Guidelines Summary

The American College of Gastroenterology (ACG) issued clinical guidelines for the diagnosis and management of focal liver lesions in 2014.^[1]The European Association for the Study of the Liver (EASL) released clinical practice guidelines on the management of benign liver tumors in 2016.^[20] Their recommendations include the following:

Imaging of hepatocellular adenoma (HCA) (hepatic adenoma) with magnetic resonance imaging (MRI) is superior to all other imaging modalities and offers subtype differentiation in many cases, especially with the hepatocyte nuclear factor (HNF) 1a-mutated HCA (H-HCA) and inflammatory HCA (I-HCA) subtypes. β-catenin activated HCA (β-HCA) subtype is not well identified by any imaging technique and should be carefully looked for given its association with hepatocellular carcinoma (HCC).^[20]
Once HCA is diagnosed, lifestyle changes including discontinuation of oral contraceptive pills (OCPs) and weight loss should be advised.^{[1, 20]}Further management is guided by sex, size, pattern of progression, and subtype.^[20]The routine use of biopsy is not recommended but may be considered in cases with inconclusive imaging or when biopsy findings may change management decisions.^[1]
HCA resection is recommended in men and in patients with proven β-catenin mutation subtype, regardless of size.^[20]
For women with HCA, initial lifestyle changes and 6 months of observation if no high-risk features are present is advised. Resection may be considered for HCAs of at least 5 cm or those that continue to grow. HCAs smaller than 5 cm should be followed with imaging, initially at 1 year from diagnosis and then annually thereafter.^[20] The ACG guidelines recommend considering follow-up imaging every 6-12 months, with subsequent intervals based on the stability of the lesion.^[1]Pregnancy is not absolutely contraindicated for HCAs smaller than 5 cm; however, an individual approach is recommended.^[1]
Patients with multiple HCAs should have their management based on the size of the largest tumor, and hepatic resection can be considered for the largest adenomas. Hepatic resection may also be considered in patients with unilobular disease or widespread HCA. Liver transplantation is not recommended for patients with multiple HCAs; however, it may be considered if underlying liver disease exists. Patients with bleeding HCAs and hemodynamic instability should undergo tumor embolization; if residual lesion is found on imaging, resection may be required.^[20]

Questions

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Author

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.

Coauthor(s)

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.

Ryan R Kahl, DO Chief Fellow, Department of Gastroenterology, Ascension Providence-Providence Park Hospital, Michigan State University College of Human Medicine

Ryan R Kahl, DO is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Society for Gastrointestinal Endoscopy

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.

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.

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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