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Hepatocellular Adenoma Treatment & Management

  • Author: Bradford A Whitmer, DO; Chief Editor: BS Anand, MD  more...
 
Updated: Oct 08, 2015
 

Medical Care

Patients should stop using oral contraceptives or anabolic steroids. This allows for regression in the size of the majority of the tumors. Complete resolution is atypical. The risk of malignant transformation remains even after the contraceptive or steroid use has been discontinued.[50]

Symptomatic tumors should be resected, regardless of size.

Pregnancy should be avoided because of the risk of growth and rupture but is not an absolute contraindication. There are no consensus guidelines. Surgical resection may be the best option in patients with hepatocellular adenomas who desire to become pregnant. Large incidental HCAs found during pregnancy may be considered for resection during the second trimester, when the risk is lowest. Asymptomatic HCAs smaller than 5 centimeters may be managed with close monitoring. MRI seems to be preferred given the lack of radiation, but cost effectiveness remains to be studied. Ruptured hepatocellular adenomas during pregnancy should be managed with resuscitation and resection.

Yearly ultrasound imaging and an assessment of serum AFP levels is a consideration in all patients with hepatocellular adenomas, especially those with multiple lesions or single lesions greater than 5 cm in diameter who do not undergo surgical resection. However, there is little evidence to support this approach.[8]

Immediate abdominal imaging is required for patients with hepatocellular adenomas who present with new or worsened abdominal pain or signs of hemodynamic instability.

Emergency hepatic arteriography with embolization should be considered to control bleeding in high-risk surgical candidates.

Transarterial embolization has been used to electively reduce the tumor mass of a large HCA, but studies are limited in using it as an elective treatment for unruptured HCA.[51, 52]

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Surgical Care

Due to the increased risk of spontaneous life-threatening hemorrhage and the possible malignant transformation associated with larger-size tumors or in patients with GSD, elective surgical resection is considered for all lesions greater than 5 cm in diameter.[53] Elective resection should be undertaken only after a reasonable period of observation if OCPs have been discontinued only recently. However, several authorities recommend that all adenomas should be resected regardless of size due to rare cases of malignant transformation after adenomas have decreased in size or disappeared after discontinuation of OCPs.

In a multicenter study of 124 patients, Deneve et al reported that tumors that were more likely to rupture were larger tumors and in women with recent hormone use.[25] The investigators recommended surgical resection when HCAs approached 4 cm in size or if hormonal therapy was required.

All patients with significantly elevated AFP levels should undergo resection of the tumor regardless of size.

The majority of tumors can be resected locally or with segmental partial lobectomy. Elective resection carries approximately 13% morbidity. Mortality is rare. Complication rates associated with emergency surgery are higher, including a mortality rate of approximately 5-8%.

Laparoscopic resection can be used in patients who have small tumors within the anterolateral liver segments and for pedunculated tumors.

Cho et al reported their experience with the management and outcomes of 41 patients with hepatocellular adenomas treated at the University of Pittsburgh between 1988 and 2007.[24] The investigators reported that surgical resection was preferable to observation if patients comorbidities and anatomical location are acceptable due to risks of hemorrhage (29%) and malignancy (5%).

In rare patients with multiple adenomas or glycogen storage disease, liver transplantation may be the only intervention that may remove all lesions and cure the underlying metabolic defect.[11, 54] Liver transplantation has also been successfully performed for spontaneous intrapartum rupture of an hepatocellular adenoma.[55]

Radiofrequency (RF) ablation can be used effectively in the treatment of hepatocellular adenoma.[56] However, multiple sessions are often required, and signs of residual adenoma might persist in some patients despite repetitive treatment. RF ablation might be especially beneficial in cases not amenable to surgery or in patients who would require major hepatic resection. Cases not amenable to surgery would include centrally located lesions or multiple HCAs in both lobes of the liver.

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Contributor Information and Disclosures
Author

Bradford A Whitmer, DO Fellow, Department of Gastroenterology, Providence Hospital

Bradford A Whitmer, DO is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Osteopathic Association

Disclosure: Nothing to disclose.

Coauthor(s)

Michael H Piper, MD Clinical Assistant Professor, Department of Internal Medicine, Division of Gastroenterology, Wayne State University School of Medicine; Consulting Staff, Digestive Health Associates, PLC

Michael H Piper, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Gastroenterology, American College of Physicians, Michigan State Medical Society

Disclosure: Nothing to disclose.

Janice M Fields, MD, FACG, FACP Assistant Professor of Internal Medicine, Oakland University William Beaumont School of Medicine; Consulting Staff, Department of Internal Medicine, Section of Gastroenterology, Providence Hospital, St John Macomb-Oakland Hosptial

Janice M Fields, MD, FACG, FACP is a member of the following medical societies: American College of Gastroenterology, American College of Physicians-American Society of Internal Medicine, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, National Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Additional Contributors

Tushar Patel, MB, ChB Professor of Medicine, Ohio State University Medical Center

Tushar Patel, MB, ChB is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association

Disclosure: Nothing to disclose.

Acknowledgements

Brian S Berk, MD Assistant Professor, Department of Medicine, Dartmouth Medical School; Director of End Stage Liver Disease, Section of Gastroenterology, Dartmouth Hitchcock Medical Center

Brian S Berk, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, and American Gastroenterological Association

Disclosure: Nothing to disclose. Kenneth Ingram, PAC Assistant Professor, Department of Medicine, Division of Gastroenterology and Hepatology, Oregon Health and Science University School of Medicine

Disclosure: Nothing to disclose.

Sandeep Mukherjee, MB, BCh, MPH, FRCPC Associate Professor, Department of Internal Medicine, Section of Gastroenterology and Hepatology, University of Nebraska Medical Center; Consulting Staff, Section of Gastroenterology and Hepatology, Veteran Affairs Medical Center

Disclosure: Merck Honoraria Speaking and teaching; Ikaria Pharmaceuticals Honoraria Board membership

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