4. Hemangioma: management
• Most hepatic hemangiomas remain stable over time and
require no treatment
• Treatment or follow-up is not indicated for asymptomatic
lesions that are < 5cm in diameter
• Rupture
– Large, peripheral-located
– Trauma
– Liver biopsy or fine needle aspiration
• Resection surgery:
– Symptomatic
– Rapidly enlarging
– > 15 cm in diameter at initial presentation
• Other treatment: radiofrequency ablation; cryoablation;
liver transplantation (for Kasabach-Merritt syndrome)
5. Adenoma: management (I)
• Depends on
– Symptoms
– Size
– Number of lesions
– Risk of bleeding, rupture, and malignant
transformation
• Risk of malignant transformation
– Around 10%
– Increase in size
– Rise in serum AFP levels
– β-catenin gene mutations
6. Adenoma: management (I)
• Small lesions (< 5cm):
– Periodic imaging
– OCP and steroid should be discontinued
– Therapy when symptomatic or increase in size despite
discontinuation of estrogen
• Resection surgery or liver transplantation
(glycogen storage disease or multiple adenomas)
• Mortality rate: < 1% in selection; 5-8% in
emergency resection of bleeding or ruptured
lesions
• Avoid pregnancy prior to resection
7. Liver adenomatosis
• Presence of 10 or more adenomas not associated
with steroid use, but with underlying glycogen
storage diseases
• Pathogenesis: thought to be secondary to
congenital or acquired abnormalities of hepatic
vasculature
• Hemorrhage appears to be common, particularly
in lesions > 4 cm
• Liver transplantation should be considered due to
high risk of bleeding, rupture and malignant
transformation
8. Management of suspected liver
benign lesions
Follow-up OCP use Pregnancy Treatment
Hemangioma Classic features:
no follow-up
Not absolutely
contraindicated
Not
contraindicated
Frequent follow-
up; resect if
symptomatic
(rarely needed)
FNH Classic features:
no follow-up
Not absolutely
contraindicated
Not
contraindicated
Frequent follow-
up; resect if
symptomatic
(rarely needed)
Adenoma Variable Stop No Stop OCP; resect if
solitary and large
(> 5cm)
Brhirwani R, Reddy KR. Aliment Pharmacol Ther 2008; 28:953-65
9. Algorithm for the diagnosis and treatment of FNH and adenoma
Nault JC, et al. Gastroenterology
2013; 144:888-902
11. Hepatic angiomyolipoma (AML):
management
• Hepatic AML was considered as a benign disease in the
past.
• Nevertheless, tumor rupture, metastasis, recurrence after
resection surgery of primary tumor, as well as concurrent
hepatic AML and HCC were reported recently.
• Conservative management with close follow-up is
reserved in asymptomatic patients with good
compliance, no chronic hepatitis, as well as small AML
which is less than 5 cm in size and is proved through fine
needle aspiration biopsy.
• Surgical intervention might be considered if the
progression of the tumor or the emergence of symptoms
occurs during the follow-up, especially for those with a
high risk for HCC.
16. Hepatic TB management and
prognosis
• Hepatic TB is treated like any other extra-pulmonary
tuberculosis lesion.
• Chemotherapy with standard anti-TB drugs remains the
corner stone of treatment.
• Most authors have used four drugs (INH, Rifampicin,
Streptomycin and Pyrazinamide) during the initial two
months, followed by INH and Rifampicin for the next seven
months.
• Cumulative mortality for hepatic tuberculosis ranges
between 15% and 42%. The factors associated with adverse
prognosis are: age < 20 years, miliary tuberculosis,
concurrent steroid therapy, AIDS, cachexia, associated
cirrhosis and liver failure.
17. Cystadenoma: treatment
• Resection surgery is preferred due to
malignant transformation occurring in 15% of
patients
• Aspiration and partial resection are associated
with worse prognosis compared with
complete resection and an increased risk of
recurrence
18. Polycystic liver disease: treatment
• Asymptomatic: require no treatment
• Large cysts with symptom: hepatic resection
• Obstructive jaundice caused by extrinic
compression of the biliary tree: unroofing of large
cysts
• Portocaval shunting may be attempted for
patients with portal hypertension
• Percutaneous TAE: decrease intrahepatic cyst
volume
• Mammalian target of rapamycin (mTOR)
inhibitors decrease polycystic liver volume by
inhibiting the proliferation of biliary epithelium