepatocellular carcinoma arising within a liver-cell adenoma in a non-cirrhotic liver was found. Malignant transformation of liver-cell adenoma has only been reported in a few case reports. Mechanisms of transformation remain unclear. The imaging findings as well as histological features are presented in detail and the literature is discussed.