Angiomyolipomas of the liver in tuberous sclerosis

Liver Angiomyolipomas in Tuberous Sclerosis Complex-Their Incidence and Course

BACKGROUND

The purpose of this study was to evaluate the epidemiology and clinical significance of hepatic angiomyolipomas in patients with tuberous sclerosis complex.

METHODS

We performed a retrospective analysis of clinical and imaging data from 187 patients with tuberous sclerosis complex. The prevalence, progression, and potential relationship between liver lesions and other clinical findings, including genetic associations, were assessed.

RESULTS

Twenty-eight of 187 patients (14.9%) had hepatic lesions. There was a predominance of female over male patients in individuals with liver lesions (17 versus 11), with statistical significance in patients under five years of age (P < 0.05). All individuals having hepatic lesions who also had available genetic testing data (n = 20) were diagnosed with a TSC2 gene mutation. All patients with liver lesions had coexisting renal angiomyolipomas (AMLs) (P < 0.05). The age of onset of renal lesions was lower and their prevalence was significantly higher in patients with liver involvement (P < 0.05). In most instances, hepatic lesions measured several millimeters in diameter and were clinically asymptomatic. Progressive lesion growth was documented in six individuals but with no clinical consequences to date.

CONCLUSIONS

This study confirms the association of hepatic lesions with TSC2 mutations, a common origin of liver and renal AMLs, as well as the predominance of female patients in this group. Hepatic AMLs are relatively common but mostly benign lesions.

Nonfunctional islet cell tumor of the pancreas in a patient with tuberous sclerosis: a case report with literature review

Islet cell tumors (ICTs) are rare tumors of the pancreas. Association of this type of tumor with tuberous sclerosis is extremely rare. Only 13 cases of pancreatic ICT with tuberous sclerosis have so far been documented in the literature. However, awareness of the association of tuberous sclerosis and ICT is important for early diagnosis and appropriate treatment of this condition. This article presents the case of a 63-year-old female with angiomyolipoma (AML) of the kidney and liver, calcified subependymal nodules and a large mass in the pancreas, which was proven to be an ICT on histopathological examination.

Hepatic angiomyolipoma: clinical, imaging and pathological features in 178 cases

The aim of the study was to review the main clinical, imaging and pathological features of hepatic angiomyolipoma (HAML). We retrospectively analyzed the imaging, pathological and clinical features of 178 patients who underwent surgical resection for HAML. Forty-three males and 135 females with a median age of 43.5 years (range: 17-76 years) were enrolled in the study. Routine blood tests, including those for α-fetoprotein, carcinoembryonic antigen, and carbohydrate antigen determinant, were normal. Liver function was classified as Child-Pugh A for all patients. Twenty-one patients were positive for hepatitis B surface antigen (HBsAg), while two had liver cirrhosis. Seventy-five lesions were located in the right hepatic lobe, 42 in the left hepatic lobe, 12 in the hepatic caudal lobe, and 49 in both left and right lobe. All patients underwent examination by ultrasound sonography (US), and additional examinations by computed tomography (CT) and magnetic resonance (MR) were carried out for 115 and 81 patients, respectively. Various diseases including HAML, liver cancer, liver hemangioma, hepatic lipoma, hepatic hamartoma, focal nodular hyperplasia and liver adenoma were diagnosed before operation. CT and MRI are more conclusive than US (US vs CT: χ(2) = 17.72, P = 0.00; US vs MRI: χ(2) = 12.14, P = 0.00), but for the sensitivity of these three imaging modalities, MRI performs the best (US vs MRI: χ(2) = 5.938, P = 0.015; CT vs MRI: χ(2) = 2.544, P = 0.111). All the patients underwent liver resection (96 right hepatic lobectomy, 41 left hepatic lobectomy and nine caudal lobe hepatic lobectomy). Several sampled tissues were positive for HBsAg (21/168, 12.5 %), β-catenin (4/41, 9.8 %), CD-34 (119/165, 72.1 %), HMB-45 (162/169, 92.9 %), SMA (145/158, 91.8 %) and vimentin (20/27, 74.1 %). The diagnosis of HAML remains difficult and mainly relies on pathological findings. For the imaging modalities, we recommend MRI examination because of its better definition and sensitivity. Although HMB-45 is considered the main histopathological biomarker for HAML, SMA may be also helpful in the diagnostic process (HMB-45 vs SMA: χ(2) = 2.37, P = 0.123). When the diagnosis of HAML is suspicious or hypothesized, surgical resection remains the recommended strategy due to the difficulty in diagnosis preoperatively and the potentially invasive growth of the lesion.

Hepatic angiomyolipoma: Dynamic computed tomography features and clinical correlation

AIM: To study the dynamic computed tomography (CT) features of hepatic angiomyolipoma (AML) in patients with or without tuberous sclerosis complex (TSC).

METHODS: The clinical information, CT findings and histopathological results of hepatic AML were analyzed retrospectively in 10 patients.

RESULTS: Hepatic AML was prone to occur in female patients (7/10), and most of the patients (8/10) had no specific symptoms. All tumors presented as well-defined, unenveloped nodules in the liver. Six patients with sporadic hepatic AML had a solitary hepatic nodule with a definite fat component. Non-fat components of the hepatic lesions were enhanced earlier and persistently. Prominent central vessels were noted in the portal venous phase in three patients. In four patients with hepatic AML and TSC, most of the nodules were within the peripheral liver. Seven fat-deficient nodules were found with earlier contrast enhancement and rapid contrast material washout in two patients. Lymphangioleiomyomatosis was found in one patient.

CONCLUSION: Imaging features of hepatic AML are characteristic. Correct diagnosis preoperatively can be made in combination with clinical features.

Coincidence of hepatocelluar carcinoma and hepatic angiomyolipomas in tuberous sclerosis complex: A case report

Tuberous sclerosis complex (TSC) is a dominantly inherited disorder which characterized by the growth of hamartomatous in multiple organs. Unlike the common development of renal angiomyolipoma, hepatic angiomyolipoma rarely occur in patients with TSC. We report here a patient with hepatic angiomyolipomas and concurrent hepatocellular carcinoma in TSC. This represents the first reported case in English literature. In this patient, multiple hepatic angiomyolipomas were diagnosed with recognition of their fat components and typical clinical settings. Hepatocellular carcinoma in the left liver lobe was definitely diagnosed by US guided biopsy. In such clinical settings, fat containing lesions in liver can be reasonably treated as angiomyolipomas, but non fat containing lesions must be differentiated from hepatocellular carcinoma, imaging guided biopsy can be adopted to confirm the diagnosis.

Frequency and imaging appearance of hepatic angiomyolipomas in pediatric and adult patients with tuberous sclerosis

OBJECTIVE

This study evaluates the frequency and imaging appearance of hepatic angiomyolipomas in pediatric and adult patients with tuberous sclerosis.

CONCLUSION

Multiple hepatic angiomyolipomas are often found in patients with tuberous sclerosis, particularly in those with bilateral diffuse renal angiomyolipomas.

Hepatic angiomyolipoma mimicking hepatocellular carcinoma

Angiomyolipoma [AML] is a rare benign lipomatous tumour of the liver. It is typically echogenic on ultrasound, hypodense on computed tomography and hyperintense on magnetic resonance imaging. Its varied imaging appearance is due to the different proportion of the three cell types which make up the tumour. This is a case report of a hepatic AML mimicking hepatocellular carcinoma [HCC] with fatty change in a hepatitis B carrier. Diagnostic difficulty and implications on subsequent management are discussed in the context of an endemic region for HCC.

Benign liver neoplasms

A variety of benign focal liver lesions are easily characterized with currently available imaging techniques and contrast agents. The most common benign liver lesions, such as hemangioma, bile duct cyst, and FNH, reveal characteristic cross-sectional imaging features that allow an accurate diagnosis. For atypical variants and more uncommon lesions, including HCA, angiomyelioma, infantile hemagioendothelioma, and mesenchymal hamartoma, integration of clinical data can often help in the interpretation of imaging studies. Finally, for the remaining lesions, such as hepatic adenomatosis, the imaging findings may not be specific enough to negate the need for a tissue biopsy.

US power Doppler of hepatic angiomyolipoma with low fat content

Hepatic angiomyolipoma (AML) is a rare tumor containing a variable amount of fat. Angiomyolipoma prevalently constituted by vessels can be difficult to differentiate from other hypervascular hepatic tumors containing a small amount of fat. We describe US power Doppler findings in a case of hepatic AML with minimal fat content.

Hepatic angiomyolipoma: a clinicopathologic study of 30 cases and delineation of unusual morphologic variants

Hepatic angiomyolipoma (AML) is frequently misdiagnosed. HMB-45 is a promising immunomarker for this tumor that leads to recognition of some AMLs with unusual morphology. The purpose of this collaborative study is to better define the morphologic variations of AML. Thirty AMLs were examined, including four biopsy specimens and two fine-needle aspirates. The diagnosis was confirmed by the presence of HMB-45-positive myoid cells. Almost half the cases were originally misdiagnosed as carcinomas or sarcomas. There was marked female predominance (25:5), and the mean age was 48.7 years (range 29-68). Three patients (10%) had evidence of tuberous sclerosis and all had renal AML. According to the line of differentiation and predominance of tissue components, the tumors was subcategorized into mixed, lipomatous (> or = 70% fat), myomatous (< or = 10% fat), and angiomatous type. The mixed type was the most common (11 resected cases), comprising sheets of epithelioid muscle cells admixed with islands of adipocytes, abnormal vessels, and frequently, hematopoietic cells. Six tumors (including three from biopsy specimens) were heavily fatty and showed predominantly adipocytes with epithelioid and short spindle myoid cells webbed between fat cells. Of 10 myomatous AMLs, five tumors showed a pure sinusoidal trabecular pattern and comprised mainly epithelioid cells. Typically, mature adipocytes were absent or scanty, but fat was seen as fine droplets within cytoplasm or as occasional large globules in sinusoids. Pelioid and inflammatory pseudotumor-like patterns were identified focally. Regarding cellular features of the myoid cells, most of the epithelioid cells were either eosinophilic or clear with spiderweb cell morphology. Three AMLs showed an almost purely oncocytic appearance with scanty fat. Large pleomorphic epithelioid cells existed as small foci. Spindle cells arranged in long fascicles were uncommon. D-PAS-positive globules were common around pelioid areas. Brown pigments with staining characteristics of hemosiderin and/or melanin were noted. In conclusion, we propose HMB-45-positive myoid cells as the defining criterion of hepatic AML, which is a tumor capable of dual myomatous and lipomatous differentiation and melanogenesis. Because of its protean morphologic appearance, recognition of the various variant patterns and cell types is important for a correct diagnosis, assisted by immunohistochemical confirmation with HMB-45. Trabecular and oncocytic cell tumors appear to stand out as distinctive subtypes.

Angiomyolipoma of the liver: significance of CT and MR dynamic study

Angiomyolipoma is a benign mesenchymal tumor that has been reported frequently in the kidney but rarely in the liver. In the present study, we present four cases of hepatic angiomyolipoma with different radiologic appearances, discuss differential diagnosis, and review previously reported cases. One of our cases was followed for 8 years. Computed tomography (plain, enhanced, and dynamic study), magnetic resonance imaging (T1-weighted spin echo, T2-weighted spin echo, and dynamic study), ultrasonography, and angiography were performed in all cases. Although different radiologic appearances were observed in the tumors, based on different proportions of fat, blood vessels, and muscle, three cases were diagnosed as angiomyolipoma. In one case, it was quite difficult to make radiologic diagnosis; hepatocellular carcinoma with fatty metamorphosis in part was most likely suspected, but histopathological examination revealed angiomyolipoma with few fat elements. In the present study, early and prolonged enhancement of the lesion with the special pattern of time density/intensity curve was significant for angiomyolipoma, and we suggest that preoperative radiologic diagnosis of the lesion is possible in most of the cases. However, it can be quite difficult to distinguish angiomyolipoma from some hepatocellular carcinomas with fatty metamorphosis.

Multiple organ involvement in tuberous sclerosis

Tuberous sclerosis is an uncommon heredito-familial disease. A rare case of multiple organ involvement is reported.

Ruptured hepatic angiolipoma in tuberous sclerosis complex

Tuberous sclerosis complex (TSC) may be associated with hepatic angiomyolipoma. In contradistinction to renal angiomyolipoma this lesion is rare, and nontraumatic hemorrhage has not so far been described. This is the first report of a spontaneously ruptured, surgically treated and histologically verified, hepatic angiomyolipoma in TSC. Anomalies of the vessel walls and consequently the hazard of bleeding are known to increase with the diameter of the tumor in other localizations. It is concluded that in cases with rapid tumor growth and marked vessel anomalies elective surgery should be considered.

Case report: variable imaging appearances of angiomyolipomas of the liver

Angiomyolipomas of the liver are rare benign tumours. We describe the variable imaging appearances of these tumours in three women. The first two patients underwent ultrasound, computed tomography (CT) and angiography, which demonstrated lesions resembling focal nodular hyperplasia and hepatocellular carcinoma, respectively. Both had histologically-proven liver angiomyolipomas surgically resected. The third patient was incidentally found to have typical features of multicomponented liver angiomyolipoma on CT. Variable proportions of fatty tissue in these tumours are the most likely explanation for their different imaging appearances on CT.