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Tsalikidis C, Mitsala A, Pappas-Gogos G, Romanidis K, Tsaroucha AK, Pitiakoudis M. Pedunculated Focal Nodular Hyperplasia: When in Doubt, Should We Cut It Out? J Clin Med 2023; 12:6034. [PMID: 37762973 PMCID: PMC10532121 DOI: 10.3390/jcm12186034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 09/10/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
Focal nodular hyperplasia (FNH) is the second most common benign hepatic tumor and can rarely present as an exophytic solitary mass attached to the liver by a stalk. Most FNH cases are usually detected as incidental findings during surgery, imaging or physical examination and have a high female predominance. However, the pedunculated forms of FNH are particularly rare and commonly associated with severe complications and diagnostic challenges. Hence, our study aims to provide a comprehensive summary of the available data on the pedunculated FNH cases among adults and children. Furthermore, we will highlight the role of different therapeutic options in treating this clinical entity. The use of imaging techniques is considered a significant addition to the diagnostic toolbox. Regarding the optimal treatment strategy, the main indications for surgery were the presence of symptoms, diagnostic uncertainty and increased risk of complications, based on the current literature. Herein, we also propose a management algorithm for patients with suspected FNH lesions. Therefore, a high index of suspicion and awareness of this pathology and its life-threatening complications, as an uncommon etiology of acute abdomen, is of utmost importance in order to achieve better clinical outcomes.
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Affiliation(s)
- Christos Tsalikidis
- Second Department of Surgery, University General Hospital of Alexandroupolis, Democritus University of Thrace Medical School, 68100 Alexandroupolis, Greece; (C.T.); (A.M.); (G.P.-G.); (K.R.); (M.P.)
| | - Athanasia Mitsala
- Second Department of Surgery, University General Hospital of Alexandroupolis, Democritus University of Thrace Medical School, 68100 Alexandroupolis, Greece; (C.T.); (A.M.); (G.P.-G.); (K.R.); (M.P.)
| | - George Pappas-Gogos
- Second Department of Surgery, University General Hospital of Alexandroupolis, Democritus University of Thrace Medical School, 68100 Alexandroupolis, Greece; (C.T.); (A.M.); (G.P.-G.); (K.R.); (M.P.)
| | - Konstantinos Romanidis
- Second Department of Surgery, University General Hospital of Alexandroupolis, Democritus University of Thrace Medical School, 68100 Alexandroupolis, Greece; (C.T.); (A.M.); (G.P.-G.); (K.R.); (M.P.)
| | - Alexandra K. Tsaroucha
- Laboratory of Experimental Surgery & Surgical Research, Democritus University of Thrace Medical School, 68100 Alexandroupolis, Greece
| | - Michail Pitiakoudis
- Second Department of Surgery, University General Hospital of Alexandroupolis, Democritus University of Thrace Medical School, 68100 Alexandroupolis, Greece; (C.T.); (A.M.); (G.P.-G.); (K.R.); (M.P.)
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Akaguma A, Ishii T, Uchida Y, Chigusa Y, Ueda Y, Mandai M, Mogami H. Laparoscopic resection for pedunculated focal nodular hyperplasia of the liver during pregnancy. Oxf Med Case Reports 2023; 2023:omad054. [PMID: 37377714 PMCID: PMC10292637 DOI: 10.1093/omcr/omad054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 03/14/2023] [Accepted: 05/04/2023] [Indexed: 06/29/2023] Open
Abstract
Focal nodular hyperplasia (FNH) is the second most common intrahepatic benign mass lesion; however, extremely rarely, FNH grows in an exophytic manner. It is unclear whether pedunculated FNH can be managed in the same way as intrahepatic FNH. A 35-year-old female presented with right upper quadrant pain, and dynamic enhanced computed tomography revealed an exophytic hyperdense mass lesion originating from the liver, suggesting a pedunculated FNH. Shortly thereafter, she conceived. Since there was a history of acute abdomen, as well as the possibility of torsion of the mass or sudden massive bleeding during pregnancy, laparoscopic resection was performed at 17 weeks of gestation. Her postoperative and pregnancy course was uneventful, and she delivered a baby by cesarean section at 41 weeks of gestation. Our case suggests that pedunculated FNH, unlike typical intrahepatic FNH, may be better managed by laparoscopic surgery during pregnancy, resulting in favorable maternal and fetal outcomes.
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Affiliation(s)
- Ai Akaguma
- Department of Gynecology and Obstetrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takamichi Ishii
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoichiro Uchida
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoshitsugu Chigusa
- Correspondence address. Department of Gynecology and Obstetrics, Kyoto University, 54 Shogoin Kawahara cho, Sakyo ku, Kyoto 606-8507, Japan. Tel: 81-75-751-3269; Fax: 81-75-761-3967; E-mail:
| | - Yusuke Ueda
- Department of Gynecology and Obstetrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masaki Mandai
- Department of Gynecology and Obstetrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Haruta Mogami
- Department of Gynecology and Obstetrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Sato H, Monden K, Iwasaki T, Hioki M, Sadamori H, Takakura N. Large focal nodular hyperplasia of the liver treated with transcatheter arterial embolization and laparoscopic resection: A case report. Asian J Endosc Surg 2023. [PMID: 37037454 DOI: 10.1111/ases.13188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/03/2023] [Accepted: 03/23/2023] [Indexed: 04/12/2023]
Abstract
Focal nodular hyperplasia (FNH) is a rare benign hepatic tumor which is frequently observed in women of reproductive age, and therapeutic intervention needs to be considered in cases wherein the tumor has a risk of rupture. The laparoscopic approach is beneficial, especially for young women, but is often challenging because the tumor is large and hemorrhagic. Herein, we report a case of large FNH in a 22-year-old woman. The patient was asymptomatic; however, the tumor was approximately 15 cm in diameter and protruded from the liver. Given the risk of rupture, we decided to perform surgical resection. Preoperative transcatheter arterial embolization led to rapid shrinkage of the tumor and control of intraoperative bleeding, which enabled us to safely perform laparoscopic liver resection. The combination of surgical resection with intravascular embolization may be a promising therapeutic option for hypervascular tumors such as FNH.
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Affiliation(s)
- Hiroki Sato
- Department of Surgery, Fukuyama City Hospital, 5-23-1 Zao, Fukuyama, 721-8511, Japan
| | - Kazuteru Monden
- Department of Surgery, Fukuyama City Hospital, 5-23-1 Zao, Fukuyama, 721-8511, Japan
| | - Toshimitsu Iwasaki
- Department of Surgery, Fukuyama City Hospital, 5-23-1 Zao, Fukuyama, 721-8511, Japan
| | - Masayoshi Hioki
- Department of Surgery, Fukuyama City Hospital, 5-23-1 Zao, Fukuyama, 721-8511, Japan
| | - Hiroshi Sadamori
- Department of Surgery, Fukuyama City Hospital, 5-23-1 Zao, Fukuyama, 721-8511, Japan
| | - Norihisa Takakura
- Department of Surgery, Fukuyama City Hospital, 5-23-1 Zao, Fukuyama, 721-8511, Japan
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Bilgic S, Sayman HB, Sager MS, Sonmezoglu K. A case of hepatic focal nodular hyperplasia mimicking hepatocellular carcinoma identified on gallium-68-prostate-specific membrane antigen positron emission tomography/computed tomography. World J Nucl Med 2021; 20:192-194. [PMID: 34321974 PMCID: PMC8285996 DOI: 10.4103/wjnm.wjnm_108_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/16/2020] [Accepted: 08/17/2020] [Indexed: 11/16/2022] Open
Abstract
Prostate-specific membrane antigen (PSMA) is a glycosylated type-II transmembrane protein highly expressed in individual tumor cells. Lesions with PSMA expression in the liver are commonly reported as prostate cancer metastasis or hepatocellular cancer previously. This is the first case reported as hepatic focal nodular hyperplasia, mimicking hepatocellular carcinoma with imaging features. This patient, having a lesion that has been enlarged from 2.0 cm to 2.5 cm in 3 months, was referred to our department for restaging by gallium-68 PSMA (68Ga-PSMA) positron emission tomography/computed tomography (PET/CT). The CT scan showed a focal segment VI hypodensity, which was significantly PSMA-avid. Consequently, its biopsy resulted as focal nodular hyperplasia in liver. His follow-up 68Ga-PSMA PET/CT ultimately revealed a mass lesion of 8 cm of axial diameter.
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Affiliation(s)
- Seckin Bilgic
- Department of Nuclear Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Haluk Burçak Sayman
- Department of Nuclear Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Muhammet Sait Sager
- Department of Nuclear Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Kerim Sonmezoglu
- Department of Nuclear Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
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Abstract
The etiologic association between focal nodular hyperplasia (FNH) and estrogen has been a subject of doubt and controversy. We present a case of a female patient with FNH that had been monitored for several years with noted size stability and later regression, who developed tumor growth during pregnancy. This case suggests that a subset of FNH is indeed hormone sensitive, as opposed to what has been frequently suggested by many other reports that question the association, a finding that may have clinical implications, in terms of monitoring of patients with high estrogen statuses.
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Oldhafer KJ, Habbel V, Horling K, Makridis G, Wagner KC. Benign Liver Tumors. Visc Med 2020; 36:292-303. [PMID: 33005655 DOI: 10.1159/000509145] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/03/2020] [Indexed: 12/12/2022] Open
Abstract
Background Due to the frequent use of medical imaging including ultrasonography, the incidence of benign liver tumors has increased. There is a large variety of different solid benign liver tumors, of which hemangioma, focal nodular hyperplasia (FNH), and hepatocellular adenoma (HCA) are the most frequent. Advanced imaging techniques allow precise diagnosis in most of the patients, which reduces the need for biopsies only to limited cases. Patients with benign liver tumors are mostly asymptomatic and do not need any kind of treatment. Symptoms can be abdominal pain and pressure effects on adjacent structures. The 2 most serious complications are bleeding and malignant transformation. Summary This review focuses on hepatic hemangioma (HH), FNH, and HCA, and provides an overview on clinical presentations, surgical and interventional treatment, as well as conservative management. Treatment options for HHs, if indicated, include liver resection, radiofrequency ablation, and transarterial catheter embolization, and should be carefully weighed against possible complications. FNH is the most frequent benign liver tumor without any risk of malignant transformation, and treatment should only be restricted to symptomatic patients. HCA is associated with the use of oral contraceptives or other steroid medications. Unlike other benign liver tumors, HCA may be complicated by malignant transformation. HCAs have been divided into 6 subtypes based on molecular and pathological features with different risk of complication. Key Message The vast majority of benign liver tumors remain asymptomatic, do not increase in size, and rarely need treatment. Biopsies are usually not needed as accurate diagnosis can be obtained using modern imaging techniques.
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Affiliation(s)
- Karl J Oldhafer
- Department für Chirurgie, Klinik für Leber-, Gallenwegs- und Pankreaschirurgie, Asklepios Klinik Barmbek, Hamburg, Germany.,Semmelweis University Budapest, Asklepios Campus Hamburg, Hamburg, Germany
| | - Victoria Habbel
- Department für Chirurgie, Klinik für Leber-, Gallenwegs- und Pankreaschirurgie, Asklepios Klinik Barmbek, Hamburg, Germany.,Semmelweis University Budapest, Asklepios Campus Hamburg, Hamburg, Germany
| | | | - Georgios Makridis
- Department für Chirurgie, Klinik für Leber-, Gallenwegs- und Pankreaschirurgie, Asklepios Klinik Barmbek, Hamburg, Germany.,Semmelweis University Budapest, Asklepios Campus Hamburg, Hamburg, Germany
| | - Kim Caroline Wagner
- Department für Chirurgie, Klinik für Leber-, Gallenwegs- und Pankreaschirurgie, Asklepios Klinik Barmbek, Hamburg, Germany.,Semmelweis University Budapest, Asklepios Campus Hamburg, Hamburg, Germany
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Bente A, Ouedraogo M, Kasbawala KN, Glasgow KM. Compression of cystic duct caused by focal nodular hyperplasia. J Surg Case Rep 2019; 2019:rjz254. [PMID: 31616554 PMCID: PMC6786132 DOI: 10.1093/jscr/rjz254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 07/26/2019] [Accepted: 08/13/2019] [Indexed: 11/24/2022] Open
Abstract
A 29-year-old female presenting with symptoms of biliary colic was found to have a liver mass compressing the cystic duct. Due to the anatomical placement of the growth, the compressed duct produced symptoms mimicking acute cholecystitis. The mass was diagnosed as focal nodular hyperplasia (FNH) upon biopsy. FNH is commonly found incidentally with nonhepatic clinical presentation or during an unrelated surgical procedure. The scope of this paper is to bring awareness to uncommon causes of biliary colic. To our knowledge, there has been one other paper published with FNH being the primary cause of biliary colic.
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Affiliation(s)
- Andreea Bente
- Clinical Rotations, Saba University School of Medicine, Devens, MA, USA
| | - Moussa Ouedraogo
- Clinical Rotations, Saba University School of Medicine, Devens, MA, USA
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Vernuccio F, Ronot M, Dioguardi Burgio M, Lebigot J, Allaham W, Aubé C, Brancatelli G, Vilgrain V. Uncommon evolutions and complications of common benign liver lesions. Abdom Radiol (NY) 2018; 43:2075-2096. [PMID: 29260281 DOI: 10.1007/s00261-017-1427-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Frequently encountered on abdominal imaging studies, the majority of common benign liver lesions are asymptomatic, confidently diagnosed by imaging, and do not require further workup, follow-up, or treatment. The increasing use of multimodality liver imaging, has allowed the recognition of uncommon evolutions of common benign liver lesions such as size changes, fibrotic regression, and content and vascularization changes, and their complications such as rupture, hemorrhage, thrombosis, extrinsic compression, and malignancy. The purpose of this pictorial review is to describe and illustrate the incidence and diagnostic features of these uncommon evolutions and complications on cross-sectional imaging, mainly on computed tomography and magnetic resonance imaging, with emphasis on those imaging clues which are helpful in the differential diagnosis or indicate the need for treatment.
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Abstract
BACKGROUND Focal nodular hyperplasia (FNH) is a benign hepatic lesion that is rare in children. The aim of the present study was to review the clinical features of children with FNH and our institution's experience in the management of this rare disease. METHODS A review of the medical records of children diagnosed as having FNH between 1999 and 2013 at West China Hospital of Sichuan University was undertaken. RESULTS Seventy-nine patients with FNH were identified: 68 patients without a history of malignancy and 11 patients with a history of malignancy. Thirty-seven (46.8%) patients were symptomatic at presentation. Patients with a history of malignancy had smaller FNH lesions and were less likely to have a central scar in FNH than do patients without a history of malignancy. Forty-seven patients underwent liver resection because of concern for malignancy, symptoms, and/or large lesions. Three patients were treated by embolization because of compression of the adjacent organs. There was no operative death or severe postoperative complications. Fourteen patients underwent liver biopsy to rule out malignant masses. The remaining 15 patients were managed expectantly with imaging surveillance. On follow-up, 2 patients for whom observation was initially recommended eventually required resection because of a mass effect. CONCLUSIONS The clinical features of pediatric FNH are variable and can be nonspecific. Our data emphasize the therapeutic approach that active management is indicated in symptomatic or progressive FNH and in children with diagnostic difficulties, whereas observation management is recommended in asymptomatic children with a definitive diagnosis.
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