Diagnosing regenerative nodular hyperplasia, the “great masquerader” of liver tumors |
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Authors: | Jason M Foster MD Alan Litwin MD John F Gibbs MD Marilyn Intengen MD Boris W Kuvshinoff MD |
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Institution: | (1) From the Department of Surgical Oncology, Roswell Park Cancer Institute, State University of New York at Buffalo, Buffalo, New York;(2) Department of Radiology, Roswell Park Cancer Institute, State University of New York at Buffalo, Buffalo, New York;(3) Department of Pathology, Roswell Park Cancer Institute, State University of New York at Buffalo, Buffalo, New York |
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Abstract: | Distinguishing benign tumors and pseudotumors of the liver from malignant tumors is a common clinical problem. Regenerative
nodular hyperplasia (RNH) represents one of the more challenging pseudotumors to diagnose, because they can appear clinically
indistinguishable from either a primary or a secondary liver malignancy. Even after comprehensive radiologic evaluation and
image-guided percutaneous biopsy, the diagnosis of RNH can remain elusive. We reviewed the pathophysiology of RNH and present
five cases illustrating the limitations of percutaneous biopsy and the utility of laparoscopic wedge biopsy in establishing
the diagnosis. All patients underwent a complete workup that included percutaneous biopsy. Patients with a nondiagnostic percutaneous
biopsy underwent a laparoscopic wedge biopsy or anatomical resection. H&E, vimentin, trichrome, and reticulin staining as
well as CD34 immunostaining were performed. Five patients were diagnosed with RNH between May 2002 and April 2004. Three had
focal nodular disease, whereas the other two had a diffuse multinodular presentation. Percutaneous biopsy definitively made
the diagnosis in only one out of the five cases. Laparoscopic wedge biopsy was necessary to accurately make the diagnosis
in three cases, whereas the fifth diagnosis was established after an anatomical resection. RNH is a unique pseudotumor of
the liver that can present either as a solitary nodule or as a multinodular process. Percutaneous biopsy is associated with
limitations in diagnosing RNH, and a more definitive surgical biopsy may be required. When RNH is considered, laparoscopic
wedge biopsy is a safe and efficient way to obtain enough tissue to preserve the hepatic architecture required for diagnosis,
while avoiding the morbidity of an unnecessary open resection. |
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Keywords: | Liver masses biopsy regenerative nodular hyperplasia laparoscopy |
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