Patient perspectives and overall satisfaction after liver resection for benign disease.

BACKGROUND: Management of benign liver lesions (BLLs) is still an object of discussion. Frequently, patients receive multiple opinions about their diagnosis and treatment from physicians specialized in different areas, which can be opposite and controversial. This study aimed to understand patients' decision-making process in electing surgery and assess their satisfaction after resection for BLLs. METHODS: A 104-question survey was administered to 98 patients who had a resection for BLLs in 4 different hepatopancreatobiliary and transplant centers in Argentina. The first section included 64 questions regarding the initial discovery of the BLL, the decision-making process, and the understanding of the patient's feelings after surgery. The second section, 42 queries, referred to the quality of life. The patient's final diagnosis and outcome were correlated with the survey results using univariate analysis. RESULTS: Among 97 patients who had undergone liver resection for BLLs, 69 (70%) completed the survey. The median age was 51.71 years (range, 18-75), and 63% of the patients were females. Moreover, 21% of patients received conflicting information from different healthcare providers. Surgeons were the best to describe the BLL to the patient (63%), and 30% of patients obtained opinions from multiple surgeons. The respondents were quite or fully satisfied with their decision to have surgery (90%) and the decision-making process (91%). Only 59% of patients considered their lifestyle better after surgery, and 89% of patients would have retaken the same decision. CONCLUSION: Patients with resected BLLs are delighted with the decision to have surgery, regardless of the final diagnosis and outcome. The role of surgeons is crucial in the decision-making process.

Patient with a novel syndrome with multiple benign hepatic lesions and extrahepatic neoplasms.

Simultaneous occurrence of benign hepatic lesions of different types is a sporadic phenomenon. To the best of our knowledge, we report the first clinical case of a syndrome with simultaneous manifestations of three different entities of benign liver tumors (hepatocellular adenoma, focal nodular hyperplasia and hemangioma) with a novel mutation detected in the liver adenoma and in the presence of a number of further extrahepatic organ neoplasms. Furthermore, we describe for the first time the presence of liver epithelial cells of hepatocytic phenotype expressing cytokeratin 7 (CK7) at the border of the adenoma. These findings may be important for explaining pathogenesis of benign as well as malignant tumors based on genetic and histopathological features.

Atypical Biliary Adenofibroma of the Liver: Related Treatment and Performance.

Biliary adenofibroma is an extremely rare benign liver tumor, but it may be a precancerous lesion of cholangiocarcinoma. So far, only 29 cases have been reported in the literature. A 30-year-old woman was admitted to our department for upper abdomen mass. The computed tomography scan showed a huge cystic and partly substantial mass between the left lobe of the liver and the descending duodenum, which was considered to be an exophytic tumor derived from the left lobe of the liver. Laparoscopic liver segment IVb resection and cholecystectomy were performed. Microscopic examination showed that the tumor was composed of glandular cavities of varying sizes and fibrous interstitium. The glandular cavity was covered with cubic or columnar epithelium without atypia. Some of the mesenchymal cells are myofibroblast-like and spindle-shaped with red-stained cytoplasm. The mesenchymal cells in some areas proliferate densely with moderate atypia. It was considered to be an atypical biliary adenofibroma with focal necrosis and active cell proliferation which may have malignant transformation potential. There was no recurrence and metastasis at a 6-month follow-up. Biliary adenofibroma is a rare benign tumor derived from the bile duct, but it may progress to malignancy and develop distant metastasis. It is difficult to distinguish it from other liver tumors through imaging examination and the gold standard of diagnosis is histopathological examination. Close clinical follow-up is recommended.

Liver transplantation for benign liver tumors.

Benign liver tumors are common lesions that are usually asymptomatic and are often found incidentally due to recent advances in imaging techniques and their widespread use. Although most of these tumors can be managed conservatively or treated by surgical resection, liver transplantation (LT) is the only treatment option in selected patients. LT is usually indicated in patients that present with life-threatening complications, when the lesions are diffuse in the hepatic parenchyma or when malignant transformation cannot be ruled out. However, due to the significant postoperative morbidity of the procedure, scarcity of available donor liver grafts, and the benign course of the disease, the indications for LT are still not standardized. Hepatic adenoma and adenomatosis, hepatic hemangioma, and hepatic epithelioid hemangioendothelioma are among the most common benign liver tumors treated by LT. This article reviews the role of LT in patients with benign liver tumors. The indications for LT and long-term outcomes of LT are presented.

Revisiting the Surgical Management of Giant Hepatic Hemangiomas: Enucleation Versus Anatomical Resection?

BACKGROUND: Resection is rarely indicated in giant hepatic hemangiomas (HHs) that are symptomatic. Enucleation (EN), compared with anatomical resection (AR), is considered the better technique to resect them as EN has been reported to have lower morbidity while conserving the normal liver tissue. But no study has yet clearly established the superiority of EN over AR. In addition, the independent predictors of postoperative morbidity have not been established. METHODS: All consecutive patients operated for HH at two specialized hepatobiliary centers were reviewed. Patient demographics, operative variables, and postoperative outcomes were analyzed and compared between two techniques. Postoperative complications were graded as per Clavien-Dindo classification of surgical complications. The aims of this study were to compare two techniques of HH resection with respect to postoperative outcomes and to identify the risk factors for 90-day major postoperative morbidity and mortality. RESULTS: A total of 64 patients, including 41 who underwent AR, 22 who underwent EN, and 1 who underwent liver transplantation, were operated for hemangiomas during the study period. Ten patients (9 who were operated for hemangiomas of size ≤4 cm and 1 who underwent transplantation) were excluded. Fifty-four patients, the majority being women (85%), with a median age of 48 years, were operated for giant HH. These patients were classified into two groups based on the technique of resection, namely, EN (22 patients) and AR (32 patients). Both groups were comparable in all aspects except that the number of liver segments resected was significantly more with AR. Postoperative outcomes were similar in both groups. Independent predictors of 90-day major complications including mortality were the use of total vascular exclusion (relative risk [RR]: 2.3, p = 0.028) and duration of surgery >4.5 h (RR: 2.3, p = 0.025). CONCLUSION: Both techniques yield similar results with respect to 90-day postoperative morbidity and mortality. The choice of technique should be based on the location of tumor and simplicity of liver resection.

S100P as a novel biomarker of microvascular invasion and portal vein tumor thrombus in hepatocellular carcinoma.

BACKGROUND: Portal vein tumor thrombus (PVTT) and microvascular invasion (MVI) are types of intrahepatic vascular metastasis of hepatocellular carcinoma (HCC) and are highly correlated with poor prognosis. However, the underlying biomarkers of PVTT and MVI are unclear. METHODS: We identified a PVTT/MVI-associated gene S100P by cDNA microarray analysis, and assess the potential value of serum S100P measurement in the differential diagnosis of HCC and prediction of MVI status with large retrospective and perspective cohort studies. RESULTS: The mRNA and protein of S100P was increased in HCCs with PVTT or MVI. High S100P immunostaining in tumors was correlated with inferior tumor-free survival. Serum S100P values discriminated patients with HCCs from those with benign liver tumors, and it showed predictive potential of MVI status in both retrospective and perspective cohorts. S100P may regulate HCC tumorigenicity and invasive ability; S100P also was associated with up-regulation of CD44, which may mediate HCC cell adhesion to form PVTT/MVI. CONCLUSIONS: Serum S100P may be a novel differential diagnostic marker for HCC and a potential predictor of MVI status pre-surgery for HCC patients. S100P overexpression in HCC is highly correlated with the formation of PVTT and MVI, which may make S100P as a potential therapeutic target for HCC metastasis.

A case of hepatocellular adenoma with pedunculated development and difficulty in diagnosis.

Hepatocellular adenoma (HCA) is a benign hepatocyte-derived epithelial tumor. HCA is associated with oral contraceptive use among Caucasian populations. We report a case of hepatocellular adenoma with a pedunculated protuberance and high protein induced by vitamin K absence or antagonist-II (PIVKA-II) levels, which made diagnosis challenging. The patient was a 22-year-old woman. In a medical check-up, a high γ-GTP level was detected and a 115-mm solid mass was found in her lower abdomen via abdominal ultrasonography. A blood test showed a high PIVKA-II level. Abdominal CT showed a tumor in the lower abdomen. Contrast-enhanced CT showed a blood vessel thought to be the left hepatic artery connecting to the mass, and a blood vessel thought to be the left hepatic vein returning from the mass to the inferior vena cava. In EOB-MRI, uneven enhancement was observed after contrast imaging, but washout in the equilibrium phase was unclear. Parenchymal hepatocyte phases showed a pale, non-uniform, high signal. These findings indicated that the tumor was derived from the left lobe of the liver and was suggestive of HCC. Surgical resection was then performed. A pathological examination led to a diagnosis of HCA, corresponding to unclassified HCA. The WHO classification of tumors of the digestive system based on an immunohistological examination includes HNF1α-inactivated HCA, ß-catenin-activated HCA, inflammatory HCA, and unclassified HCA. In summary, our patient had a large HCA with pedunculated protrusion into the extrahepatic pelvic cavity. This case was challenging to diagnose because of abnormally high PIVKA-II levels, and it was resected laparoscopically.

Pediatric intrahepatic bile duct adenoma - rare liver tumor: A case report.

BACKGROUND: Intrahepatic bile duct adenoma (BDA) is one of the rarest of the rare benign tumors of the liver in the pediatric age group. It arises from the epithelial lining of intrahepatic bile ducts. The overall incidence of BDA is 1.3% of all primary benign liver tumors. Few case reports of this rare tumor occurring in adult population are present in the literature and to date, only one pediatric case has been reported worldwide. CASE SUMMARY: An 18-month-old male child presented with chief complaints of mass per abdomen for 8 mo. Computerized tomography abdomen revealed a well-defined exophytic solid tumor arising from the posteroinferior margin of the right lobe of the liver with heterogenous enhancement and cystic changes, suggesting a suspicion of hepatoblastoma. Non-anatomical liver resection was done and a tumor of 10 cm × 9.5 cm was excised. Histopathology of the specimen was conclusive with the diagnosis of intrahepatic bile duct adenoma, which was further supported by immunohistochemistry panel testing. The post-operative period was uneventful. On follow-up, the child was doing well and had no post-operative complication. CONCLUSION: Intrahepatic bile duct adenoma in children is very rare and to date only one case has been reported. This is the second pediatric case of intrahepatic bile duct adenoma in the world. Additionally this is the first ever case of such a large tumor presenting in a child.

Clinical Presentation and Anatopathologic Finding of a Hepatic Vascular Hamartoma: a Case Report.

HVH (hepatic vascular hamartoma) is a tumor like malformation arising from the vascular tissue of the liver. HVH has been previously reported in animals and presents distintive features from the most frequent benign tumor like malformation of the liver, the hepatic mesenchymal hamartoma (HMH). Herein we report a case of HVH localized in hepatic segment 4b, involving the gastro hepatic ligament, successfully treated with total excision. We describe the anatomo-pathologic findings focusing on the clinical and radiological presentation, the intraoperative characteristics and the differential diagnosis.

Immunohistochemical Staining on an Excision Biopsy Specimen as a Diagnostic Modality for Rare Idiopathic Hepatocellular Adenoma: A Case Report.

Hepatocellular adenoma is an extremely rare benign tumor of the liver which predominantly in young women. Its rare incidence with estimated 3-4 cases per 1.000.000 annually makes it a diagnostic challenge. Here we present a 30-year-old female patient with hepatocellular adenoma without classic risk factors. A series of work up tools have been performed in order to diagnose the condition. None but excision biopsy from segmental resection had been showed to increase diagnostic confidence. This case illustrates the role of immunohistochemical staining from excision biopsy as the best diagnostic modality of hepatocellular adenoma as well as therapeutic modality to prevent malignant transformation.

Can point shear wave elastography differentiate focal nodular hyperplasia from hepatocellular adenoma.

PURPOSE: Focal nodular hyperplasia (FNH) and hepatocellular adenoma (HCA) are liver tumors that require different management. We assessed the potential of point shear wave elastography (pSWE) to differentiate FNH from HCA and the interobserver and intraobserver reliability of pSWE in the examination of these lesions and of native liver tissue (NLT). METHODS: The study included 88 patients (65 FNH, 23 HCA). pSWE was performed by two experienced liver sonographers (observers 1 [O1] and 2 [O2]) and acquired within the lesion of interest and NLT. Group differences, optimal cutoff for characterization and interobserver reliability was assessed with Mann-Whitney-U, area under the ROC curce (AUROC) and intraclass correlation coefficient (ICC). Intraobserver reliability in NLT was assessed in 20 healthy subjects using ICC. RESULTS: Median stiffness was significantly higher in FNH than in HCA (7.01 kPa vs 4.98 kPa for O1 (P = 0.017) and 7.68 kPa vs 6.00 kPa for O2 (P = 0.031)). A cutoff point for differentiation between the two entities could not be determined with an AUROC of 0.67 (O1) and 0.69 (O2). Interobserver reliability was good for lesion- stiffness (ICC = 0.86) and poor for NLT stiffness (ICC = 0.09). In healthy subjects, intraobserver reliability for NLT-stiffness was poor for O1 (ICC = 0.23) and moderate for O2 (ICC = 0.62). CONCLUSION: This study shows that pSWE cannot reliably differentiate FNH from HCA. Interobserver and intraobserver reliability for pSWE in NLT were insufficient. Interpretation of results gained with this method should be done with great caution.

Clinical correspondence to hepatocellular carcinoma-related lesions with atypical radiological pattern.

In patients at risk of hepatocarcinogenesis, tumors are frequently detected with atypical radiological patterns related to hepatocellular carcinoma (HCC) on imaging studies. Despite their high potential for malignancy, whether to resect such lesions immediately is controversial. Based on histological findings, patients with non-enhanced tumors or enhanced tumors without washout were divided into two groups: those with tumors that should be treated containing well, moderately, and poorly differentiated HCC (Group 1), and those that can be observed containing early HCC, hepatocellular adenoma, focal nodular hyperplasia, dysplastic nodules, and regenerative nodules (Group 2), and we elucidated the clinical correspondence to these tumors. Seventy-two patients had a single tumor with atypical radiological pattern: 39 patients had HCC (Group 1), while 33 patients had benign tumors or early HCC (Group 2). Among nine baseline variables, serum α-fetoprotein (AFP) level in Group 1 (median, 13.2 ng/mL; range, 0.6-5881.6) was significantly higher than that in Group 2 (5.6 ng/mL; 0.8-86.3, P = 0.003). The cut-off value of AFP was 36.4 ng/mL for prediction of Group 1, and the median overall and recurrence-free survival periods of 23 patients in the high-AFP (≥ 36.4 ng/mL) group (5.3 years; 95%CI, 2.1 - N.A. and 1.6 years; 0.5-2.2) were significantly shorter than those of the 49 patients in the low-AFP (< 36.4) group (7.5 years; 7.5 - N.A., P = 0.047, and 2.8 years; 1.9-3.3, P = 0.001). Taken together, HCC-related tumors with an atypical radiological pattern could be observed unless serum AFP level is elevated.

Serum levels of HGF, IL-6, and TGF-α after benign liver tumor resection.

PURPOSE: Literature is void of data on the relationship between pre- and postoperative levels of hepatocyte growth factor (HGF), interleukin 6 (IL-6), and tumor growth factor α (TGF-α) after liver resection performed for particular benign liver tumors. The purpose of this study was to assess whether there is a different degree of liver regeneration through the kinetics of HGF, IL-6, and TGF-α in 2 particular types of benign liver lesions. MATERIAL/METHODS: The study included 9 patients diagnosed with hepatic hemangioma and 13 patients with focal nodular hyperplasia (FNH) who underwent liver resection. HGF, IL-6, and TGF-α were measured using enzyme-linked immunosorbent assay (ELISA) from blood serum drawn at 6 time points during an 8-day period. Statistical analysis was based on two-factor variance analysis with replicate measurements. RESULTS: The HGF, IL-6, and TGF-α levels in patients who underwent FNH resection were not significantly different from the levels observed in hemangioma resection patients. Significant increases in HGF, IL-6, and TGF-α concentrations were observed only during the first 24h after resection in both groups of patients. CONCLUSIONS: Obtained results suggest that the pre- and post-operative levels of HGF, IL-6, and TGF-α do not depend on the particular type of benign tumor. After resection of FNH and hemangioma tumors, the serum levels of HGF, IL-6, and TGF-α increased at similar rates during the first 24h, followed by significant declines back to pre-operative levels.

Hypervascular benign and malignant liver tumors that require differentiation from hepatocellular carcinoma: key points of imaging diagnosis.

Most liver tumors are benign and hypervascular, and it is important to avoid unnecessary interventions for benign lesions. This review describes the typical and atypical imaging features of common hypervascular benign liver tumors and outlines a general approach to distinguishing between benign and malignant hepatic lesions. There are many types of benign liver tumors that need to be differentiated from hepatocellular carcinoma (HCC). Therefore, it is very important to know the imaging characteristics of benign tumors. Gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging is helpful in diagnosing hypervascular pseudotumors, focal nodular hyperplasia, and nodular lesions associated with alcohol-induced hepatitis. There are also some hypervascular malignant tumors, such as cholangiocarcinoma, cholangiolocellular carcinoma, mixed type tumors, and metastatic liver tumors, which also required differentiation from HCC.

Epidemiology and risk factors of biliary tract and primary liver tumors.

Primary liver and biliary tract tumors encompass a range of benign and malignant neoplasms. They consist of histologically distinct types of tumors that arise from and are influenced by hepatocytes, biliary epithelial cells, and mesenchymal cells. Improvements in imaging have allowed the detection and diagnosis of these neoplasms to be refined. Investigation at the histologic, molecular, and genetic levels has allowed neoplasms to be categorized and treated. Epidemiology has improved understanding of geographic, ethnic, gender, and cultural differences that link exposures with cancer risk. This article focuses on the epidemiology of major primary adult liver and biliary tract tumors.

Improvement of nutritional support strategies after surgery for benign liver tumor through nutritional risk screening: a prospective, randomized, controlled, single-blind clinical study.

OBJECTIVE: The rising of individualized therapy requires nutritional risk screening has become a major topic for each particular disease, yet most of the screenings were for malignancies, less for benign diseases. There is no report on the screening of patients with benign liver tumors postoperatively. We aim to evaluate the nutritional support strategies post operation for benign liver tumors through nutritional risk screening. METHODS: In this prospective, randomized, controlled study, 95 patients who underwent hepatectomy for benign tumors were divided into two groups. Fifty patients in the control group were given routine permissive underfeeding nutritional supply (75 kJ/kg/d), and 45 patients in the experimental group were given lower energy (42 kJ/kg/d) in accordance of their surgical trauma. Routine blood tests, liver/kidney function were monitored before surgery and at the day 1, 3, 5, 9 after surgery, patients were observed for the time of flatus, complications, length of hospitalization (LOH), nutrition-related costs, and other clinical parameters. This completed study is registered with Clinicaltrials.gov, number NCT01292330. RESULTS: The nutrition-related expenses (494.0±181.0 vs. 1,514.4±348.4 RMB, P<0.05) and the total hospital costs (18,495.2±4735.0 vs. 21,432.7±8,291.2 RMB, P<0.05) for patients in the experimental group were significantly lower than those in the control group. Meanwhile, the lowered energy supply after the surgeries did not have adverse effects on clinical parameters, complications, and LOH. CONCLUSIONS: Patient with benign liver tumors can adopt an even lower postoperative nutritional supply that close to that for mild non-surgical conditions, and lower than the postoperative permissive underfeeding standard.

Laparoscopic partial hepatectomy of focal nodular hyperplasia.

Focal nodular hyperplasia is a benign liver lesion incidentally discovered with increasing frequency because of the proliferation of imaging studies. Radiographic characterization can diagnose this pathologic lesion and nonoperative therapy is the standard of care. However, surgical resection may be required for diagnostic reasons or symptomatic patients. Depending on the anatomic location of the lesion, biopsy and/or resection can be performed laparoscopically. We herein report the case of a 26-year-old Japanese woman with a hepatic tumor who required a medical examination. Her medical history was negative for alcohol abuse, oral contraceptive administration and trauma. Clinical examination showed no significant symptoms. Ultrasonography, computed tomography and magnetic resonance imaging showed a mass located in the left lateral segment of the liver with a diameter of about 40 mm. It was difficult to diagnose the tumor definitively from these imaging studies, so we performed laparoscopic partial hepatectomy with successive firing of endoscopic staplers. The histopathological diagnosis was focal nodular hyperplasia. Surgical procedures and postoperative course were uneventful and the patient was discharged from the hospital on postoperative day 5.

A case of very large intrahepatic bile duct adenoma followed for 7 years.

A 70-year-old man was referred to our hospital due to abnormal liver function. A tumor of 92 mm × 61 mm was detected on ultrasound screening of the left liver lobe. Although the tumor was suspected to be intrahepatic bile duct carcinoma, he had chronic heart disease and was unable to undergo surgery. Therefore, he was followed without further testing. No increase in tumor serum markers or tumor size was observed for the subsequent 7 years. We continued to suspect intrahepatic bile duct carcinoma, and we decided to perform a tumor biopsy. Tumor biopsy findings indicated intrahepatic bile duct adenoma (BDA), which is a rare benign epithelial liver tumor typically ranging from 1 mm to 20 mm. We herein report a case of very large BDA followed for 7 years.

Primary hepatic benign schwannoma.

Schwannoma is predominantly a benign neoplasm of the Schwann cells in the neural sheath of the peripheral nerves. Occurrence of schwannoma in parenchymatous organs, such as liver, is extremely rare. A 64-year-old man without neurofibromatosis was observed to have a space-occupying lesion of 23mm diameter in the liver during follow-up examination for a previously resected gastrointestinal stromal tumor (GIST) in the small intestine. He underwent lateral segmentectomy of the liver under a provisional diagnosis of hepatic metastatic recurrence of the GIST. Histological examination confirmed the diagnosis of a benign schwannoma, confirmed by characteristic pathological findings and positive immunoreactions with the neurogenic marker S-100 protein, but negative for c-kit, or CD34. The tumor was the smallest among the reported cases. When the primary hepatic schwannoma is small in size, preoperative clinical diagnosis is difficult. Therefore, this disease should be listed as differential diagnosis for liver tumor with clinically benign characteristics.

Hiperplasia nodular focal hepática / Focal nodal hyperplasia

La hiperplasia nodal focal es el segundo tumor benigno más frecuente del hígado, y debe incluirse en el diagnóstico diferencial de las lesiones sólidas hepáticas. Se presenta el caso de una paciente adolescente con dolor abdominal crónico y hallazgo de masa abdominal al examen físico y en los estudios de imágenes. Se realizó resección quirúrgica de la masa debido a la persistencia de la sintomatología y la incertidumbre en el diagnóstico. Se realiza una revisión de la literatura sobre este tema con el objetivo de conocer las indicaciones quirúrgicas en este tipo de patología...

Focal nodal hyperplasia is the second most common benign tumor of the liver and should be included in the differential diagnosis of solid liver lesions. We present a case of an adolescent with chronic abdominal pain and abdominal mass fi nding on physical examination and imaging studies. Surgical resection of the mass was performed, due to the persistent symptoms and uncertainty in diagnosis. We make a literature review on this topic with the objective of known the surgical indications in this pathology...