Hepatocellular Adenoma Treatment & Management

Updated: Feb 21, 2018
  • Author: Bradford A Whitmer, DO; Chief Editor: BS Anand, MD  more...
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Treatment

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. [56]

Symptomatic tumors should be resected, regardless of size.

Pregnancy should be avoided because of the risk of tumor growth and rupture, but it 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 serum alpha-fetoprotein (AFP) levels is a consideration in all patients with hepatocellular adenomas, especially those with multiple lesions or single lesions larger 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. [57, 58]

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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. [59] 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. [27] 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.

With regard to timing of resection, Klompenhouwer et al suggest that a 6-month cut-off point in women is too early for assessment of regression of hepatocellular adenomas larger than 5 cm to no more than 5 cm. [60]  Rather, they indicate that in women with typical, non-β-catenin-activated hepatocellular adenomas, regardless of the baseline diameter, the cut-off point may be extended to 12 months. [60]

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.

In a retrospective (1989-2013) multi-institutional European study of all patients who had undergone open or laparoscopic hepatectomies for hepatocellular adenomas to investigate the effects of the surgical approach on postoperative morbidities, Landi et al found that open surgery and laparoscopy showed similar postoperative morbidity rates and severities. [61] However, laparoscopy was associated with significantly less blood loss, a reduced need for transfusion, and a shorter hospital stay. [61]

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. [26] 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, 62] Liver transplantation has also been successfully performed for spontaneous intrapartum rupture of an hepatocellular adenoma. [63]

Radiofrequency (RF) ablation can be used effectively in the treatment of hepatocellular adenoma. [64] 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.

In a retrospective single-arm study of 36 patients with 58 hepatocellular adenomas who underwent 44 procedures with percutaneous thermal ablation, investigators reported a primary efficacy of 88% and a secondary efficacy of 100%, with a major complication rate of 4.5% (postprocedural hemorrhage). [65] At a median follow-up of 1.7 years, there was 100% clinical efficacy with no reports of malignant transformation, adenoma-related hemorrhages, or deaths.

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