A case of hepatocellular carcinoma arising within large focal nodular hyperplasia with review of the literature (original) (raw)

2006, World Journal of Gastroenterology

https://doi.org/10.3748/WJG.V12.I40.6567

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Abstract

Focal nodular hyperplasia (FNH) is a relatively rare benign hepatic tumor, usually presenting as a solitary lesion; however, multiple localizations have also been described. The association of FNH with other hepatic lesions, such as adenomas and haemangiomas has been reported by various authors. We herein report a case of a hepatocellular carcinoma arising within a large focal nodular hyperplasia, in a young female patient.

Hepatic Focal Nodular Hyperplasia: A Benign Incidentaloma or a Marker of Serious Hepatic Disease?

HPB Surgery, 1992

Amongst 17 patients with hepatic focal nodular hyperplasia (FNH) encountered at Westmead Hospital between 1981 and 1990, FNH was found in association with hepatocellular carcinoma (HCC) in three (3/ 17), one male and two females, one of whom also had peliosis and an hepatic adenoma. FNH was also found in association with other conditions which may affect hepatic function, structure or circulation, including chronic obstructive airways disease (2), congestive cardiomyopathy (1), chronic active hepatitis (1), granulomatous hepatitis (1), coeliac artery stenosis (1) and metastatic malignant melanoma (1). This report, derived from our experience with FNH over 10 years draws attention to a possible link between FNH, hepatic malignancy and conditions which may disturb the hepatic circulation. We suggest that patients with FNH should be investigated thoroughly and an aggressive management policy should be adopted.

Telangiectatic focal nodular hyperplasia: a variant of hepatocellular adenoma

Gastroenterology, 2004

Background & Aims: "Telangiectatic focal nodular hyperplasia" designate atypical lesions considered as variants of focal nodular hyperplasia (FNH). However, because "telangiectatic FNH" share several morphologic patterns with hepatocellular adenomas, classification of such lesions deserve further clarification. Therefore, the aim of the present study was to reconsider the classification of telangiectatic FNH with the help of a molecular approach. Methods: Ten telangiectatic FNH, 6 typical FNH, and 6 hepatocellular adenomas were studied. DNA, RNA, and protein from each lesion were extracted. Clonality was assessed by the study of the X chromosome inactivation pattern (HUMARA assay). Angiopoietin (ANGPT-1 and ANGPT-2) mRNA, genes the expression of which is typically modified in FNH, were quantified by a real-time RT-PCR procedure. Protein profiles were analyzed by SELDI-TOF PROTEINCHIP (Cyphergen Biosystem, Inc., Fremont, CA) technology. Results: Although all informative cases of FNH (5 of 6) and hepatocellular adenomas (6 of 6) were polyclonal and monoclonal, respectively, clonal analysis showed a nonrandom pattern of X chromosome inactivation consistent with a monoclonal lesion in 6 of 8 cases of telangiectatic FNH. The mean value of the ANGPT-1/ANGPT-2 mRNA ratio was 21.4 in FNH, 2.6 in adenomas, and 2.1 in telangiectatic FNH (P < 0.001 in telangiectatic FNH vs. FNH). SELDI-TOF PROTEINCHIP profiling and hierarchical clustering analysis showed that all except 1 telangiectatic FNH clustered within the group of hepatocellular adenomas. Conclusions: These results show that telangiectatic FNH display a molecular pattern closer to that of hepatocellular adenomas than to FNH and suggest that these lesions should instead be referred to as "telangiectatic hepatocellular adenomas." F ocal nodular hyperplasia (FNH) is a frequent benign lesion of the liver, usually observed in female patients. 1,2 Morphologically, FNH is characterized by a central fibrous scar containing numerous dystrophic vessels and reactive ductules surrounded by regenerative hepatocyte nodules. A distinct entity referred to as "tel-angiectatic FNH" has been recently described. This lesion is characterized by marked vascular disorders, including sinusoidal dilatation and peliosis, without significant fibrosis. 3-5 Such morphologic changes are also classic hallmarks of hepatocellular adenomas, resulting in difficulty in diagnosis on the basis of morphologic, radiologic, and pathologic aspects. 6 This also results in ambiguity in the classification of these telangiectatic lesions, thus requiring further clarification.

Focal Nodular Hyperplasia of the Liver Presenting as Right Upper Quadrant Mass

Journal of Case Reports, 2018

Background: Focal nodular hyperplasia (FNH) is the second most common benign liver tumor, which in the vast majority of cases occurs in young women. The lesion is often discovered incidentally as a result of the widespread availability and application of modern cross-sectional imaging on the abdomen. We herein present a case of symptomatic FNH that had successful resection. Case Report: A 22-year old female patient with a history of recurrent right upper quadrant abdominal pain of 11 years duration was reviewed in our facility. Abdominal examination revealed a roughly mobile oval swelling in the right upper quadrant. Contrast abdominal computerized tomography scan revealed a mass isoattenuating in density relative to muscle, enhanced intravenous contrast and displacing bowel loops measuring 13.9×8.3 cm in the transverse mesocolon. She had resection of the mass with an excellent post-operative quality of life. Pathological examination using Hematoxylin-eosin staining examination revealed focal nodular hyperplasia of the liver. Conclusion: Symptomatic focal nodular hyperplasia can be safely resected with excellent rates of morbidity and zero mortality.

Diagnosis and management of hepatic focal nodular hyperplasia

Journal of Ultrasound, 2007

Focal nodular hyperplasia (FNH) is the second most common benign tumor of the liver, after hemangioma. It is generally found incidentally and is most common in reproductive-aged women, but it also affects males and can be diagnosed at any age. Patients are rarely symptomatic, but FNH sometimes causes epigastric or right upper quadrant pain. The main clinical task is to differentiate it from other hypervascular hepatic lesions such as hepatic adenoma, hepatocellular carcinoma, or hypervascular metastases, but invasive diagnostic procedures can generally be avoided with the appropriate use of imaging techniques. Magnetic resonance (MR) imaging is more sensitive and specific than conventional ultrasonography (US) or computed tomography (CT), but Doppler US and contrast-enhanced US (CEUS) can greatly improve the accuracy in the diagnosis of FNH. Once a correct diagnosis has been made, in most cases there is no indication for surgery, and treatment includes conservative clinical follow-up in asymptomatic patients.

Histologic scoring of liver biopsy in focal nodular hyperplasia with atypical presentation

Hepatology, 2002

The contribution of radio-guided transcutaneous biopsy in the diagnosis of focal nodular hyperplasia (FNH) of the liver was compared with the findings on surgical specimens to assess its contribution in clinical and radiologic atypical cases. This retrospective study involved 30 patients with atypical tumors on imaging who underwent liver biopsy and then surgery. All surgical specimens were diagnosed as FNH, either classical (n ‫؍‬ 18) or nonclassical (n ‫؍‬ 12). Imaging data were reviewed according to 4 radiologic criteria on magnetic resonance imaging (MRI) and/or computed tomography (CT) scan (hypervascularity, homogeneity, nonencapsulation, and presence of a central scar), and classified depending on the number of criteria found (group I, 4 of 4; group II, 3 of 4; group III, 2 or fewer). Histologic assessment of ultrasound (US)-guided liver biopsy recorded major diagnostic features (fibrous bands, thick-walled vessels, reactive ductules, and nodularity) and minor features (sinusoidal dilatation and perisinusoidal fibrosis). "Definite FNH" (3 or 4 major features) was diagnosed in 14 biopsies, "possible FNH" (2 major and 1 or 2 minor features) in 7 cases, and "negative for FNH" (2 or fewer major features without minor features) in 9 cases. The diagnosis of FNH on biopsy was reached in 14 cases (58.3%) in patients with 2 or fewer imaging criteria (group III; n ‫؍‬ 24). Biopsies with a diagnosis of "possible FNH" corresponded to a large proportion of telangiectatic-type FNH on the specimen. In conclusion, liver biopsy does not appear to be necessary in cases in which imaging is typical. However, the absence of radiologic diagnostic criteria in FNH does not preclude a positive diagnosis on liver needle biopsy. Using the proposed histologic scoring system, surgical management may be avoided in these cases. (HEPATOLOGY 2002;35:414-420.) Abbreviations: FNH, focal nodular hyperplasia; CT, computed tomography; MRI, magnetic resonance imaging; US, ultrasound.

Hepatic adenoma and focal nodular hyperplasia: Diagnosis and criteria for treatment

Liver Transplantation and Surgery, 1997

The diagnosis of benign hepatic tumors as hepatic adenoma (HA) and focal nodular hyperplasia (FNH) remains a challenge for clinicians and surgeons. The importance of differentiating between these lesions is based on the fact that HA must be surgically resected and FNH can be only observed. A series of 23 female patients with benign liver tumors (13 FNH, 10 HA) were evaluated, and a radiologic diagnostic algorithm was employed with the aim of establishing preoperative criteria for the differential diagnosis. All patients were submitted to surgical biopsy or hepatic resection to confirm the diagnosis. Based only on clinical and laboratory data, distinction was not possible. According to the investigative algorithm, the diagnosis was correct in 82.6% of the cases; but even with the development of imaging methods, which were used in combination, the differentiation was not possible in four patients. For FNH cases scintigraphy presented a sensitivity of 38.4% and specificity of 100%, whereas for HA the sensitivity reached 60% and specificity 85.7%. Magnetic resonance imaging, employed when scintigraphic findings were not typical, presented sensitivities of 71.4% and 80% and specificities of 100% and 100% for FNH and HA, respectively. Preoperative diagnosis of FNH was possible in 10 of 13 (76.9%) patients and was confirmed by histology in all of them. In one case, FNH was misdiagnosed as HA. The diagnosis of HA was possible in 9 of 10 (90%) adenoma cases. Surgical biopsy remains the best method for the differential diagnosis between HA and FNH and must be performed in all doubtful cases. Surgical resection is the treatment of choice for all patients with adenoma and can be performed safely. With the evolution of imaging methods it seems that the preoperative diagnosis of FNH may be considered reliable, thereby avoiding unnecessary surgical resection.

Focal Nodular Hyperplasia Within Accessory Liver

Journal of Computer Assisted Tomography, 2014

Accessory liver tissue is a rare but probably underreported entity that may harbor the same spectrum of pathology as that of the parent organ. The rarity and aberrant locations of such lesions cause confusion and may lower diagnostic confidence despite otherwise classic radiographic appearances. Focal nodular hyperplasia (FNH) is the most common non-hemangiomatous benign hepatic tumor, but to our knowledge, ectopic FNH has been reported only once before in the gastroenterology literature. We present the first case of ectopic FNH in the radiology literature.

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Focal Nodular Hyperplasia and Hepatocellular Adenoma of the Liver

American Journal of Roentgenology, 2001

Introduction: the history of benign liver cell tumors, namely, focal nodular hyperplasia (FNH), and hepatocellular adenoma (HcA), has recently progressed thanks to molecular biology and imaging studies that made it possible a new classification used in European, American and East countries. case report: A review was performed of the numerous published articles, with focus on the management and clinical outcome of benign liver cell tumors is an attempt to promote more standardized guidelines. conclusion: the discovery of genetic drivers of HcA has refined our knowledge of the life history of HcA from risk factors of malignant transformation. the clinical management of FNH and HcA have changed in the recent years. this will have an impact on the management of these lesions including surveillance.

Focal nodular hyperplasia, hepatocellular adenomas: Past, present, future

Gastroentérologie Clinique et Biologique, 2010

In the 1958 monograph on liver tumors, Edmondson established that we have to distinguish between two basically different forms of benign liver tumors. For one, he reserved the designation hepatocellular adenoma (HCA), for the second the term focal nodular hyperplasia (FNH) .

Hepatocellular carcinoma associated with focal nodular hyperplasia

Virchows Archiv, 2001

We describe a hepatocellular carcinoma partially surrounded by focal nodular hyperplasia in a 65year-old female patient. In order to clarify the relationship of the hepatocellular carcinoma and the adjacent focal nodular hyperplasia, clonal analysis was conducted. The clonal analysis was based on the methylation pattern of the polymorphic X-chromosome-linked androgen receptor gene (HUMARA). The allelic bands from the amplification of the focal nodular hyperplasia and of the hepatocellular carcinoma showed a significant reduction in the intensity of one of the two alleles as compared with two alleles of equal intensity in the buff coat after HhaI digestion, which indicated that these two parts were monoclonal. However, the inactivated allele in the focal nodular hyperplasia and that in the hepatocellular carcinoma were not identical. Therefore, the focal nodular hyperplasia and hepatocellular carcinoma probably derived from the clonal expansion of two different clones.

Focal nodular hyperplasia and hepatic adenoma: current diagnosis and management

Updates in Surgery, 2013

Benign liver tumors are common lesions that can be classified into cystic and solid lesions. Cystic lesions are the most frequent; however, they rarely represent a diagnostic or therapeutic challenge. In contrast, solid lesions are more difficult to characterize and management remains controversial. The wide availability and use of advanced imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging have led to increased identification of incidental liver masses. Although some of these incidentally discovered masses are malignant, most are benign and must be included in the differential diagnosis. In this article we review FNH and HA. Its etiology, biological behavior, diagnosis, and treatment will be highlighted.

A case of progressing focal nodular hyperplasia and its molecular expression pattern

Clinical Journal of Gastroenterology, 2014

We report the case of an adult male with progressing focal nodular hyperplasia (FNH). Although imaging studies suggested that the tumor was a classical FNH, the tumor biopsy showed glutamine synthetase expression and heat shock protein 70 in part of the tumor. As we could not definitely distinguish this case of FNH from early hepatocellular carcinoma (HCC), we performed laparoscopic partial hepatectomy. The surgical resected specimen showed that the tumor had a central scar with vascular and cholangiolar proliferation, which is compatible with FNH. Immunohistochemical analysis showed that the molecular expression pattern was compatible with FNH in the center of the tumor, whereas it partly resembled early HCC in the periphery of the tumor. FNH progression is occasionally found, and the molecular pattern of the progressing area in FNH might resemble that of early HCC due to morphologic and phenotypic changes induced by the regenerative mechanism and the alteration of blood flow. We should carefully observe progressing FNH.

Triphasic dynamic CT findings of 63 hepatic focal nodular hyperplasia in 46 patients: correlation with size and pathological findings

Abdominal Imaging, 2008

Background To correlate the dynamic computed tomography (CT) of hepatic focal nodular hyperplasia (FNH) with its size and pathology. Methods The clinical data, pathological and dynamic CT findings of 36 FNHs in 24 males and 27 lesions in 22 females were reviewed. The pathological and CT findings of the 32 small FNHs (diameter < 3 cm) and 31 large FNHs (diameter ≥ 3 cm) were compared and analyzed. Results All FNHs were hypervascular at arterial phase except for central scarring. The mean diameter of FNHs with hypoattenuating, isoattenuating, hyperattenuating on delayed scans were 5.05 cm, 3.06 cm, and 2.70 cm, respectively (p = 0.026). As compared with small FNHs, large ones were significantly more likely to reveal central scarring (p = 0.005), vascular displacement (p < 0.001), and abnormal vessels around lesions (p < 0001). Coexistent bile ductile proliferation and bridging septa were more commonly observed in small FNHs (p = 0.028 for both). FNHs without aberrant vessels tended to feature hyperattenuating during the portal venous phase (p = 0.041). Conclusions FNHs with different tumor sizes may manifest various dynamic CT findings that are more or less related to the different pathological findings.

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